CASE DESCRIPTION
A 37-year-old G8P5 African American female at 31 weeks’ gestation and with a past medical history significant for hypertension, gastric bypass surgery, gastro-esophageal reflux disease, and gestational diabetes mellitus presented emergently to an outside hospital with abdominal pain radiating to the neck with right arm numbness and weakness, as well as diarrhea, nausea, and emesis. Workup revealed an unremarkable electrocardiogram, normal troponins, and unremarkable chest x-ray. Hypotension 70/46 mmHg was noted, and the patient was admitted with a diagnosis of gastroenteritis with concern for sepsis. Two days later, in conjunction with persisting abdominal pain, the patient was found to have significantly lower blood pressures in the right upper extremity (65/48mmHg) compared to the left upper extremity (122/58mmHg). CT Angiogram revealed a Stanford Type A AD involving the ascending aorta, aortic arch, descending thoracic aorta, and abdominal aorta with a dissection flap just below the origin of the superior mesenteric artery (Figure 1 and 2 ).
The patient was transferred to our institution where a multidisciplinary team of obstetricians, cardiac surgeons, and anesthesiologists decided to use a staged approach due to her clinical stability. The patient underwent an emergent cesarean section under general anesthesia. Concurrently, transesophageal echocardiography (TEE) was performed and showed preserved left ventricular systolic function (ejection fraction 60%), mild aortic regurgitation, and moderate mitral and tricuspid regurgitation. Importantly, the TEE indicated no pericardial effusion. The newborn was healthy and transferred to the NICU as a precaution. The patient was extubated and recovered from the cesarean delivery and 3 days later, the patient underwent a hemiarch replacement to repair the type A dissection. The patient was extubated the following day, soon weaned from vasoactive medications and had an uneventful recovery. She was discharged home on post-operation day 12. Written informed consent was obtained from the patient for their anonymized information to be published in this article.