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.