Obstetric Considerations in a Rare Cardiovascular Catastrophe Needing Multidisciplinary Care

Cardiovascular emergencies especially aortic dissections are rare in pregnancy. We report a case of Stanford Type A aortic dissection at 33 weeks of pregnancy presenting in shock. Rapid multidisciplinary approach and special obstetric considerations led to a successful outcome in this case. 1. Introduction Cardiovascular emergencies needing precipitous decision making is somewhat rare in pregnancy. Only about 5% of nontraumatic sudden deaths in the young population are caused by aortic dissections and it is even less common in females [1, 2]. The majority are associated with connective tissue disorders [3]. As such, obstetricians rarely encounter the much-dreaded dissections of ascending aorta (Stanford Type A) [3]. We present one such case managed successfully at our institution. 2. Case Summary A 28-year-old, previously healthy, third gravida at 33 weeks and 4 days with previous two vaginal deliveries presenting with syncope, chest pain, profound hypotension, and weakness of right arm at the Emergency Department. CT angiogram, following an Emergency Medicine consult, revealed a massive type A aortic dissection of the thoracic aorta extending proximally from the aortic root to proximal arch with extension into proximal innominate artery (Figure 1). Her syphilis serology was normal. There were no stigmata of Marfan’s syndrome and emergent Trans Thoracic Echo did not reveal any underlying congenital cardiac malformation. Her height was 156？cm and weight 63？kg. Repair of aorta was planned after initial stabilization and obstetrics consult sent for cesarean delivery immediately preceding it. She received two doses of antenatal corticosteroids (betamethasone) for fetal lung maturity, second dose being on the day of surgery. Perioperatively, the patient was heparinised and monitored by Trans Esophageal Echocardiogram (TEE) and general anesthesia given in left lateral tilt. Lower Segment Cesarean Section (LSCS) with tubal sterilization was done with controlled and gradual fetus extraction to avoid sudden abdominal decompression. While the heparinisation added to the risk of intraoperative and obstetric hemorrhage, avoiding bleeding in postpartum period was of utmost priority in this patient. Oxytocin could precipitate hypotension and prostaglandins are unsafe because of the cardiovascular considerations. Also it was prudent to avoid vasopressors in case she did have obstetric hemorrhage. Prophylactic bilateral uterine artery ligation was done and 20？U Oxytocin was added to 500？mL Ringer’s lactate and then tapering over an extended period of 48 hours.