Acute aortic dissection during pregnancy: Trials and tribulations

Abstract

Background Type A acute aortic dissection (TAAD) during pregnancy is a life‐threatening event for both the mother and the unborn baby. Pregnancy has been recognized as an independent risk factor for TAAD, postulated to be due to physiological changes that cause hyperdynamic circulation. This review seeks to outline the current controversies around this unique group. Methods A comprehensive literature search was carried out across large databases to assimilate relevant papers regarding acute aortic dissection in pregnant women. Results The presentation can be atypical in many cases and further concern from clinicians of fetal radiation exposure can result in missed or delayed diagnoses. Investigation via the quickest form of imaging, whether computed tomography, magnetic resonance imaging, or transesophageal echocardiography, should be carried out promptly due to the high risk of mortality. Surgical management of TAAD in pregnancy revolves primarily around the decision to deliver the fetus concomitantly or to perform the aortic repair with the fetus in utero. Conclusions Management of this group includes rapid and dynamic assessment without delay. From conception to postpartum, there are multiple stages in which to manage these women. Challenges in carrying out management in the form of operative techniques and cardiopulmonary bypass place the fetus at risk and must be approached with caution, particularly as there is little evidence‐base for many of these decisions. Further research into reducing maternal and fetal mortality is necessary.

Obstetric considerations for aortopathy in pregnancy

“…CT is the fastest and preferred method for diagnosis if there is a high index of suspicion for AD based on symptoms and vital signs ( 20 , 53 ). The American College of Obstetrics and Gynecology (ACOG) states that ionizing radiation used in imaging should not be withheld from a pregnant person if it is thought to be necessary.…”

Understanding pregnancy‐related aortic dissection‐still a long way to go?

“…Surgery for AAD is generally a complex procedure which becomes particularly challenging when required during the first two trimesters of pregnancy, when adequate conduction of anesthesia and cardiopulmonary bypass, coupled with a fast and effective repair, must provide adequate fetal oxygenation by minimizing hemodilution and avoiding hypothermia 5 …”