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Miyazaki Y, Orisaka M, Kato M, Kawamura H, Kurokawa T, Yoshida Y. Acute type B aortic dissection in a pregnant woman with undiagnosed Marfan syndrome: A case report and review of the literature. Case Rep Womens Health 2021; 32:e00342. [PMID: 34354931 PMCID: PMC8325095 DOI: 10.1016/j.crwh.2021.e00342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 07/09/2021] [Accepted: 07/13/2021] [Indexed: 11/15/2022] Open
Abstract
Aortic dissection during pregnancy is rare but can be life-threatening to both the mother and the foetus. Marfan syndrome is a major risk factor for acute aortic dissection during pregnancy. Here, we present the case of a woman who had not been diagnosed with Marfan syndrome prior to pregnancy and who developed acute type B dissection at 32 weeks of gestation. The maternal hemodynamic status was stable, and foetal well-being was ensured. However, under conservative treatment, the dissection extended to the descending aorta, reaching the bilateral iliac artery 2 days later. Due to foetal distress, preterm delivery was performed via caesarean section. The primary treatment of type B aortic dissection is conservative medical treatment, with the goals of hemodynamic stabilisation, minimising the extent of the dissection and decreasing the risk of rupture. However, type B aortic dissection, even the uncomplicated type, in pregnant women may require early and aggressive obstetric interventions to improve maternal and foetal prognoses.
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Affiliation(s)
- Yumiko Miyazaki
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, University of Fukui, Japan
| | - Makoto Orisaka
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, University of Fukui, Japan
| | - Masataka Kato
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, University of Fukui, Japan
| | - Hiroshi Kawamura
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, University of Fukui, Japan
| | - Tetsuji Kurokawa
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, University of Fukui, Japan
| | - Yoshio Yoshida
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, University of Fukui, Japan
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Rimmer L, Mellor S, Harky A, Gouda M, Bashir M. Pernicious pregnancy: Type B aortic dissection in pregnant women. J Card Surg 2021; 36:1232-1240. [PMID: 33533078 DOI: 10.1111/jocs.15354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/22/2020] [Accepted: 10/14/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Type B aortic dissection (TBAD) occurs seldomly, particularly in pregnancy, but has disastrous consequences for both mother and fetus. The focus of immediate surgical repair of type A aortic dissection due to higher mortality of patients is less clear in its counterpart, TBAD, in which management is controversial and debated. This article collates knowledge so far on this rare event during pregnancy. METHODS A comprehensive literature search was performed in PubMed, Scopus, Google Scholar, Embase, and Medline. Key search terms included "type B aortic dissection," "pregnancy," and corresponding synonyms. Non-English papers were excluded. RESULTS Risk factors for TBAD include aortic wall stress due to hypertension, previous cardiac surgery, structural abnormalities (bicuspid aortic valve, aortic coarctation), and connective tissue disorders. In pregnancy, pre-eclampsia is a cause of increased aortic wall stress. Management of this condition is often conservative, but this is dependent on a number of factors, including gestation, cardiovascular stability of the patient, and symptomology. In most cases, a cesarean section before intervention is carried out unless certain indications are present. CONCLUSIONS Due to a scarce number of cases across the decades, it is difficult to determine which management is optimal. The gold-standard management of TBAD has traditionally been the medical treatment for uncomplicated cases and open surgery for those needing urgent intervention, but with the advent of techniques, such as thoracic endovascular aortic repair, the management of these group of patients continues to develop.
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Affiliation(s)
- Lara Rimmer
- Vascular Surgery Department, Royal Blackburn Teaching Hospital, Blackburn, UK
| | - Sophie Mellor
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Amer Harky
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Mohamed Gouda
- Vascular & Endovascular Surgery, Mataria Teaching Hospital, Cairo, Egypt
| | - Mohamad Bashir
- Vascular Surgery Department, Royal Blackburn Teaching Hospital, Blackburn, UK
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Ma WG, Zhu JM, Chen Y, Qiao ZY, Ge YP, Li CN, Zheng J, Liu YM, Sun LZ. Aortic dissection during pregnancy and postpartum in patients with Marfan syndrome: a 21-year clinical experience in 30 patients. Eur J Cardiothorac Surg 2020; 58:294-301. [PMID: 32259204 DOI: 10.1093/ejcts/ezaa048] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 01/14/2020] [Accepted: 01/31/2020] [Indexed: 01/15/2023] Open
Abstract
Abstract
OBJECTIVES
Pregnancy-related aortic dissection (AoD) in Marfan syndrome is a lethal catastrophe. Due to its rarity and limited clinical experience, there is no consensus regarding the optimal management strategy. We seek to present our 21-year experience in such patients , focusing on management strategies and early and late outcomes.
METHODS
Between 1998 and 2019, we managed 30 pregnant women with Marfan syndrome (mean age 30.7 ± 4.3 years) who sustained AoD at a mean of 28.3 ± 8.8 weeks of gestation (GWs). AoD was acute in 21 (70%), type A (TAAD) in 24 (80%) and type B (TBAD) in 6 (20%). Fourteen TAADs (58.3%, 14/24) and 2 TBADs (33.3%, 2/6) occurred in the third trimester or postpartum. The maximal aortic size was < 45 mm in 26.7% (8/30; 3 TAADs, 5 TBADs). Management strategy was based on the types of dissection and GWs (i.e. surgical versus medical treatment, surgery or delivery first).
RESULTS
TAADs were treated medically in 1 and surgically in 23. The timing of delivery and surgery were caesarean first at 35.4 ± 6.1 GWs in 7 (29.2%), followed by surgery after mean 46 days; single-stage C-section and surgery at 32.0 ± 5.0 GWs in 10 (41.7%); and surgery first at 18.0 ± 5.8 GWs in 6 (25%), followed by C-section after 20 days. Maternal and foetal mortality were 28.6% (2/7) and 14.3% (1/7), 10.0% (1/10) and 20.0% (2/10) and 16.7% (1/6) and 83.3% (5/6), respectively. Five TBADs (83.3%) were managed with C-section followed by surgery in 2 and medical treatment in 3. The respective maternal and foetal mortality were 50% (1/2) and 100% (2/2) and 33.3% (1/3) and 33.3% (1/3), respectively. One TBAD was managed surgically first followed by C-section, resulting in maternal survival and foetal death. Follow-up was complete in 95.8% (23/24) at 3.7 ± 2.9 years. Four late deaths occurred and reoperation was performed in 1 patient. Maternal and foetal survival were 64.3% and 54.1% at 6 years, respectively.
CONCLUSIONS
Management of AoD in pregnant women with Marfan syndrome should be based on types of dissection (surgical versus medical) and gestational age (delivery or surgery first), which largely determine maternal and foetal survival. Aortic repair should be considered prior to conception in women with Marfan syndrome even at diameters smaller than recommended by current guidelines.
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Affiliation(s)
- Wei-Guo Ma
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Jun-Ming Zhu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Yu Chen
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Zhi-Yu Qiao
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Yi-Peng Ge
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Cheng-Nan Li
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Jun Zheng
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Yong-Min Liu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Li-Zhong Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
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Taglialegna GDM, Katz L, Albuquerque LMAD, Freitas MMD, Lucena AJGD, Amorim MMRD. Chronic Aortic Dissection and Pregnancy: Clinical Case Report. Arq Bras Cardiol 2020; 112:321-323. [PMID: 30916197 PMCID: PMC6424040 DOI: 10.5935/abc.20190044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 07/02/2018] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Leila Katz
- Instituto de Medicina Integral Professor Fernando Figueira, Recife, PE - Brazil
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Aortic dissection in the third trimester pregnancy without risk factors. Taiwan J Obstet Gynecol 2019; 58:723-724. [DOI: 10.1016/j.tjog.2019.07.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2018] [Indexed: 12/26/2022] Open
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Patel PA, Fernando RJ, MacKay EJ, Yoon J, Gutsche JT, Patel S, Shah R, Dashiell J, Weiss SJ, Goeddel L, Evans AS, Feinman JW, Augoustides JG. Acute Type A Aortic Dissection in Pregnancy-Diagnostic and Therapeutic Challenges in a Multidisciplinary Setting. J Cardiothorac Vasc Anesth 2018. [PMID: 29519602 DOI: 10.1053/j.jvca.2018.01.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rohesh J Fernando
- Cardiothoracic Section, Department of Anesthesiology, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, NC
| | - Emily J MacKay
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jeongae Yoon
- Cardiothoracic Anesthesiology, Department of Anesthesiology, Lewis School of Medicine, Temple University, Philadelphia, PA
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Saumil Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ronak Shah
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jillian Dashiell
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stuart J Weiss
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lee Goeddel
- Divisions of Cardiac Anesthesia and Adult Critical Care, Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Adam S Evans
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jared W Feinman
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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