A 38 year old peripartum female presents to the ED with severe chest pain due to aortic dissection

38-year-old Maori woman normally fit and well. Presents day 6 post-vaginal delivery with:

–chest pain (since delivery)

–shortness of breath

–nausea

–lightheadedness  
Vaginal delivery difficult – episiotomy, Ventouse-assisted, PPH 600 mL Hypertensive in pregnancy

CTPA: no PE, but pericardial effusion, ascites, and R pleural effusion of unclear cause

Echo: marked dilatation of ascending aorta, mild-mod aortic insufficiency, pericardial effusion

CTA:
Aortic intimal flaps (red arrows) initially reported as “ulceration” After rediscussion with radiology, diagnosed as type A dissection involving ascending aorta

Pregnancy alone is independent risk factor for dissection

•Hypertension

•Hyperdynamic, hypervolaemic state

•Hormonal effects on vasculature

•Gravid uterus compressing descending aorta and iliac arteries -> increased stress/pressures in upper aorta

 Dissections occur in third trimester or in peripartum period

Mortality if untreated in a dissection of the ascending aorta.

–33% of patients die within the first 24 hours

–50% die within 48 hours

–Undiagnosed ascending aortic dissection has two-week mortality of 75%

One of the great saves of my career as a clinical cardiologist! Kia Ora from the land of the long white cloud.