Surgical management of type A aortic dissection during the second trimester: a case report.

Background: Acute aortic dissection during pregnancy is a relatively rare but often life-threatening conditio. A previous study showed that the overall incidence of the disease was about 4 in 1 million women aged 15-45 years. Hormonal and Hemodynamics changes during pregnancy are a major cause of aortic dissection, and these changes may begin in the first and second trimesters, but are most pronounced in the third trimesters(about 50% and 33%, respectively).In addition, some genetic disorder such as Marfan syndrome may be associated with AD during pregnancy.

Case presentation: A 29-year-old pregnant woman at 21 weeks of gestation presented with acute, non-radiating retrosternal tearing pain lasting 15 h, unrelieved and accompanied by three episodes of vomiting. Ultrasonography identified aortic root dilatation with aortic regurgitation, and contrast-enhanced aortic computed tomography (CT) confirmed type A aortic dissection (AD). Emergency surgery was performed, including ascending aortic replacement, total arch replacement with prosthetic graft placement, stented elephant trunk implantation (Sun's procedure), and aortic valvuloplasty under cardiopulmonary bypass (CPB). The patient was discharged on postoperative day (POD) 9, and the fetus remained viable. At 26 weeks of gestation, the family expressed concerns regarding maternal safety, prompting an early request for cesarean delivery due to cervical insufficiency and preeclampsia, resulting in the delivery of a healthy infant with no adverse events.

Conclusion: Although AD during pregnancy is uncommon, clinicians must maintain a high index of suspicion for pregnant women presenting with severe chest pain. CTA is essential for diagnosing the condition and determining surgical options. After 28 weeks of pregnancy, cesarean section should be prioritized [17-18]. In the early second trimester, ensuring fetal safety involves appropriately increasing mean arterial pressure, minimizing circulatory arrest time, and closely monitoring the fetus post-surgery.