Original ArticleOutcomes in pregnant women with acute aortic dissections: a review of the literature from 2003 to 2013
Introduction
Acute aortic dissection, a potentially catastrophic event, is characterized by an intimal tear of the aortic wall which allows blood to flow into the medial layer. Dissection can propagate both proximal and distal to the tear and this may involve arteries branching from the aorta which can result in coronary, cerebral, spinal, and visceral ischemia, or culminate in aortic rupture. Acute aortic dissections are classified into those that involve the ascending aorta (Stanford type A; DeBakey types I and II) and those not involving the ascending aorta (Stanford type B; DeBakey type III) (Fig. 1).1, 2 Stanford type A dissections can result in coronary ischemia, cardiac tamponade, acute aortic regurgitation and stroke, and without surgical intervention have high mortality rates: 20% by 24 h and 40% by day seven in the general population.2 In contrast, uncomplicated Stanford type B dissections have a 30-day mortality rate of 10% and are typically managed medically in the absence of tissue ischemia or risk of aortic rupture.2 In spite of emergency treatment, aortic dissection can result in significantly increased mortality and morbidity.
The incidence of acute aortic dissection in the general population is estimated to range from 2.6 to 3.5 per 100 000 person-years, with women typically presenting at an older age compared to men (67 vs. 60 years).3, 4, 5, 6 In women younger than 40 years of age, pregnancy is associated with a significant increase in the risk for acute aortic dissection (odds ratio approximately 25). Most dissections in women of childbearing age occur during pregnancy and result in adverse maternal and fetal outcomes.7 In the general population, hypertension and atherosclerosis are important risk factors, but in pregnant women acute aortic dissections occur more commonly secondary to inherited forms of connective tissue disorders, valvular abnormalities and vascular inflammation that predisposes to aortopathy.7, 8, 9 Over the last decade, there have been significant advances in the understanding of genetic and pathogenic mechanisms leading to aortopathy and acute aortic dissection. These include enhanced transforming growth factor beta (TGF-β) signaling in Marfan syndrome (MFS) and the discovery of mutations in genes that result in Loeys–Dietz syndrome (LDS) and Familial Thoracic Aortic Aneurysms and Aortic Dissections (TAAD).10, 11, 12, 13, 14 However, the outcomes of pregnant women with acute aortic dissection have been less well studied. Given their rarity in pregnancy and the difficulties in conducting prospective studies, data on risk factors, clinical characteristics, interventions, and outcomes are largely limited to case reports and small case series. We conducted a systematic review of literature to describe the maternal and fetal outcomes in pregnant women with acute aortic dissection in the last decade.
Section snippets
Methods
We conducted a literature review to identify publications related to acute aortic dissection in pregnancy during a 10-year period between January 2003 and June 2013. The PubMed database was queried using combinations of the terms: “pregnancy” or “antepartum” or “postpartum” and “aortic dissection” or “aortic aneurysm” or “genetic disorder”. Isolated case reports, small case series, and population-based studies were included in the analyses if they met the following criteria: patients having
Results
From the 59 studies, a total of 75 patients with acute aortic dissection in pregnancy were identified. Twenty patients were nulliparous, 14 had one previous pregnancy, and 14 had a history of three or more pregnancies. Parity could not be ascertained in the remaining 27 patients. The mean ± standard deviation (SD) age of the patients was 32.5 ± 4.5 years. Most dissections occurred in the third trimester (n = 44, 58.6%) with the median gestational age at presentation of 32 weeks [interquartile range
Discussion
Pregnancy confers a significant increase in the risk of acute aortic dissection. The physiologic changes of pregnancy, with increased stroke volume, heart rate, cardiac output and left ventricular mass, significantly increase the hemodynamic stress on the aortic wall.73 Aortic compression by the gravid uterus has been hypothesized to increase the outflow resistance of the arterial tree.74 Pregnancy-induced hormonal changes have also been suggested to play a role in the increased risk. Estrogen
Disclosure
No external funding was received and the authors report no conflict of interest.
Acknowledgements
The authors are grateful to Dr Maya Suresh for critical review of the manuscript. We thank Dr Jennifer Wu for help with the initial literature search and Dr Sriram M Gubbi for the illustrations.
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