Chest Pain in Pregnancy: Part 2 Aortic Dissection
Rebecca Bavolek, MD and Mel Herbert, MD
PEARLS
- Aortic dissection in pregnancy is rare, and often accompanied by traditional risk factors such as hypertension, collagen vascular disease or bicuspid aortic valve.
- In pregnancy, Stanford Type A dissection is more common.
- The incidence increases throughout pregnancy; it is most common in the 3rd trimester and the postpartum period
- Clinical features of the presentation are no different than in non-pregnant patients.
- Diagnosis is by CT or transesophageal echocardiography (TEE).
- Management consists of heart rate and blood pressure control. Surgical consultation may also be advised depending on type of dissection.
Related Links
EM:RAP 2020 December: The Big 3: Part 1 Coronary Dissection
EM:RAP 2016 March: PE in Pregnancy
EM:RAP 2010 December: Chest Pain in Pregnancy
Kamal G., M.D. - January 22, 2021 11:02 AM
Any thought about using MRI to r/o thoracic aortic dissection in pregnancy?
Rebecca B., MD - January 26, 2021 3:54 PM
Hello! MRI is indeed a very sensitive and specific imaging modality for aortic dissection. However, I see a few potential issues with its use. First, it would depend on the stability off the patient and the relative safety of putting an unstable acute aortic dissection patient in an MRI machine potentially far away from the ED without immediate access due to the length of the test, etc. That aside, MRI for aortic dissection relies on use of gadolinium for aortic angiography to identify the dissection. Gadolinium is contraindicated in pregnancy, which precluding its use in the pregnant patient. There is not a wealth of data, but the studies on gadolinium are based on on patients who mostly had accidental exposure during pregnancy in the first trimester and looking at outcomes in those populations as compared to a cohort. However, exposure to gadolinium is associated with a range of adverse outcomes in neonates, leading to its avoidance. As you can imagine, with that, there are no randomized controlled trials that will help figure this out! There are some non-gadolinium protocols for aortic dissection but these are more specialized and less widespread in availability with less information on their specificity and sensitivity. Thank you for listening and thank you for your question! -R. Bavolek