Spontaneous rupture of acute ascending aortic dissection in a young pregnant woman: A sudden unexpected death

Pregnancy-associated aortopathy and sudden postpartum death

A 39-year-old woman who had undergone an uncomplicated elective cesarean section for a low-lying placenta collapsed and died the following day. At autopsy, there was dissection of an aneurysmally-dilated thoracic aorta with 400 mls of fluid and clotted blood in the pericardial sac. There were no features of Marfan syndrome or other connective tissue disorders. Histology revealed thinning of the aortic wall with fragmentation of elastic fibers and no inflammation. Vessels elsewhere were normal. This case demonstrates a rare complication of pregnancy that may not present until after delivery with unexpected collapse and sudden death. Predisposing factors include an increased cardiac output, reduction in systemic vascular resistance, an increase in left ventricular muscle mass, and alterations in serum progesterone and estrogen levels which may cause structural changes to the aortic wall. The possibility of syndromic and familial connective tissue disorders should also be considered.

Sudden death of a post-partum female with anomalous origin of the coronary artery with bicuspid aortic valve

Modern techniques have enabled routine diagnosis of congenital cardiac defects, notwithstanding, there will be some that remain undiagnosed and asymptomatic until adulthood. But this is rarely the case with the patent foramen ovale, with the anomalous aortic origin of the left main coronary artery and bicuspid aortic valve. This case describes the sudden death of a female in her post-partum period due to cardiac tamponade following a ruptured aneurysm of the coronary artery at its origin at the sinus of Valsalva. Autopsy shows patent foramen ovale findings and anomalous aortic origin of coronary artery (AAOCA) and bicuspid aortic valve. The association of AAOCA with bicuspid aortic valve and patent foramen ovale is rare.

Aortic dissection during pregnancy and postpartum

BACKGROUND

Patients with aortic dissection during pregnancy and postpartum period exhibit a high mortality. At present, a complete overview of aortic dissection during pregnancy and postpartum period is lacking. ​Methods: This systematic review included 80 reports published from 2000 to 2020, comprising a total study population of 103 patients with aortic dissection. ​Results: We found that Stanford Type A aortic dissection was more common in prepartum cases, especially in the third trimester, while postpartum cases of aortic dissection were more common in Stanford Type B. The most common risk factor was connective tissue disease, with no other known risk factors. The mode of delivery had no significant effect on the type of postpartum aortic dissection. Reduced maternal and fetal mortality was observed when patients with Stanford Type A aortic dissection occurring after 28 gestational weeks underwent cesarean section followed by aortic replacement. Patients with Stanford Type B aortic dissection were treated mainly with medication and/or endovascular repair. ​Conclusion: Contemporary management of patients during pregnancy and within 12 weeks postpartum requires multidisciplinary cooperation and includes serial, noninvasive imaging, biomarker testing, and genetic risk profiling for aortopathy. Early diagnosis and accurate treatment are essential to reduce maternal and fetal mortality.

Sudden Death Due to Thoracic Aortic Dissection in Young People: A Multicenter Forensic Study

INTRODUCTION AND OBJECTIVES

Thoracic aortic dissection (TAD) is infrequent in young people and its characteristics differ from those in the adult population. This study aimed to analyze the clinical and pathological characteristics of sudden death due to TAD in people aged 1 to 35 years.

METHODS

Multicenter population-based study based on forensic autopsies conducted in the provinces of Biscay (1991-2016), Valencia (2000-2016), and Seville (2004-2016).

RESULTS

We identified 35 individuals with sudden death due to TAD (80% males), with a mean age of 29±5 years. The incidence was 0.09/100 000 inhabitants/y. Eighteen persons had at least 1 risk factor for TAD, and this figure increased to 29 when postmortem findings were included: congenital heart disease (n=16), suspicion of familial TAD (n=11), cocaine use (n=6), and hypertension (n=5). Twenty-four individuals, 12 with at least 1 risk factor, had prodromal symptoms, and 16 of them visited their physician, but TAD was not suspected in any of them. The most frequent symptom was chest pain (n=12). The main autopsy findings were cystic degeneration of the media (n=27), dilatation of the ascending aorta (n=21), cardiac hypertrophy (n=20), and bicuspid aortic valve (n=14).

CONCLUSIONS

The incidence of sudden death due to TAD in young people was very low. The most frequent risk factors were congenital heart disease followed by suspicion of familial TAD and cocaine use. TAD should be included in the differential diagnosis of chest pain in young people, mainly male patients with at least 1 risk factor.

Pregnancy-related acute aortic dissection in Marfan syndrome: A review of the literature

A well-established association exists between acute aortic dissection and pregnancy, particularly in women with Marfan syndrome. However, there is debate regarding appropriate management guidelines. In particular, there are differing opinions regarding when prophylactic aortic root repair should be recommended as well as the efficacy of beta blockers in this clinical scenario. The current study evaluated 10 years of published literature (2005-2015) in the PubMed/Medline database. Fifty articles, describing 72 cases of women who presented with aortic dissection in the antepartum or postpartum period were identified. Comparisons on demographic variables and clinical outcomes between cases of women with Marfan syndrome (n = 36) and without Marfan syndrome (n = 36) were conducted. There were no significant differences in demographics (age, gravidity, parity) between the Marfan and non-Marfan cases. Marfan patients presented with antepartum dissections significantly earlier in pregnancy than those without Marfan syndrome (P = .002). However, there were no significant difference between the 2 groups in maternal mortality, fetal mortality, or obstetric outcomes (mode of delivery and gestational age at delivery). Eight cases described events in Marfan women with an aortic root diameter ≤40 mm. Six events occurred in Marfan women who were managed with beta blockers. Current guidelines rely on aortic root diameter for stratification of Marfan women into risk categories, but we identified several cases that would be missed by these guidelines. Specifically, the existing literature suggest that women with Marfan syndrome should take precautions throughout pregnancy, rather than the third trimester.

Massive Hemothorax Occurring with Intramural Hematoma of the Descending Aorta in the Early Postpartum Period

Postpartum aortic intramural hematoma (IMH) is a rare but potentially lethal condition. We report a case of aortic IMH with massive hemothorax in a postpartum woman. The patient was a 31-year-old woman who had delivered twins by cesarean section. Two days after delivery, she complained of sudden-onset dyspnea. Chest computed tomography revealed a massive left hemothorax. Exploratory thoracotomy was performed, and we found a defect measuring approximately 6 mm in the adventitial layer of the thoracic aorta and an IMH. We repaired the defect primarily, and no more bleeding was observed. The patient was discharged on the 19th postoperative day without any complications.