Pregnancy Outcomes in Women with Peripartum Aortic Dissection

The aim of this study was to define the clinical characteristics and outcomes in a cohort of patients with peripartum aortic dissection (AD). We retrospectively reviewed clinical characteristics, operative data, in-hospital outcomes, and survival up to 20-years for patients with history of peripartum AD. Peripartum AD included pregnancy-associated AD and 12 months post-partum AD. Fifty patients with history of peripartum AD at median age of 33 years (interquartile range [IQR], 29-37 years) were included. Thirty-four presented with type A dissections (TAAD) (68%; median age, 34 years [IQR, 29-37 years]), and 16 presented with type B dissection (TBAD) (32%; median age, 33 years [IQR, 31-34 years]). Thirty (60%) were multiparous at the time of pregnancy-associated AD (median, 2 deliveries), and 16 had never been pregnant. Twenty-four dissections (48%) occurred during pregnancy (n = 24); third trimester (n = 18), second (n = 2), and first (n = 1); the timing was unknown in three antepartum cases. Twenty-six dissections (52%) occurred postpartum at median 1.4 weeks (IQR, 1-2.6 weeks) after delivery. Five (10%) had known aortic root or ascending aortic dilatation before pregnancy, and two of these previously underwent aortic repair. In those with TAAD, aortic-diameter prior or at-time of AD was available for 18 patients, median root diameter was 40 mm (IQR, 40-49 mm) and the median ascending diameter was 45 mm (IQR, 37-55 mm), at time of dissection. Twenty-five women (50%) had a family history of thoracic aortic disease; four were diagnosed with a heritable thoracic aortic disease (HTAD) before their peripartum AD. Twenty-six (52%) were confirmed by genetic testing to have HTAD after their peripartum aortic event. Cumulative incidence of maternal mortality associated with all peripartum AD was 20% (95% confidence interval [CI], 11-34) at 30 days and 29% (95% CI, 16- 48) at 15 years (Fig 1), with a median 6-year follow-up period. There was a total of three confirmed fetal losses in the cohort. Thirty patients with TAAD and seven with TBAD underwent open repair, and three TBAD cases had endovascular intervention. Most patients (n = 25) delivered before their aortic repair, and 12 required aortic reintervention. The cumulative incidence of survival was 88% at 30 days for the 40 patients who underwent surgical intervention to treat their pregnancy-associated aortic event. The majority of patients with peripartum AD have TAAD; they present in the third trimester or postpartum period; and 50% of them had a family history of thoracic aortic disease. Early identification of this high-risk population allows for increased surveillance and intensive medical management to prevent dissection-related deaths, particularly in the third trimester and postpartum period.