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Nearly Missed: Postpartum Type B Aortic Dissection

Presentation

A new mother was evaluated 3 times over 2 weeks before the aortic tear responsible for her symptoms was identified. The patient, a 37-year-old woman who had been previously healthy, was 1 week postpartum when she presented to the emergency department with chest pain, shortness of breath, and lower extremity swelling. She was discharged after a negative work-up for pulmonary embolism and postpartum cardiomyopathy. One week later, she returned with sudden onset of sharp, “knife-like” flank pain radiating up her back. This was accompanied by chest pain and a severe headache. A review of systems was otherwise negative. Her family history was significant for Loeys-Dietz syndrome in a distant relative, but it was negative for myocardial infarction in first-degree relatives.

 

Assessment

During the patient’s initial presentation, her vital signs were normal, and the physical examination showed mild pitting edema. Computed tomography angiography (CTA) for pulmonary embolism was negative. A transthoracic echocardiogram (TTE) showed an ejection fraction of 65% without regional wall motion abnormalities. Subsequently, she was discharged home with a diuretic.

At her second visit to the emergency department, the patient’s vital signs were as follows: blood pressure, 186/108 mmHg; heart rate, 68 beats per minute; temperature, 98.2°F (36.8°C), and respiratory rate, 14 breaths per minute. Her oxygen saturation was 98% on room air. Cardiopulmonary and abdominal examinations were normal. Peripheral pulses were palpable and symmetric. Laboratory data, urinalysis, and electrocardiogram were unremarkable. CT without contrast of the abdomen and pelvis failed to reveal acute pathology.

Preeclampsia was suspected at this point, and the patient received magnesium sulfate in the emergency department and an antihypertensive regimen. She was discharged home with a plan to obtain an outpatient TTE. One week later, she underwent the imaging, which was concerning for aortic dissection. CTA confirmed a type B aortic dissection without malperfusion. The dissection extended from the origin of the left subclavian artery to below the right common femoral artery.

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–Monica Ahluwalia, MD, Michael S. Parmacek, MD, Farzana A. Sayani, MD, Prashanth Vallabhajosyula, MD

This article originally appeared in the November 2015 issue of The American Journal of Medicine.

 

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