Treatment process
All five patients received β-blockers to control blood pressure (≤120/80 mm Hg) and heart rate (<70 beats/min). Drugs for pain relief and sedation were also given. Other supporting treatments were applied according to the patients’ condition. All the patients received aortic repair and cesarean section following the above essential medicine treatment. The operative data for the five patients is shown in Table 2.
Based on the recommendation of Chinese experts’ consensus of standardized diagnosis and treatment for aortic dissection9, the first patient with a gestational age of over 32 weeks, suffering from preeclampsia, underwent a cesarean section under combined spinal and epidural anesthesia first. However, she experienced a rapid elevation of blood pressure within minutes after delivery of the fetus, leading to rupture of dissection. Although a thoracotomy was performed, the patient died due to hemorrhagic shock. The newborn of this patient had no asphyxia. Based on the lessons learned from case one, the subsequent four cases underwent TEVAR first, followed by a cesarean section under general anesthesia for better control of blood pressure. Case two completed the TEVAR and cesarean section without any adverse effects on the mother or fetal outcomes. The third case chose to continue the pregnancy after TEVAR since her gestational age was only 27 weeks plus three days. The status of the mother and fetus was closely monitored by obstetricians and surgeons. However, she presented with back pain at 30 gestational weeks, and her CTA showed strip-like leakage of contrast agent into the false lumen. A cesarean section was performed at 31 weeks plus five gestational weeks following fetal lung maturation-promoting therapy. Her newborn infant had mild asphyxia (Apgar score of 7 at 1 min) but recovered well after primary resuscitation initiated immediately after delivery. The fourth case had severe preeclampsia and fetal distress before surgery. The mother experienced a rupture of the right iliac artery during the pushing stent-graft delivery system, and the bleeding was stopped by compressing temporarily. She underwent a cesarean section and femoral iliac artery artificial vascular replacement. The newborn of case four had a 1-min Apgar score of 5 and a 5-min Apgar score of 2, and the rescue was given up eventually. With the same procedure as that of the above patient case, the fifth case also underwent TEVAR and subsequent cesarean section. The 1-min Apgar score was 5 and the 5-min Apgar score was 7 for her newborn. Unfortunately, she developed TAAD three days later. Then, she received total aortic arch artificial vascular replacement and stent elephant trunk surgery (Sun’s Surgery) plus aortic valve and ascending aortic replacement and coronary transplantation (Bentall Surgery).
Four preterm live births were recorded. Neonatal death occurred in case four at a gestational age of 29 weeks plus five days, and the pregnancy was complicated by fetal distress before surgery. Neonate one and two had a gestational age exceeding 36 weeks, and Apgar scores at birth were 8 at 1 min and 9 at 5 min. Neonate three and five had a gestational age of 31 weeks and a birthweight of around 1700g. These two neonates experienced transient mild asphyxia but were discharged without any complications. During the follow-up period, routine physical examinations of four live births showed no abnormalities. Their thyroid function was within normal range on the 14th day after delivery.