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.