Dissection of a Complicated Pregnancy

Aortic dissection in pregnancy is a rare, although not unheard of, complication.

     "Medic One…..respond to a woman in labor. Reporting party states the patient is having trouble breathing." En route, you go over in your mind the procedure for problem deliveries. It was only two months ago that you assisted a mother in delivering a healthy baby girl at home, so the procedure is fresh in your mind. The night air is crisp, and the slight draft through your partially open window serves only to stimulate you in the early morning hours. Your EMT partner seems much calmer, most likely because he knows you'll be "in charge."

     On arrival, you make your way into the bedroom to find an obviously pregnant 21-year-old female lying on the bed writhing in pain and hyperventilating. She tells you that she woke up with pain in her back and it is steadily getting worse. You continue with your history-taking while assisting the patient onto your cot. As you peel back the covers to assist her, you notice a fluid stain in the middle of the bed. She tells you that at the height of pain, her water broke. Her husband verifies that his wife is 39 weeks along and the baby is due in "about a week." It's apparent that the baby is threatening to make an early appearance.

     As you assist her from the bed to the cot, she says she can't feel her legs. "They're just numb," she reports. You prepare to start an IV, which is made more difficult due to her constant movement. Your partner applies oxygen. When you ask the patient if she has the urge to push, she replies, "No, but my back is killing me!"

     "This woman is going to deliver the baby right here if we don't scoot to the hospital," you whisper to your partner. After a quick check for crowning, you load her into the ambulance. En route, she continues to complain of severe back pain.

     You attempt to time the pains so you can give the hospital some information about the frequency of contractions; however, there seems to be no consistency to the duration of the pains.

     On arrival at the hospital, you make your way to Labor & Delivery. The patient tells you she can't move her legs now, and she needs more help than usual moving onto the bed. You recite a quick report to the managing nurse, collect your equipment and head back up to the ambulance bay. You remember thinking, "A routine OB call." But days later, while talking with your medical director, you find out that the "routine" call turned out to be a pathophysiologic nightmare.

     The obstetrician assessed the patient to be in active labor with poor progression. The amniotic sac had ruptured and, due to the patient's severe pain, an emergency C-section was done. The obstetrician noted that the patient was complaining of difficulty moving and feeling her legs, but thought it might be due to fetal pressure on the lumbar nerves that supply the lower extremities. The C-section was "textbook" and an 8 lb., 3 oz. healthy-appearing infant was delivered.

     As the mother woke up from general anesthetic, she continued to writhe. The obstetrician noted that only her upper body was moving; no spontaneous movement was seen from her waist down. After a neurologic consultation and an emergent MRI, the worst was confirmed: The patient had an aortic dissection extending from the aortic valve to mid-abdomen. Emergency surgery was performed, leaving the patient with a new aortic valve and a Dacron graft to replace her ascending and a portion of descending aorta. The patient continued to recover in the CVICU.

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