Back Pain Concealing a Life-Threatening Normotensive Aortic Dissection in a Pregnant Lady

The absence of hypertension should not be considered sufficient to rule out aortic dissection. In fact, clinical characteristics such as the type, intensity, and sudden onset of symptoms often yield greater diagnostic insight than isolated blood pressure values. During pregnancy, normal physiological adaptations can mask or mimic critical conditions like aortic dissection, further complicating timely diagnosis. This case report illustrates that principle through the presentation of a 32-year-old woman, gravida 2 para 1, at 28 weeks of gestation, who arrived at the emergency department with acute interscapular back pain of three hours’ duration. She subsequently developed intermittent hypotension, prompting advanced imaging with chest radiography, transesophageal echocardiography, and magnetic resonance aortography, which collectively confirmed the diagnosis of a Stanford type A aortic dissection associated with pregnancy. The patient underwent emergent surgical repair with favorable maternal and fetal outcomes, and a long-term surveillance plan was established. The case underscores ongoing uncertainties in the literature regarding optimal clinical strategies during the "gray zone" of gestational age—specifically between 28 and 32 weeks—where standardized guidance is lacking.