Emergency surgical management of acute Stanford type A aortic dissection in a primigravida at 29 weeks gestation

RATIONALE: Acute aortic dissection during the 3rd trimester of pregnancy is a catastrophic cardiovascular emergency. The management is complex, requiring a multidisciplinary strategy to balance the competing risks of aortic rupture and fetal prematurity, as well as the conflict between surgical anticoagulation and postpartum hemorrhage. PATIENT CONCERNS: We report a case of a 34-year-old primigravida (29 weeks and 3 days of gestation) presenting with sudden, severe chest and back pain lasting over 7 hours following physical exertion. She had a history of developmental dysplasia of the left hip and thalassemia. DIAGNOSES: Computed tomography angiography confirmed acute Stanford type A aortic dissection involving the ascending aorta and aortic arch branches and extending to the bilateral common iliac arteries, with severe true-lumen compression. INTERVENTIONS: Given the life-threatening nature of the dissection and fetal viability, a multidisciplinary team performed an emergency coordinated sequential combined procedure. Cesarean delivery was undertaken 1st. Because of initial uterine atony and the requirement for subsequent full systemic heparinization for cardiopulmonary bypass, a Bakri intrauterine balloon was inserted to secure uterine hemostasis. After abdominal closure, the patient underwent aortic valve commissural resuspension, total arch replacement, and frozen elephant trunk implantation. OUTCOMES: A viable preterm female infant weighing 1320 g was delivered and survived to neonatal intensive care unit discharge after respiratory support. Maternal uterine hemostasis was maintained during systemic heparinization, with estimated surgical blood loss of approximately 600 mL. Despite the patient's underlying thalassemia, no allogeneic red blood cell transfusion was required; transfusion was limited to 1 therapeutic unit of irradiated apheresis platelets. The mother recovered without neurological deficits. LESSONS: This case illustrates a coordinated cesarean-delivery-followed-by-aortic-repair strategy that avoided fetal exposure to cardiopulmonary bypass. Bakri balloon tamponade provided an organ-sparing means of securing uterine hemostasis before systemic heparinization. In young patients with thoracic aortic disease and possible syndromic features, structured genetic evaluation and family surveillance may be considered when feasible.