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Two weeks ago, in the midst of spring flowers, Ms. Lin (pseudonym), 41, was safely discharged from run Run Run Shaw Hospital, affiliated with Zhejiang University School of Medicine. At present, the four-week-old baby is closely supervised by a medical staff in the neonatal care unit, and the signs are stable and thriving, and can soon be discharged from the hospital to reunite with the family.
Ms. Lin and her family are grateful to the medical staff of Zhejiang University Shaw Hospital, who have taken good care of their mother and son for nearly a month. Because, for Ms. Lin's family, the current mother and child safety and health are not easy to come by, and there are too many thrilling moments of treatment and countless emotions behind it.
Sudden severe pain at 31 weeks of pregnancy
Brother Hospitals made timely and prompt referrals
On February 27, 2022, Ms. Lin, who lives in Wuyi and is 31 weeks pregnant, suddenly developed tearing pain in her left chest without obvious inducement, which was severe and unbearable, followed by pain in her entire back, which was persistent.
Ms. Lin had a caesarean section and gave birth to a child 6 years ago, and had no chronic history of hypertension, diabetes and other chronic diseases, but had hepatic hemangioma surgery 2 years ago. During this pregnancy, Ms. Lin's psychological pressure was relatively large, and as soon as something was abnormal this time, she did not dare to delay the immediate medical treatment.
Ms. Lin was urgently sent to the emergency department of wuyi County First People's Hospital (Wuyi Branch of Zhejiang University Shaw Hospital), and after doing cardiac ultrasound, local doctors considered aortic dissection, which was extremely dangerous for pregnant women!
The First People's Hospital of Wuyi County, as a contracted branch of zhejiang university shaw hospital "shanhai improvement" project, immediately contacted Qian Ximing, director of the cardiac surgery department of run run shaw hospital, and was transferred to Zhejiang university shaw hospital for rescue through the green channel.
On the way to the hospital, Zhejiang University Shaw Hospital paid close attention to the progress of the patient's condition, and at the same time, Vice President Huang Yi immediately launched the MDT consultation with the participation of cardiac surgery, intensive care medicine, emergency department, obstetrics, anesthesiology, neonatology and other multidisciplinary participation.
After seamlessly connecting to Run Run Shaw Hospital of Zhejiang University, Ms. Lin underwent a full CT examination of the aorta, suggesting "aortic dissection Stanford Type A", which is a high-risk disease. Qian Ximing, a department of cardiac surgery at Zhejiang University Shaw Hospital, said that the survival rate of untreated A-type dissection is low, with a mortality rate of up to 50% within 48 hours and a mortality rate of nearly 90% within 3 months.
Critical condition, multidisciplinary team urgently improve preoperative preparations, at 11 o'clock that night, Zhejiang University Shaw Hospital Obstetrics Department Liang Fengbing chief physician team emergency "lower uterine caesarean section", in order to preserve the uterus, minimize Ms. Lin postpartum bleeding, during the operation bilateral uterine artery ascending branch ligation, and with uterine yarn tamponade, so that Ms. Lin smoothly through the surgical period, 48 hours after the removal of the yarn, postpartum bleeding is not much.
"Pregnancy with aortic dissection usually occurs in the third trimester or early postpartum period, and is associated with high dynamic circulatory status and high estrogen and progesterone levels in the third trimester of pregnancy, with an increase in maternal blood volume of 35% to 45% around 32 weeks of pregnancy, increasing the impact on the aortic wall, while an increase in estrogen levels damages the elastomeric fibers and collagen in the middle layer of the aortic wall, resulting in changes in the structure of the aortic wall."
In order to avoid the extracorporeal circulation affecting the blood supply of the placenta in cardiac macrovascular surgery, considering that the elderly pregnant woman has been 31 weeks pregnant, the fetus is basically mature, and the caesarean section is performed first, and the series of operations such as bilateral ascending branch ligation of the uterine artery during the operation also makes a successful attempt to treat such women and preserve the uterus. Liang Fengbing said.
Newborns with a birth weight of 1900g and a score of 6 to 8 points were transported to the neonatal intensive care unit in time, and the monitoring and treatment of premature babies was seamlessly coordinated by Jiang Zhou's team.
Multidisciplinary teams are intertwined
Make every effort to ensure the safety of mothers and children
Ms. Lin was placed in the Intensive Care Unit (ICU) for close monitoring. At the same time, the multidisciplinary team improved the preoperative preparation for major surgery of cardiac macrovascular aortic dissection.
The next morning, The team of chief physician Qian Ximing of the Department of Cardiac Surgery of Zhejiang University Shaw Hospital performed aortic dissection surgery under cardiopulmonary bypass for Ms. Lin, replacing the patient's torn aortic dissection blood vessel with artificial blood vessels, and after 5 hours, the difficult and high-risk pregnancy combined aortic dissection surgery finally came to a perfect end.
Director Qian Ximing introduced that this high-risk pregnant aortic dissection patient, the onset of emergency, critical condition, during the operation found that the blood vessel wall has been as thin as a cicada wing, there is a risk of rupture and bleeding at any time, the timing of surgery after careful discussion and decision-making by multidisciplinary expert groups, can be described as very timely.
"Patients can be discharged from the hospital thanks to the joint efforts of cardiac surgery, obstetrics and gynecology, intensive care medicine, anesthesiology, neonatology and other departments." Director Qian Ximing said.
The successful treatment of the case made Pan Konghan, chief physician of the Department of Critical Care Medicine of Zhejiang University Shaw Hospital, very emotional, he pointed out that the patient can be treated immediately after the onset of illness, Wuyi Branch clear treatment, take effective early initial treatment and immediately transfer to Zhejiang University Shaw Hospital for further rescue treatment, Zhejiang University Shaw Hospital Intensive Care Department with rich experience in managing acute and critically ill patients, give full play to the advantages of multidisciplinary treatment mode, interlocking, and ultimately ensure the safety of mother and child.
Aortic dissection should not be underestimated
Preventable and treatable to improve disease awareness
Chief Physician Pan Konghan introduced that the acute aortic dissection is dangerous, and the occurrence of aortic dissection during pregnancy seriously threatens the life safety of the mother and fetus, and timely detection and efficient treatment are particularly critical.
It is reported that aortic dissection is a variety of reasons that cause the aortic intima and the middle layer to tear. Blood enters the middle from the incision of the intimal tear and continues to tear and expand along the aorta towards the distal and/or proximal end, resulting in a state of peeling off the aortic lining and the middle layer, and dividing into true and false chambers.
Aortic dissection can involve important organs such as the heart, brain, lungs, kidneys, intestines, and limbs, and lead to organ/tissue ischemia and secondary dysfunction. Fatal complications include acute cardiac tamponade, acute myocardial infarction (coronary artery involvement), stroke (cerebrovascular occlusion), shock, and sudden death. Common complications include respiratory failure, acute kidney injury, and acute heart failure (aortic valve involvement).
The onset of the disease is abrupt, rapid in progression, with many complications and a very high case fatality rate. The Stanford typing that determines the mode of treatment is based on where the dissection originates, and is called Stanford A in anyone involved in the ascending aorta; all aortic dissections that do not involve the ascending aorta are called Stanford B. Untreated type A dissection has a lower survival rate.
Pregnancy with aortic dissection is a double catastrophic disease for pregnant women. According to literature reports, the proportion of aortic dissection that occurs in the early, middle and third trimesters of pregnancy is 4%, 18% and 78% respectively, of which about 50% is Marfan syndrome. Its prognosis and treatment are closely related to the Stanford typing. Aortic dissection is the most common type of pregnancy-related aortic dissection, accounting for 50% to 89%, requiring emergency surgical treatment, poor prognosis, B aortic dissection accounts for 11% to 21%, can be treated surgically or drug-based, the prognosis is better than A type A.
Wang Yonggang, deputy chief physician of the ICU of Zhejiang University Shaw Hospital, said that some aortic dissections can be prevented and treated, and early diagnosis and treatment can improve prognosis, so the public should improve the awareness of acute and critical cardiac large blood vessel diseases such as aortic dissection, take preventive measures early, and identify the disease as soon as possible, which can improve treatment efficiency and improve results.
The most prominent symptom of aortic dissection is acute chest and back pain, which is often described as a "tear-like" or "knife-like" pain that is persistent and unbearable. Stanford A dissection often presents with anterior chest or back pain, and Stanford B dissection often presents with low back pain or abdominal pain, but the two pain sites may be crossed.
The clinical manifestations of acute aortic dissection depend on the scope and extent of cardiovascular involvement, and vary due to different organs affected and the severity of ischemia, and manifestations similar to acute cerebral infarction, myocardial infarction, and acute abdomen may occur. Limb blood pressure asymmetry is often present, the left and right blood pressure differences are large, pulse pressure difference > 20 mmHg, pulse loss or weakening with limb weakness should be particularly vigilant for aortic dissection. Therefore, when aortic dissection is clinically suspected, the blood pressure of the extremities should be routinely measured.
Source: Orange Persimmon Interactive
Compiled by the comprehensive editor of Run Run Shaw Hospital
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