A 32-year-old woman, gravida 1 para 0, at 32 weeks gestation is brought to the emergency department due to anterior chest and neck pain that began 3 hours ago. The pain was severe at onset but has decreased to moderate discomfort. She also has had mild nausea and epigastric discomfort. After the onset of the chest pain, the patient experienced tingling and weakness of her right arm accompanied by blurry vision and headache that lasted approximately 20-30 minutes. She has had a healthy pregnancy except for development of gestational diabetes mellitus at 24 weeks gestation. The patient's blood pressure was elevated during her last prenatal visit, and she was started on an antihypertensive medication. She has no other significant medical history. She does not use tobacco, alcohol, or illicit drugs.
On physical examination, the patient appears comfortable. Blood pressure is 176/104 mm Hg in the right arm and 180/99 mm Hg in the left arm, and pulse is 96/min. Oxygen saturation is 94% on room air. Her right pupil measures 4 mm and her left pupil measures 2 mm. There is slight ptosis on the left side. Lung fields are clear to auscultation with equal air entry on both sides. Cardiac examination reveals regular heart sounds with normal S1 and S2. The neurologic examination is otherwise unremarkable. Peripheral pulses are equal in all extremities. There is 2+ pitting peripheral edema of both lower extremities with some engorged varicose veins. There are normal deep tendon reflexes without clonus.
ECG shows sinus rhythm and a 1-mm downsloping ST-segment depression in leads aVL, V5, and V6. Urinalysis shows 1+ ketones, no protein, and no glucose.
Which of the following is the best next step in management of this patient?

Question

A 32-year-old woman, gravida 1 para 0, at 32 weeks gestation is brought to the emergency department due to anterior chest and neck pain that began 3 hours ago.  The pain was severe at onset but has decreased to moderate discomfort.  She also has had mild nausea and epigastric discomfort.  After the onset of the chest pain, the patient experienced tingling and weakness of her right arm accompanied by blurry vision and headache that lasted approximately 20-30 minutes.  She has had a healthy pregnancy except for development of gestational diabetes mellitus at 24 weeks gestation.  The patient's blood pressure was elevated during her last prenatal visit, and she was started on an antihypertensive medication.  She has no other significant medical history.  She does not use tobacco, alcohol, or illicit drugs.
On physical examination, the patient appears comfortable.  Blood pressure is 176/104 mm Hg in the right arm and 180/99 mm Hg in the left arm, and pulse is 96/min.  Oxygen saturation is 94% on room air.  Her right pupil measures 4 mm and her left pupil measures 2 mm.  There is slight ptosis on the left side.  Lung fields are clear to auscultation with equal air entry on both sides.  Cardiac examination reveals regular heart sounds with normal S1 and S2.  The neurologic examination is otherwise unremarkable.  Peripheral pulses are equal in all extremities.  There is 2+ pitting peripheral edema of both lower extremities with some engorged varicose veins.  There are normal deep tendon reflexes without clonus.
ECG shows sinus rhythm and a 1-mm downsloping ST-segment depression in leads aVL, V5, and V6.  Urinalysis shows 1+ ketones, no protein, and no glucose.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_95c3_b08f_853d_c133f9feaa1f_MD0002_00 This pregnant patient with hypertension, chest pain, and Horner syndrome likely has a peripartum acute aortic dissection. Spontaneous dissection of the aorta and coronary arteries can occur in pregnancy, most commonly in the third trimester, due to the hyperdynamic state and hormonal effect on vasculature. Horner symptoms, (anisocoria, ptosis) are due to the dissection extending into the internal carotid artery and externally compressing the left superior cervical sympathetic ganglion. Patients may also present with vocal cord paralysis due to compression of the left recurrent laryngeal nerve. Pulse deficits are classic, but they are seen in <30% of patients and are less common in women. Multiple imaging modalities may be used for diagnosis of aortic dissection, with the choice of study dependent on the patient and imaging availability. CT angiography is most commonly used due to its widespread availability in emergency departments and rapidity; however, if possible, CT scans should be avoided during pregnancy due to radiation exposure to the fetus.Transesophageal echocardiography can be performed quickly by a cardiologist in the emergency department and avoids radiation exposure. Transthoracic echocardiography is a less sensitive and specific alternate because it may fail to adequately assess large portions of the aorta, particularly in pregnant women.MR angiography is generally a slower modality but avoids radiation and does not require iodinated contrast. CT angiography is most commonly used due to its widespread availability in emergency departments and rapidity; however, if possible, CT scans should be avoided during pregnancy due to radiation exposure to the fetus. CT angiography is most commonly used due to its widespread availability in emergency departments and rapidity; however, if possible, CT scans should be avoided during pregnancy due to radiation exposure to the fetus. Transesophageal echocardiography can be performed quickly by a cardiologist in the emergency department and avoids radiation exposure. Transthoracic echocardiography is a less sensitive and specific alternate because it may fail to adequately assess large portions of the aorta, particularly in pregnant women. Transesophageal echocardiography can be performed quickly by a cardiologist in the emergency department and avoids radiation exposure. Transthoracic echocardiography is a less sensitive and specific alternate because it may fail to adequately assess large portions of the aorta, particularly in pregnant women. MR angiography is generally a slower modality but avoids radiation and does not require iodinated contrast. MR angiography is generally a slower modality but avoids radiation and does not require iodinated contrast. (Choice A) Cardiac catheterization is usually indicated for acute coronary syndrome (ACS), which may present as acute-onset chest pain. However, this patient's age, sex, and nonspecific ECG findings make ACS very unlikely. (Choice B) Magnesium is used for seizure prevention in preeclampsia, which presents with hypertension and may cause edema, visual disturbances, abdominal pain, and headaches. However, the presence of Horner syndrome (ptosis, anisocoria) and the absences of proteinuria and, in particular, of hyperreflexia make aortic dissection more likely than preeclampsia. (Choice C) Nitroprusside use is contraindicated in pregnancy due to possible risk of fetal cyanide poisoning. In patients with suspected aortic dissection, beta blockers are first-line agents for blood pressure control. Nitroprusside can be added if goal systolic blood pressure (eg, 100-120 mm Hg) is not achieved; however, its use alone can cause reflex sympathetic stimulation, leading to increased left ventricular contractility and aortic wall shear stress with potential risk of propagation of aortic dissection. (Choice D) MRI of the head is used to evaluate for an acute stroke, which could cause Horner syndrome but would not be expected to cause chest or abdominal pain. Educational objective: Although aortic dissections are classically associated with tearing chest pain and blood pressure variation, a minority of patients can present with subtle clinical findings, including faint diastolic murmur of aortic regurgitation, waxing and waning neurologic deficits, Horner syndrome, or vocal cord paralysis. Transesophageal echocardiogram, MR angiography, or CT angiography may be used to establish diagnosis. __________ References: Acute aortic dissection in third trimester pregnancy without risk factors. (http://www.ncbi.nlm.nih.gov/pubmed/22224164)

A 32-Year-Old Woman, Gravida 1 Para 0, at 32 Weeks