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• Poor index of suspicion as a major hinderance to optimum management
  oscar,m jolobe
  Published on: 28 November 2022

• Published on: 28 November 2022

  Poor index of suspicion as a major hinderance to optimum management

  • oscar,m jolobe, retired geriatrician British Medical Association

  In the event of the occurrence of aortic dissection as a complication of aortopathy in pregnancy a low index of suspicion for aortic dissection can be a major hinderance to correct diagnosis. Suboptimal diagnostic awareness is attributable to the fact that, clinicians confronted with the crisis of "collapse in a pregnant woman" , are likely to prioritise recognition of PE over recognition of dissecting aortic aneurysm(DAA) , given the fact that PE is the leading cause of maternal mortality in the developed world[1]. This cognitive bias is most likely to operate when symptoms of DAA overlap with symptoms of PE.
  For example, when a woman at 37 weeks gestation presented with the association of chest pain, breathlessness and raised D-dimer levels, the referral for computed tomography angiography(CTA) was prompted by the intention "to evaluate for pulmonary embolism". In the event CTA disclosed the presence of DAA[2].
  Women with undifferentiated the "collapse" in pregnancy" syndrome are best served by a multidimensional evaluation which includes a differential diagnosis with a minimum of 3 parameters, namely, PE, acute myocardial infarction, and DAA[3]. The workings of that diagnostic approach were exemplified in a woman who presented at 28 weeks gestation with breathlessness, throat pain, and syncope . In view of elevated D-dimer and T wave inversion in lead III "there was concern for a pulmonary embolism....as t...

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  In the event of the occurrence of aortic dissection as a complication of aortopathy in pregnancy a low index of suspicion for aortic dissection can be a major hinderance to correct diagnosis. Suboptimal diagnostic awareness is attributable to the fact that, clinicians confronted with the crisis of "collapse in a pregnant woman" , are likely to prioritise recognition of PE over recognition of dissecting aortic aneurysm(DAA) , given the fact that PE is the leading cause of maternal mortality in the developed world[1]. This cognitive bias is most likely to operate when symptoms of DAA overlap with symptoms of PE.
  For example, when a woman at 37 weeks gestation presented with the association of chest pain, breathlessness and raised D-dimer levels, the referral for computed tomography angiography(CTA) was prompted by the intention "to evaluate for pulmonary embolism". In the event CTA disclosed the presence of DAA[2].
  Women with undifferentiated the "collapse" in pregnancy" syndrome are best served by a multidimensional evaluation which includes a differential diagnosis with a minimum of 3 parameters, namely, PE, acute myocardial infarction, and DAA[3]. The workings of that diagnostic approach were exemplified in a woman who presented at 28 weeks gestation with breathlessness, throat pain, and syncope . In view of elevated D-dimer and T wave inversion in lead III "there was concern for a pulmonary embolism....as the etiology for her presentation". CTA showed an ascending thoracic aortic aneurysm, moderate pericardial effusion but neither aortic dissection nor PE. Nevertheless , due to concern for a concealed dissection, surgical exploration was undertaken. This disclosed significant haemopericardium and a 1 cm ascending thoracic aortic rupture tamponaded by the pulmonary artery[4].
  Diligent evaluation of family history and genetic testing both powerfully augment the index of suspicion , as was the case in a patient whose father experienced DAA at the age of 20 , and had tested positive for a variant of the MYH11 gene. During pregnancy the patient , herself, tested positive for the same variant of the MYH11 gene. She was placed on metoprolol during pregnancy and post partum. Three days post partum she presented with pleuritic pain radiating through to the back, and new diastolic murmur was elicited.. Both transthoracic echocardiography and cardiac computed tomography disclosed the presence of DAA. Aortic repair was successfully undertaken[5].
  I have no conflict of interest
  References
  [1]Bourjeily G., Paidas M., Khalil H., Rosene Montella K., Rodger M
  Pulmonary embolism in pregnancy
  Lancet 2020;375:500-512
  [2]Braverman AC
  Acute aortic dissection
  Circulation 2010;122:184-188
  [3[ Lombaard H., Soma-Pillay P., Farrell E-M
  Managing acute collapse in pregnant women
  Best Practice & Research Clinical Obstetrics and Gynaecology 2009;23:339-355
  [4]Bogaert K., Christensen K., Cagliostro M., Ferrara L
  Contained aortic rupture in a term pregnant woman during COVID-19 pandemic
  BMJ Case Reports 2020;13:e238370
  [5]Sathananthan G., Rychel V., Yam J., Barlow A., Grewal J., Kiess M
  A postpartum Type A dissection
  JACC Case Reports 2020;2;150-153

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  Conflict of Interest:
  None declared.

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