The differential diagnosis of pre-eclampsia should include the association of severe hypertension and aortic dissection

Editor – When severe hypertension in pregnancy is defined as a sustained systolic blood pressure of ≥160 mmHg or a diastolic blood pressure of ≥110 mmHg, related disorders that should be considered include not only pre-eclampsia but also dissecting aortic aneurysm (DAA), a disorder sometimes misdiagnosed as pre-eclampsia when it presents with hypertension.^1,2

In one report, a 29-year-old primigravida woman presented at 37 weeks gestation with a blood pressure of 160/110 mmHg and a 24-hour urinary protein of 2,462 mg. She was given a diagnosis of severe eclampsia.² She received antihypertensive treatment and her baby was delivered by caesarean section. Six days later, she experienced severe back pain radiating to the chest, her blood pressure on that occasion was 190/100 mmHg. She was initially diagnosed with postpartum eclampsia in spite of persisting severe back pain and chest pain. Subsequent computed tomography with angiography showed type B aortic dissection. As a result of appropriate operative intervention, she made a complete recovery.

The association of severe hypertension and pregnancy-related DAA can also occur in the context of conventional risk factors for DAA (such as Marfan's syndrome), exemplified by a 24-year-old woman with clinical stigmata of Marfan's syndrome and a blood pressure of 174/110 mmHg during pregnancy.³ She had a fatal DAA postpartum.

Key points

• The differential diagnosis of pre-eclampsia should include DAA whenever symptoms of DAA occur in a patient with a provisional diagnosis of pre-eclampsia. This differential diagnosis should prevail during pregnancy and also during the puerperium.

• A pregnant woman with severe hypertension should also be evaluated for stigmata of Marfan's syndrome and for stigmata of coarctation of the aorta.