Infarto agudo de miocardio y gestación

Acute myocardial infarction is rare in women of reproductive age and consequently is uncommon during pregnancy. However, when this event does occur, the risk of maternal-fetal mortality is greatly increased, since, in addition to the risk posed by the myocardial infarction, pregnancy hinders diagnosis and treatment.     

Treatment of acute myocardial infarction in pregnancy with coronary artery balloon angioplasty and stenting

Acute myocardial infarction in pregnancy is a rare condition with substantial risk of maternal and fetal mortality. We present a case of myocardial infarction during pregnancy which was treated by percutaneous coronary artery balloon angioplasty and stenting with excellent pregnancy outcome.     

Myocardial Infarction in Pregnancy

Myocardial infarction is a rare complication during pregnancy, with an estimated incidence of one in 10,000 pregnancies. Less than 100 cases have been reported. Pregnancy is associated with profound alterations in the maternal cardiovascular system, making pregnancy in the presence of maternal cardiac disease hazardous. Labour and delivery increase cardiovascular stress. Maternal mortality in pregnancies complicated by myocardial infarction is 35 percent. Delivery within two weeks of infarction, or reinfarction during pregnancy is associated with mortality as high as 50 percent. Perinatal mortality is related to maternal outcome.Clinical management of the pregnant woman with myocardial infarction should be multidisciplinary, involving input from obstetrics, cardiology, and anaesthesia. The goals of management are to decrease cardiac work, prevent extension of infarction, increase oxygenation, and prevent complications. During labour and delivery, adequate analgesia, preferably epidural, is essential. The mode of delivery is controversial, however most authors recommend that Caesarean section be reserved for obstetric indications, with assisted vaginal delivery to shorten the second stage of labour being the preferred method. Cardiac arrest in pregnancy is a rare event, but one for which physicians should be prepared. Perimortem Caesarean section to save the fetus should be considered if maternal resuscitation is unsuccessful. Early recognition of myocardial infarction will facilitate effective management, prevention of complications, and improvement in maternal and perinatal survival.     

A myocardial infarction during pregnancy treated by percutaneous transluminal coronary angioplasty and stent implantation. Case report

Acute myocardial infarction is an un-frequent event during pregnancy. It clearly causes an increase in both maternal and fetal mortality. We describe a case of pregnancy complicated during the second trimester by an acute myocardial infarction witch was treated by percutaneous transluminal coronary angioplasty combined with stenting. The challenge involved in managing this condition during pregnancy is briefly discussed.     

Myocardial infarction in the 34th week of gestation: case report

Acute myocardial infarction during pregnancy is a rare event that is often associated with a very high maternal mortality, estimated to be from 19 to 37%. During the last decades the incidence of myocardial infarction during pregnancy has increased . The main contributing factor could be a higher prevalence of the metabolic syndrome. The strongest predictors correlated with a myocardial infarction are hypertension, diabetes mellitus and advanced maternal age. In addition, improved diagnostic tools could explain the elevated incidence of myocardial infarction during pregnancy. In general gestation is not considered a risk factor for myocardial infarction but gravidity is accompanied by an increase in oestrogen and progesterone levels. It is generally accepted that oral contraceptives increase the risk of coronary heart disease. We present a case where a 37-year-old gravida was admitted to hospital with diffuse thoracic pain. In the patient's history, we found several putative reasons for the thoracic pain that pointed to a musculoskeletal cause. Based on an elevation of ischaemic heart markers and continuous non-specific thoracic pain we performed a primary Cesarean section. In the coronary angiography procedure that followed, a thrombotic occlusion of the ramus diagonalis was diagnosed. We here describe the differential diagnosis as well as the problems associated with diagnosing myocardial infarction in the third trimester of pregnancy.     

Pregnancy in a woman with a prior myocardial infarction: a case report]

Myocardial infarction during pregnancy is a rare event but is considered to be associated with very high mortality of both mother and fetus. We report uncomplicated cesarean section in the 3rd pregnancy in woman with a prior myocardial infarction that occurred during the first hours after cesarean section delivery of the 2nd pregnancy. Intensive cardiological and obstetrical supervision are required for correct management of the pregnancy.     

双胎妊娠两次经阴道宫颈环扎成功分娩一例并文献复习

宫颈机能不全是导致妊娠晚期反复流产和早产的主要原因之一。早产可增加围生期发病率与死亡率,给妊娠妇女及家庭带来严重心理和经济负担。目前在国内外,宫颈环扎术被推荐使用于单胎妊娠,对其在双胎妊娠中的应用报道较少,指征不明确。回顾分析1例双胎妊娠经2次宫颈环扎术获2名健康活婴的病例资料并进行文献复习,探讨宫颈环扎术在双胎妊娠中的应用。     

Heart Disease in Pregnancy 4: Ischemic Heart Disease and Cardiomyopathy in Pregnancy

Ischemic heart disease and cardiomyopathy in pregnancy are both rare. Therefore, a high level of suspicion is required by the obstetric caregiver when women complain of the often vague symptoms that are indicative of these conditions. Early diagnosis, consultation with a cardiologist, and aggressive therapy are the keys to reducing morbidity and mortality. Women who suffer myocardial infarction in pregnancy should be stabilized, and delivery within the first two weeks post event should be avoided if possible. Women who completely recover from peripartum cardiomyopathy can be reassured when considering future pregnancies. Pregnancy should be considered contraindicated in women with Class H diabetes, and efforts should be made to establish reliable contraception.This is the fourth in a series of five articles reviewing in detail the assessment and management of specific cardiac disorders in pregnancy.     

Pregnancy-associated spontaneous coronary artery dissection

Spontaneous coronary artery dissection is a rare cause of acute myocardial infarction that occurs particularly in women during the pregnancy and in the postpartum period. We describe a dramatic case of pregnancy-related spontaneous left main coronary artery dissection that resulted in acute myocardial infarction with severe left ventricular dysfunction and was complicated by acute heart failure and cardiogenic shock. Urgent revascularization and restoration of myocardial perfusion that were performed in this case resulted in marked left ventricular function recovery and clinical improvement.     

Coronary artery disease in diabetic pregnancies

Severe vascular complications of diabetes mellitus include myocardial infarction and when this occurs during pregnancy it is associated with a high risk of maternal mortality. In the absence of myocardial infarction, information is unavailable on pregnancy outcome in diabetic patients with severe coronary artery disease or with prior coronary artery bypass graft. Such a case is presented together with a review of the literature.     

妊娠期高血压危象的早期识别及应急救治策略

妊娠期高血压危象会导致孕产妇和胎婴儿严重并发症,如脑血管意外、肺水肿、心肌梗死、急性肾功能衰竭、子宫-胎盘血液灌流不足、胎盘早剥等,是围产期母婴发病及死亡的主要原因。早期识别、严密监测、及时诊断和处理可有效降低严重并发症发生,改善母婴预后。     

Myocardial infarction in early pregnancy

Acute myocardial infarction (AMI) during pregnancy is usually transmural and occurs in late pregnancy with a peak incidence during the peripartum or postpartum periods. We report a pregnancy-related AMI, which occurring as early as the first trimester, was treated conservatively with antithrombotic and anti-ischemic drugs both acutely and through the rest of the ultimately successful pregnancy.     

Dynamics of cervical remodeling during pregnancy and parturition: mechanisms and current concepts

The cervix serves as a protective barrier from invading microorganisms and as a structural barrier to delivery of the fetus. Among all biological processes, the phenomenal connective tissue remodeling that occurs in the cervix during and after parturition is unparalleled in scope and magnitude. The process of connective tissue remodeling in the cervix during pregnancy occurs in four stages: softening, ripening, dilation, and repair. Although overlapping in time, each stage is uniquely regulated. Results from studies using serial measurements of cervical length indicate that cervical ripening precedes myometrial contractions of labor by several weeks, suggesting that parturition in women is a process of long duration and that uterine contractions of labor are late events in the parturition process. A clear understanding of the biologic mechanisms that regulate cervical remodeling during pregnancy is needed to influence the preterm birth rate and to develop strategies to prevent preterm dilation of the cervix.     

Differential regulation of the progesterone receptor A and B in the human uterine cervix at parturition.

The concept of a blockade of progesterone during human pregnancy and withdrawal of this blockade at parturition remains controversial There is no sharp fall in serum progesterone before parturition, but treatment with an antiprogestin is successful for labor induction at term pregnancy. The human progesterone receptor (PR) exists in two isoforms (PR-A and PR-B), mediating different biological responses. Here, the hypothesis of a progesterone withdrawal at parturition in terms of a change in PR isoforms was tested. Cervical biopsies were obtained at term before the onset of labor, immediately after parturition and from non-pregnant women. Solution hybridization showed a tendency for the PR mRNA level to be decreased at parturition. Immunohistochemistry displayed decreased PR(A + B) and PR-B levels (p < 0.05) immediately after parturition. The relative importance of PR-A seemed higher immediately after parturition as compared to its importance in non-pregnant and term pregnant women. Our results are consistent with the concept of a functional progesterone blockade at the receptor level at term pregnancy, and withdrawal of this blockade at parturition. These observations may have important clinical and therapeutic implications.     

Myocardial infarction as a complication of pheochromocytoma in a pregnant woman

Pheochromocytoma is an unusual cause of hypertension during pregnancy. We present a 40-year-old woman who had a myocardial infarction during pregnancy in whom pheochromocytoma was subsequently diagnosed. This disorder carries a high risk of maternal and perinatal mortality, if undiagnosed prior to delivery. Therefore, the diagnosis of pheochromocytoma should be considered in pregnant patients who exhibit a marked fluctuation in hypertension. Urinary concentrations of catecholamines and their metabolites should be measured in such cases.     

Successful Pregnancy in Patients with Diabetes Following Myocardial Infarction

EDITORIAL COMMENT: We accepted this paper for publication to remind readers that women in Australia with severe medical disease, which in the past would be considered grounds for sterilization or even termination of pregnancy (Case 2) now expect or hope to tackle pregnancy successfully. It will be a challenge for obstetricians to maintain the maternal mortality rate in Australia at 1 in 7,860 births with current expectations of low and high-risk mothers (A). In Case 2 the mother died more than 6 weeks after delivery and so would not be classified as a maternal death. Such cases explain why Henry et al have discussed the value of the maternal mortality definition being changed to include all deaths of women dying within 1 year of confinement (B). This paper informs us that women with a past history of significant myocardial infarction can cope safely with pregnancy and the puerperium.

• (A) 

  Report on Maternal Deaths in Australia, 1988–1990.
• (A) 

  Henry OA, Sheedy MT, Beischer NA. When is a maternal death a maternal death? A review of maternal deaths at the Mercy Maternity Hospital, Melbourne, M J Aust 1989; 151:629–631. Also editorial comment, same issue, 615–616.

Summary: Two cases of successful pregnancy are described in insulin-dependent diabetic patients following myocardial infarction. Both mothers survived the pregnancies but 1 died from presumed cardiovascular causes 3 months postpartum. The relevant current literature is reviewed.     

Plasma Antithrombin III Levels in Pre-Eclampsia

In a prospective study plasma AT III was determined in 2423 samples obtained from 653 women during pregnancy and post partum. The women were allocated to groups, according to the highest diastolic blood pressure, in the third trimester. AT III levels were normal throughout pregnancy, during labour and after vaginal delivery, except in 57 women with pregnancy induced or aggravated hypertension. We present evidence that AT III depression in pre-eclampsia is caused by increased consumption. AT III levels correlate with maternal morbidity as revealed by hepatorenal damage. A weak but significant correlation of AT III and platelets with placental infarction was demonstrated. Proteinuria was the best predictor of fetal outcome. AT III plasma levels increased the number of correct predictions. Following vaginal delivery AT III plasma levels rapidly returned to normal values.     

Acute myocardial infarction during the second trimester of pregnancy

Acute myocardial infarction during pregnancy is a very rare event. It occurs from 1 per 10,000 to 1 per 30,000 deliveries. Diagnosis of myocardial ischaemia is difficult because of typical complaints in pregnancy such as breathlessness and pain in chest. Its first recognisable symptom is very often loss of consciousness and cardiac death. We present the case of a 36-year-old woman with cardiac arrest in the second trimester of pregnancy. The defibrillation was applied four times with power ranging from 150 J to 200 J. Acute myocardial infarction was diagnosed on the basis of biochemical and electrocardiological examinations. Pharmacological treatment consisted of adrenalin, lidocaine, dopamine, heparin, insulin and cordarone. Uncomplicated pregnancy and delivery by caesarean section is described. A review of literature follows. CONCLUSION: Although myocardial infarction is a rare complication of pregnancy, it always should be taken in consideration, especially in case of multipara older than 32, suffered from hypercholesterolemia or diabetes, treated with beta-mimetics or ergot alkaloid.     

Systolic hypertension in pregnancy and cardiovascular mortality: a 44-year follow-up study.

OBJECTIVE: To assess role of systolic hypertension during pregnancy in long-term mortality. METHOD: A total of 4,090 Finnish women who delivered in the period from 1954 to 1963 were followed up for an average of 44 years. Mortality data were obtained from the Finnish cause-of-death registry. Cox-proportional hazard models were used for analysis. RESULTS: Cardiovascular mortality was significantly higher among women with systolic hypertension in early or late pregnancy. Women with systolic hypertension in early pregnancy without proteinuria had a significantly increased risk for cardiovascular death. Primiparas with systolic hypertension and proteinuria had a higher risk for cardiovascular death. CONCLUSION: By considering women with systolic hypertension in pregnancy as being at higher risk for cardiovascular diseases, there may be an opportunity to prevent untimely mortality.     

孕兔子宫平滑肌自发电活动的研究

用不锈钢记录电极对妊娠中期、妊娠晚期、分娩期和分娩后的48只家兔子宫平滑肌自发电活动进行在体和离体测定的记录表明,从妊娠中期至分娩后期,自发电活动存在着一定的规律性:先以单波为主(62.6±6.3个/10分),偶有爆发波(2.5±1.5个/10分);随着妊娠的进程,单波频率减低,爆发波频率增加,分娩期爆发波频率最高(10.8±1.6个/10分);分娩后,则爆发波逐渐减少,而单波逐渐增加。另外,爆发波的产生均伴随着宫内压的升高,且先于宫内压的升高。