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.     

Pneumomediastinum as a cause of acute chest pain postpartum.

Pneumomediastinum can easily be mistaken for a pulmonary embolus or myocardial infarction. We describe herein a case of pneumomediastinum postpartum. A primigravida complained five-hours postpartum of acute chest pain and mild dyspnea. The initial (working) diagnosis was pulmonary embolus and the patient was treated with antithrombotic therapy. A CT scan revealed the real cause of the chest pain: pneumomediastinum. The patient was given adequate analgesia and two days later was able to leave the hospital in good clinical condition. We suggest that in the case of acute chest pain during or shortly following labor, pneumomediastinum should be considered.     

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.     

Ergonovine-induced coronary artery spasm and myocardial infarction after normal delivery

Reported is the first known case of postpartum myocardial infarction probably induced by ergonovine maleate, a drug known to provoke coronary artery spasm in susceptible patients.     

Fatal Myocardial Infarction Associated with Bromocriptine for Postpartum Lactation Suppression

Summary: Bromocriptine (Parlodel®) has attracted widespread controversy for its use for postpartum lactation suppression because of recent reports of cerebral and cardiovascular complications. This case describes a maternal death in which bromocriptine therapy may have triggered myocardial infarction in a patient with asymptomatic coronary artery disease. We suggest its use with caution, especially in patients with identifiable risk factors of coronary artery disease or arteriovascular disease.     

Fatal Myocardial Infarction Associated with Bromocriptine for Postpartum Lactation Suppression

Summary: Bromocriptine (Parlodel®) has attracted widespread controversy for its use for postpartum lactation suppression because of recent reports of cerebral and cardiovascular complications. This case describes a maternal death in which bromocriptine therapy may have triggered myocardial infarction in a patient with asymptomatic coronary artery disease. We suggest its use with caution, especially in patients with identifiable risk factors of coronary artery disease or arteriovascular disease.     

Early diagnosis of postpartum acute myocardial infarction with combined use of troponin T and heart-type fatty acid-binding protein rapid assay

Acute myocardial infarction (AMI) during pregnancy or in the early postpartum period is a rare event but may cause perinatal morbidity and mortality. Early diagnosis of AMI is critical for appropriate treatment. We report a case of postpartum AMI in a 40-year-old multiparous woman with varicose veins. On postpartum day 3, the patient suffered severe chest pain. She had been administered oral methylergometrine. In addition to ST-segment elevation in her electrocardiogram, the patient presented with a positive result on whole blood rapid panel tests for troponin T and heart-type fatty acid-binding protein (H-FABP). These findings indicated AMI in the anterolateral wall. The chest pain disappeared with the prompt administration of intravenous pentazocine hydrochloride and sublingual nitroglycerin spray. Angiography did not reveal any signs of coronary stenosis. To our knowledge, this is the first report of postpartum AMI diagnosed rapidly with combined use of troponin T and H-FABP qualitative panel tests.     

HELLP syndrome, multifactorial thrombophilia and postpartum myocardial infarction

A case of postpartum acute myocardial infarction with intraventricular thrombus occurred in a woman with HELLP syndrome. Since coronary artery disease was ruled out angiographically, the assumed pathophysiological mechanism for myocardial malperfusion was intermittend coronary vasospasm and thrombosis. There were several thrombophilic risk factors detectable (heterozygous factor V Leiden, low levels of antithrombin III, protein S deficiency), whose possible impact in this rare but severe clinical condition is discussed.     

Neonatal myocardial infarction due to thrombotic occlusion.

Neonatal myocardial infarction is rare and its prognosis is poor. We describe the clinical course and autopsy findings of a newborn female with myocardial infarction. Her clinical course was rapidly progressive, becoming fatal before we could detect the cause. Autopsy demonstrated significant occlusion of the left coronary artery as well as evidence of new infarction, suggesting that the event occurred at birth. This case illustrates myocardial infarction as a possible cause of early neonatal death.     

Neonatal myocardial infarction due to thrombotic occlusion

Neonatal myocardial infarction is rare and its prognosis is poor. We describe the clinical course and autopsy findings of a newborn female with myocardial infarction. Her clinical course was rapidly progressive, becoming fatal before we could detect the cause. Autopsy demonstrated significant occlusion of the left coronary artery as well as evidence of new infarction, suggesting that the event occurred at birth. This case illustrates myocardial infarction as a possible cause of early neonatal death.     

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 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.     

Myocardial Infarction in a Young Indian Grandmultipara

EDITORIAL COMMENT": We accepted this case report for publication to remind readers that myocardial infarction or ischaemia can occur in women in the reproductive age group. In the 1988–1990 triennium in Australia there were 33 indirect maternal deaths, in 3 of which myocardial infarction or ischaemia was the primary cause.     

Creatine kinase and its MB isoenzyme in the third trimester and the peripartum period.

Forty-nine normal pregnant women were recruited late in the third trimester for serial determinations of creatine kinase (CK) and its MB isoenzyme fraction (CK-MB) at four different times: (1) on recruitment between 36 and 40 weeks' gestation, (2) on admission in active labor, (3) immediately after delivery, and (4) on the first postpartum day. In the patients with vaginal delivery (n = 43) total CK was significantly elevated at time 4 compared with times 1, 2 and 3 (P value < .0001). CK-MB fraction was also significantly elevated at time 4 compared with times 1, 2 and 3 (P value < .0001). In 35.7% of the patients at time 4, CK-MB was sufficiently elevated to give the laboratory interpretation of "borderline" or "consistent with a myocardial infarction," even though none of the patients had cardiac symptoms or complications. A review of the literature shows that CK-MB is found not only in myocardium but also in uterus and placenta. The implication of this study is that elevations in total CK and CK-MB should be used with caution during the peripartum period to diagnose myocardial ischemia or infarction.     

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.     

The use of hormone replacement therapy in women with acute myocardial infarction: an audit of current practice

We undertook criterion-based audit of the current practice of prescribing hormone replacement therapy for women with acute myocardial infarction; the audit included 181 consecutive women admitted to one hospital with this diagnosis in one calendar year. The set standard was that, barring any contraindication, all postmenopausal women with acute myocardial infarction should be prescribed hormone replacement therapy before discharge from hospital. The evidence base of this standard derives from more than 30 epidemiological and clinical studies and a large body of biological data. Only 4.7% of the women were current users of hormone replacement therapy and the set standard was met in only 3% of eligible nonusers. Professionals caring for women who have had a myocardial infarction need to consider hormone replacement therapy as a secondary prophylaxis of myocardial infarction. Gynaecologists should liaise with colleagues in other specialties and general practice to ensure that information on the nongynaecological benefits of hormone replacement therapy is widely disseminated.     

Extensive hepatic infarction in severe preeclampsia as part of the HELLP syndrome (hemolysis,elevated liver enzymes,and low platelets): Evolution of CT findings and successful treatment with plasma exchange therapy

ObjectiveWe describe the serial computed tomography (CT) findings of extensive hepatic infarction and successful plasma exchange therapy in a severe preeclamptic woman with postpartum HELLP syndrome.Case ReportA 38 year-old woman presented with elevated blood pressure of 140–180/90–120 mmHg and 3+ proteinuria at 28 weeks of gestation. Two days after admission, the patient suddenly complained of severe epigastric pain and headache. Her blood pressure rose sharply to 195/120 mmHg. A 980 g female was delivered by emergency cesarean section. Following delivery, the patient's clinical condition and laboratory values deteriorated, with progressive liver insufficiency (peak AST level = 4246 IU/L, ALT = 3685 IU/L, LDH = 6237 IU/L, platelets = 72,000/mm³). Two consecutive plasma exchanges (PEX) were undertaken on the 3^rd and 4^th postpartum day. A contrast-enhanced CT of the abdomen performed 8 days postpartum showed geographically wedge-shaped areas of low attenuation, with a mottled appearance in the right hepatic lobe. Shortly thereafter, the patient recovered and all laboratory parameters gradually normalized 3 weeks after delivery. Follow-up CT-scan of the liver 2 months postpartum showed no evidence of infarction, with complete recovery.ConclusionWe recommend that severely ill patients with HELLP syndrome having epigastric pain should undergo CT imaging of the liver. A trial of postpartum PEX therapy should be considered for treatment of the HELLP syndrome complicated with hepatic infarction, which is recalcitrant to conventional medical management, and fails to abate within 72–96 hours of delivery.     

Survival after intrauterine myocardial infarction: noninvasive assessment of myocardial perfusion with 99mTc-Sestamibi scintigraphy

Survival after severe intrauterine myocardial infarction has not been reported previously. We describe the course of a neonate with a structurally normal heart, who presented with cardiogenic shock at birth due to intrauterine myocardial infarction with a huge ventricular aneurysm. Myocardial perfusion was assessed noninvasively by means of 99mTc-Sestamibi, a radiopharmaceutical agent recently introduced in nuclear cardiology to avoid repeated coronary angiography. The patient survived with improved cardiac function and normal neurodevelopmental outcome.     

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.     

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.