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.     

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 during pregnancy: a review

In the present review the world literature on pregnancy complicated by myocardial infarction is summarized, and two additional cases are presented. It is apparent that the majority of pregnant women who have died after myocardial infarction did so at the time of initial infarction, and maternal mortality was greatest if the infarction was late in pregnancy. Moreover, delivery within two weeks of infarction was associated with increased mortality as was reinfarction during labor. These results suggest that the increasing cardiovascular stresses of late pregnancy, especially when intensified by parturition, seriously compromise women with ischemic heart disease. Efforts should therefore be made to limit myocardial oxygen demand/consumption throughout pregnancy, and particularly during parturition. Although principles of management can be generalized, these high risk patients require individualization of care by a multidisciplinary team of cardiologists, anesthesiologists, and obstetricians.     

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 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.     

Coronary Stenting after Myocardial Infarction during Twin Pregnancy – A Case Report

Objective. We report the case of a 46-year-old woman presenting with acute chest pain in the 20th week of a twin pregnancy after oocyte donation. Case report. The Patient's medical history comprised several cardiovascular risk factors, such as hypertension, obesity, hypercholesterolemia, smoking, and a positive family history. After diagnosis of myocardial infarction, coronary catheterization and stenting was performed. Ten weeks later, Cesarean was indicated because of severe superimposed preeclampsia with lung edema. Mother and babies recovered uneventfully. Conclusion. In respect to increasing rates of higher maternal age and obesity during pregnancy, more attention to maternal health is required, particularly in programs for assisted reproductive techniques.     

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.     

Maternal alcohol ingestion and the incidence of respiratory distress syndrome

The risk of respiratory distress syndrome in infants born to mothers with varying quantities of alcohol intake during pregnancy was assessed. In infants less than 37 weeks' gestation, there was a decreasing incidence of respiratory distress syndrome with increasing maternal alcohol consumption (p less than 0.02). In addition, in infants less than 37 weeks' gestation, maternal alcohol ingestion was associated with a decreased risk of respiratory distress syndrome even when adjusted for other factors such as smoking, gestational age, birth weight, Apgar score, and sex of the infant. It is suggested that maternal alcohol ingestion enhances the maturation of the fetal lung.     

Maternal experience of musculoskeletal pain during pregnancy and birth outcomes: Significance of lower back and pelvic pain

Aimto examine the association between back and pelvic pain during pregnancy and birth outcomes.Backgroundback and pelvic pain during pregnancy is a common occurrence. It is known to affect maternal functioning and well-being during pregnancy and can persist postnatally and beyond. However, there has been little examination of the impact upon birth outcomes such as birth mode, duration of labour and pain experience.Methodfive hundred and eighty mothers with an infant aged zero to six months completed a retrospective questionnaire documenting their pain during pregnancy and birth outcomes (e.g. mode, duration, interventions, perception of pain). Participants also rated overall pain and pain in specific body regions for each of the three trimesters. Estimations of fetal position before birth were given.Findingshigher pain ratings during the third trimester of pregnancy were associated with increased incidence of caesarean section, assisted delivery and a longer duration of labour. Specifically, lower back and pelvic pain were associated with an increase in complications, potentially due to occurrence of malpositioning of the fetus during pregnancy.Conclusionmothers who experience high levels of pain during pregnancy may be at increased risk of complications during labour. Explanations for this may be physiological, mechanical or psychological but greater awareness should be given to the potential impact of maternal pain ratings during pregnancy upon birth outcomes.     

Microvascular dysfunction: a link between pre-eclampsia and maternal coronary heart disease

Epidemiological studies have recently demonstrated a relationship between pre-eclampsia and coronary heart disease. Insulin resistance has been implicated as a common factor. We have demonstrated, for the first time, using laser Doppler imaging in vivo , impaired microvascular function in women 15–25 years following a pregnancy complicated by pre-eclampsia. Thus, microvascular dysfunction, which is associated with insulin resistance, may be a predisposing vascular mechanism for both coronary heart disease and pre-eclampsia. Pregnancies complicated by pre-eclampsia may identify women at risk of vascular disease in later life and may provide the opportunity for lifestyle and risk factor modification to alter maternal vascular disease risk.     

Myocardial infarction in pregnancy associated with clomiphene citrate for ovulation induction: a case report

BACKGROUND: Clomiphene citrate (CC) is commonly prescribed for ovulation induction. It is considered safe, with minimal side effects. Thromboembolism is a rare but life-threatening complication that has been reported after ovulation induction with CC. Spontaneous coronary thrombosis or thromboembolism with subsequent clot lysis has been suggested as one of the most common causes of myocardial infarction (MI) during pregnancy, with a subsequently normal coronary angiogram. CASE: A 33-year-old woman with a 5-week gestation had recently received CC for ovulation induction and presented with chest pain. An electrocardiogram showed a lateral and anterior wall myocardial infarction. Cardiac enzymes showed a peak rise in troponin I to 9.10 ng/mL. An initial exercise stress test was normal. At the time of admission, the patient was at high risk of radiation injury to the fetus, so a coronary angiogram was postponed until the second trimester. It showed normal coronary vessels. CONCLUSION: This appears to be the first reported case documenting a possible association between CC and myocardial infarction. Thrombosis might be a rare but hazardous complication of CC. Given this life-threatening complication, appropriate prophylactic measures should be used in high-risk woman undergoing ovarian stimulation.     

Ischemic heart disease in pregnancy

While ischemic heart disease in reproductive-age women is rare, cardiac disease is a leading cause of maternal mortality. In turn, coronary artery disease is one of the most common causes of maternal cardiac death. The incidence of coronary artery disease in pregnancy may be rising due to the increasing prevalence of comorbid risk factors. Diagnosis and clinical management of ischemic cardiac disease is largely similar in the pregnant and non-pregnant patient, and the majority of medications and diagnostic and interventional procedures are compatible with pregnancy with a few important exceptions. Care for ischemic cardiac disease in pregnancy may be suboptimal because: (1) diagnosis is delayed because many symptoms of ischemic cardiac disease are common in pregnancy, (2) a diagnostic workup is insufficiently thorough, and/or (3) consultants may be hesitant to perform diagnostic and interventional procedures in obstetric patients. Obstetric providers should be aware of the possibility of ischemic cardiac disease in pregnancy, particularly in patients with comorbid risk factors. If ischemic cardiac disease is suspected, a thorough workup should be performed.     

Menstrual and reproductive factors and the risk of myocardial infarction in women under fifty-five years of age

The relationship between menstrual and reproductive factors and subsequent risk of coronary heart disease was investigated in a hospital-based case-control study of 202 women with acute myocardial infarction and 374 control subjects admitted for a wide spectrum of acute conditions unrelated to any of the established risk factors for ischemic heart disease. No consistent association was observed with age at menarche or menopausal status, but women with a lifelong irregular menstrual cycle pattern were at significantly elevated risk of myocardial infarction (relative risk = 1.8, 95% confidence interval = 1.1 to 2.9). No clear trend in risk was evident with the number of livebirths, miscarriages, or induced abortions. However, women whose first pregnancy or livebirth occurred before age 20 years showed elevated risks of subsequent myocardial infarction compared with nulliparous ones (relative risks = 2.3; 95% confidence interval = 1.1 to 4.9), and there was a significant trend of increasing risk with earlier first birth. These associations were evident in both younger and middle-age women and were not explained by allowance for several identified potential confounding factors.     

Pregnancy, labour and puerperium in patient after replacement of the descending thoracic aorta with a synthetic graft for aneurysm

Aortic aneurysms occurs very rarely in young women. They usually accompany congenital heart diseases, Marfan's syndrome, bicuspid aortic valve and coarctation. What is more, they may be the consequence of syphilis and trauma, however less frequently. Despite their rare incidence, aortic aneurysms seem to be an important problem due to high maternal mortality during gestation. Hemodynamic changes which occur in pregnancy favour the appearance of this pathology, deteriorating the prognosis even further--half of the cases of aortic ruptures in women aged below 40 years are associated with pregnancy. Until recently only a few cases of aneurysm repairs during pregnancy have been reported. Also, only one pregnancy and one delivery in a patient after the repair of aortic aneurysm have been described in the literature. In our research we wish to report the successful management of a pregnancy, ended by vaginal route, 8 years after the replacement of descending thoracic aorta with a synthetic graft for aneurysm.     

Intrapartum analgesia and its association with post-partum back pain and headache in nulliparous women

BACKGROUND: The effect of intrapartum analgesia on post-partum maternal back and neck pain, headache and migraine, is uncertain. AIMS: To determine if nulliparous women having epidural analgesia during labour have a similar incidence of the above-mentioned post-partum symptoms compared with women managed using other forms of pain relief. METHODS: Secondary analysis of cohort data from a randomised trial in which nulliparous women intending to deliver vaginally were randomised to either epidural analgesia (EPI) or continuous midwifery support (CMS) at admission for delivery. Because of high cross-over rates, groups were initially defined by the randomised treatment allocation and the actual treatment received (CMS-CMS n = 185, EPI-CMS n = 117, EPI-EPI n = 376 and CMS-EPI n = 314). Univariate analysis showed no difference between groups, so final analysis was based on the actual treatment received. RESULTS: Six hundred and ninety women received epidural analgesia (EPIDURAL) and 302 received other methods of pain relief including CMS. Back pain was common before, during and after pregnancy, and risk factors for post-partum back pain at six months were back pain prior to pregnancy or at two months post-partum. Epidural analgesia, mode of delivery, spontaneous or induced labour, birthweight and back pain during pregnancy had no significant relationship with post-partum back pain at six months. Headache was significantly more common in the EPIDURAL group during pregnancy and at two months post-partum, but not at six months. Migraine was not associated with intrapartum analgesia. CONCLUSIONS: This analysis supports previous research suggesting that epidural analgesia is not a significant risk factor for persisting post-partum back pain, headache or migraine.     

Condyloma in pregnancy is strongly predictive of juvenile-onset recurrent respiratory papillomatosis

OBJECTIVE: To assess the risk of juvenile-onset recurrent respiratory papillomatosis conferred by a maternal history of genital warts in pregnancy, and to identify additional cofactors such as the method of delivery (cesarean versus vaginal) and procedures or complications during pregnancy. METHODS: A retrospective cohort design was used to evaluate maternal and infant characteristics associated with respiratory papillomatosis among Danish births between 1974 and 1993. Using data from Danish registries, we identified 3033 births with a maternal history of genital warts during pregnancy. Fifty-seven respiratory papillomatosis cases were identified by review of medical records from ear, nose, and throat departments. RESULTS: Seven of every 1000 births with a maternal history of genital warts resulted in disease in the offspring, corresponding to a 231.4 (95% confidence interval 135.3, 395.9) times higher risk of disease relative to births without a maternal history of genital warts. In women with genital warts, delivery times of more than 10 hours were associated with a two-fold greater risk of disease. Cesarean delivery was not found to be protective against respiratory papillomatosis, and no other procedures or complications during pregnancy were observed to increase the risk of respiratory papillomatosis. CONCLUSION: A maternal history of genital warts in pregnancy is the strongest risk factor for respiratory papillomatosis in the child. Future studies should examine the efficacy of genital wart treatment for the prevention of disease.     

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.     

Acute myocardial infarction associated with prostaglandin E2

Prostaglandin E2 is rarely associated with serious maternal side effects when used for second-trimester pregnancy termination. Acute myocardial infarction complicating therapeutic pregnancy termination with prostaglandin E2 in a patient with chronic glomerulosclerosis and severe hypertension is reported.     

Autoimmune hepatitis and pregnancy

Autoimmune hepatitis (AIH) is a rare liver disease of autoimmune aetiology that classically affects women at reproductive age. Diagnosis of AIH is not always straightforward, and other causes of chronic liver disease must be excluded. Pregnancy in patients with AIH is associated with an increased risk of adverse maternal and foetal outcomes. In older studies, the incidence of adverse outcomes was high, with a large number of flare-ups, maternal deaths, and perinatal complications. In the most recent series, improved care based on multidisciplinary surveillance, a larger number of patients treated before and during pregnancy, and reduced incidence of cirrhosis at conception have led to better maternal outcomes and a live-birth rate similar to that in the general population. Nonetheless, AIH is still associated with preterm birth, foetal growth restriction, and unpredictable liver flares, and it represents a group of patients who need close evaluation during pregnancy.     

Glycemic control in the diabetic pregnancy: is tighter always better?

Glucose is the principal nutrient that the mother supplies to the fetus through the placenta by way of concentration-dependent mechanisms. In the presence of maternal hypoglycemia, with limited glucose supply, fetal hypoglycemia and hypoinsulinism ensue. This may be viewed as an adaptive mechanism to increase the chances of fetal survival in the face of limited maternal supply, albeit of a growth-restricted fetus. Fetal nutrient deprivation and the resulting hypoinsulinism may have both short- and long-term consequences. Intrauterine growth failure is associated with higher rates of gestational age-specific neonatal mortality and with long-term cognitive deficits. Furthermore, epidemiologic data suggest that diabetes, coronary artery disease, and hypertension are more common among adults who were small for gestational age at birth. Thus, pancreatic failure in adulthood may be either a response to excessive exposure to glucose as a result of maternal hyperglycemia, or as a result of hypoglycemia where nutrient deprivation leads to fetal growth restriction and reduced islet cell proliferation. Because low mean concentrations of maternal glucose in gestational diabetes are associated with an increased risk of fetal growth restriction, overzealous glycemic control during pregnancy may raise concerns regarding the possible effects on the infant. In the mother with Type 1 diabetes, strict glycemic control is often associated with an increased incidence of severe hypoglycemia. Up to 40% of women report at least one episode of severe hypoglycemia during pregnancy, requiring assistance by another person or professional intervention. It is quite possible that in some patients striving to optimize pregnancy outcome by maintaining the best possible glycemic control jeopardizes the well-being of the mother and the fetus. Thus, with respect to tight glycemic control of pregnant women with diabetes, the question arises: How tight is too tight? Is there a threshold below which the trade-off in terms of maternal morbidity as well as fetal growth restriction and its consequences outweighs the benefits of preventing the effects of maternal hyperglycemia?