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.     

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.     

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.     

Postpartum Depression and Apical Ballooning Syndrome (Takotsubo Syndrome)

BackgroundAcute cardiac complications occur occasionally during pregnancy and in the immediate postpartum period. Some of these cardiac scenarios are rare and provide a diagnostic challenge. We report a case of apical ballooning syndrome (ABS), also known as takotsubo cardiomyopathy or broken-heart syndrome, in a postpartum patient.CaseA 32-year-old multigravid woman presented at 17 days after delivery with chest pain typical for cardiac ischemic pain. Her prior obstetrical history included two uncomplicated vaginal deliveries, and the current postpartum period had been uncomplicated until the time of presentation. Cardiac catheterization was performed and showed normal coronary blood vessels with no evidence of coronary artery occlusion. Left ventricular systolic function was moderately depressed, with an ejection fraction of 45%. The patient had full recovery of myocardial function in less than 40 days, with a subsequent echocardiogram during that time showing a normal ejection fraction of 65%.ConclusionApical ballooning syndrome is a rare reversible cardiac condition that should be differentiated from ischemic and peripartum cardiomyopathy, especially in the immediate postpartum period.     

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.     

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.     

Pregnancy after myocardial infarction: are we playing safe?

The safety of pregnancy after myocardial infarction remains a significant dilemma for both the obstetrician and the cardiologist. Only 20 cases of pregnancy after myocardial infarction have been reported. To clarify this problem, we add our experience of four such cases in which conception occurred 9 months to 9 years after myocardial infarction with no previous consultation. Each woman had an uneventful pregnancy with no cardiac or obstetric complications related to the myocardial infarction. All patients were under the strict supervision of an obstetrician and a cardiologist during pregnancy in our conjoined antepartum-cardiologic clinic. The mode of delivery in all patients was related to the obstetric indications. Our experience and the accumulated experience in the literature demonstrate good prognosis for patients who conceive after myocardial infarction.     

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.     

Case report: successful pregnancy and delivery after myocardial infarction and essential thrombocythemia treated with clopidrogel

We describe a case of a woman with essential thrombocythemia (ET) who had a subsequent successful pregnancy after a myocardial infarction and aortocoronary bypass grafting. We report the therapeutic management with clopidogrel and low molecular weight heparin. A healthy child was born spontaneously after 41 weeks of pregnancy. The placenta was morphologically normal. No maternal cardiac problems occurred.     

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.     

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.     

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.     

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.     

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.     

Atresia of proximal coronary arteries in pulmonary atresia with intact ventricular septum - fetal and neonatal findings

Pulmonary atresia with intact ventricular septum (PA+IVS) is a rare congenital cardiac malformation which is associated with ventriculocoronary arterial communications from the right ventricle. We present a case of PA+IVS with a bilateral atresia of the coronary ostia, and thus, a completely right ventricular-dependent coronary circulation followed up by fetal echocardiography. Eventually the infant died of myocardial infarction at 2 days of age.     

Anwendungsbeschränkung von Aspirin während der Schwangerschaft

The case of a high-risk pregnant woman is reported (morbid obesity, gestation-related hypertension, and diabetes mellitus) who died of hemorrhagic shock a few hours after giving birth by Cesarian section followed by intra-abdominal bleeding and emergency hysterectomy. The patient had been taking acetylsalicylic acid (aspirin, 100 mg per day) until the day before delivery due to her history of a brainstem infarction. Indications for low-dose, administration of aspirin during pregnancy include (1) secondary prophylaxis for myocardial or cerebral infarction, (2) prevention of placental insufficiency with intrauterine growth restriction, (3) prevention of pre-eclampsia, and (4) treatment of antiphospholipid syndrome. Aspirin inhibits platelet thromboxane A2 formation, even at very low doses (e.g. 40–60 mg per day). Since this pharmacological effect persists for the lifespan of the entire circulating platelet population (7–10 days), even after a single dose the drug must be discontinued at least 5 days prior to any scheduled operation. During pregnancy, aspirin (including low-dose administration) must be stopped in all cases after the 37th week of gestation and, if possible, should not be administered during the last 3 months of gestation. For individual patients, an alternative antithrombotic treatment with a low-molecular-weight heparin may be considered.     

Twin pregnancy in the right horn of a uterus didelphys: a case report

A rare case of a twin pregnancy occurring in the right horn of a uterus didelphys (double uterus, double cervix and septate vagina) is reported. The occasional diagnosis of this uterine anomaly was made after the pregnancy was detected. Both embryos, with cardiac actions which proved the viability of the gestation from the very early stage of pregnancy, were detected by transvaginal ultrasonography. Two male infants were delivered by Cesarean section in the 34th week. The importance of the transvaginal sonography and the handling of the case during this high-risk pregnancy are reported.     

Splenic infarction in pregnancy

We present a case of splenic infarction in pregnancy, secondary to acute bacterial endocarditis. Left upper quadrant pain in pregnancy can be due to a variety of causes and in the septic or unwell patient, splenic infarct should be considered in the differential diagnosis. The diagnosis of splenic infarct should be considered especially in those at increased risk of bacterial endocarditis. Acute bacterial endocarditis can occur even in patients without any risk factors. Bacterial endocarditis is rare in pregnancy and splenic infarction is even rarer. However when it occurs, rapid diagnosis and management are necessary to minimize embolic phenomena. With the increasing use of intravenous drugs and with increasing numbers of Pacific Islanders in our pregnant population, it is important to be alert to the risk of bacterial endocarditis and to avoid serious sequelae. Patient education to the importance of medical follow-up in order to prevent such a life-threatening condition, and to avoid more complicated acute treatment, is imperative.