CLINICAL CASE OF SUCCESSFUL MANAGEMENT OF ACUTE MYOCARDIAL INFARCTION DURING PREGNANCY
SKUTECZNE LECZENIE OSTREGO ZAWAŁU SERCA U KOBIETY W CIĄŻY
Oleh A. Loskutov, Andrii O. Zhezher, Yevhen M. Sulimenko
Department of Anesthesiology and Intensive Care of Shupyk National medical academy of postgraduate education, Kyiv, Ukraine
Introduction: There have recently been increasingly frequent reports of myocardial infarction (MI) in pregnancy and in the postpartum period. Pertinent and timely treatment affect maternal and fetal morbidity and mortality.
Clinical case: We are reporting about a 42 years old woman at the 19th week of gestation, with complains of chest pain with irradiation into the left arm, and shortness of breath. It was known from the history of present illness, that at the time of the event ventricular fibrillation was recorded and resuscitation measures with cardioversion were performed. Subsequently, after an additional examination in the hospital, a diagnosis of MI has been determined. Coronary angiography with cardiac ventriculography (CVG) has been performed and stenosis of left anterior descending coronary artery (LAD) and right coronary artery (RCA) detected. A revascularization with the insertion of the bare-metal stent system has performed and double antiplatelet therapy prescribed. At 37 weeks of gestation, the patient gave birth to a healthy child by caesarean section.
Conclusions: This clinical case illustrates the importance of minimizing the time to hospitalization of a pregnant woman with a MI to a specialized center for timely and complete diagnostic measures, which, in turn, allow to properly choose the tactics of patient management. Timely revascularization and properly selected anticoagulation are the key factors of the successful management in this category of patients.
Key words: pregnancy, acute myocardial infarction, coronary angiography with cardiac ventriculography, revascularization, antiplatelet therapy
Wiad Lek 2019, 72, 2, 298-301
Cardiovascular pathology in pregnant occupies one of the first positions in the structure of maternal morbidity and mortality [1-3].
Nowadays there is a tendency for the childbirth by women in older age. This, along with other risk factors, raises coronary artery disease to higher positions in the structure of cardiovascular disease in pregnant [1,4 -7].
It has been reported that the incidence of MI in pregnant is 3 to 6 cases per 100,000 pregnancies [1,4,8-10]. The development of this pathology accounts for 11% of maternal mortality and 9% of fetal loss .
MI is more common in the third trimester of pregnancy (STEMI – 25%, NSTEMI – 32%) or in the postpartum period (STEMI – 45%, NSTEMI – 55%) . If MI takes place during 2 weeks after delivery, then mortality may be as high as 37% – 45% [5,6]. The localization of the pathological process in 69% of cases is the front wall of the left ventricle, in 27% of cases – the lower wall, and the side wall in 4% of cases .
James A.H. et al, in their studies, noted that the MI in pregnant women was caused by coronary artery (CA) dissection in 16% of cases, in 21% of cases coronary thrombosis without atherosclerotic disease, atherosclerosis with or without an intracoronary thrombus in 43% of cases, and in 29% of cases, the MI was registered in pregnant women who did not have pathomorphological changes in CA .
Complications that arise in case of MI in pregnant are both specific (rapid decompensation, premature childbirth, antenatal death of the fetus) and general, as for all populations (which depend on the zone, area and depth of infarction).
We present a clinical case of pregnancy, which was accompanied by an acute MI and management variant according to modern recommendations.
A pregnant 42 years old woman, with third pregnancy, two of which ended with childbirth, has been hospitalized to “State Institution Heart Institute of the Ministry of Health of Ukraine” (Kyiv) with complaints of severe pain in the cardiac area with irradiation into the left arm of compressive character, with a feeling of heaviness in the chest.
It has been known from the history of present illness that the pain appeared at night at 2:00 am. An emergency team was called, an ECG study has been performed and acute MI recorded. Later, ventricular fibrillation was recorded and resuscitation measures with cardioversion performed. Amiodarone and Esmolol have been chosen for pharmacological support. Therapy with IV unfractionated heparin and acetylsalicylic acid has been initiated.
It has been known from the history of present illness that the patient had stage II hypertension, which existed before pregnancy, that the woman was a smoker, and overweight (BMI 32). Before this case, she had no cardiac complaints.
The physical examination has shown that the patient suffered from shortness of breath at minimal physical activity, SpO2 = 90%, had moderate tachycardia (HR = 90-110 beats/min). Blood pressure was 140/90 mm. Hg. on both hands. Auscultation: Heart tones muffled, rhythmic.
Concerning pregnancy and fetus state: pregnancy of 19-20 weeks, with the signs of threatening miscarriage, fetal heartbeat rhythmic, 168-170 beats/min.
Results of ECG study has shown signs of acute MI of the anterior-membrane-apical region (pathological Q in V2-V4 leads, ST elevation in V2-V4 leads). Echocardiography has shown hypokinesia of the apex of the LV, with slightly enlarged left atrium (LA), and preserved contractile ability (EF = 58%).
The results of serum chemistry studies have shown a significant increase in Troponin I serum concentrations of up to 5.1 ng/ml, and creatine phosphokinase-MB up to 120 IU/L.
The results of the urgent coronary angiography (which has been performed with appropriate protection of the pregnant uterus – shielding the patient’s abdomen) have shown LAD occlusion in its middle portion, and 40% RCA stenosis in the proximal portion (Fig. 1a).
Considering the vital indications, the right side radial artery access was used for occluded LAD segment recanalization and subsequent angioplasty with a 2.0 × 15 mm balloon was performed. The PRO-Kinetic Energy 3.0 × 18 mm cobalt-chrome coronary stent system has been implanted into the stenotic segment of the LAD (Fig.1b).
Clopidogrel has been added to anticoagulant therapy that had been administered at the pre-hospital stage.
The postoperative period proceeded without peculiarities.
On the same day the pregnant woman, with appropriate recommendations, was transferred to the regional cardiology clinic for further treatment and rehabilitation. The pregnant woman received dual antiplatelet therapy – clopidogrel, acetylsalicylic acid, as well as beta-blockers.
Pregnancy and fetus follow-up has been carried out collaboratively by obstetrician-gynecologist with cardiologists. However, this pregnancy was complicated by moderate severity pre-eclampsia due to arterial hypertension that existed before pregnancy.
At gestational age of 35 weeks the woman has been hospitalized to the obstetric clinic for supervision, and later, due to moderate severity pre-eclampsia, at gestational age of 37 weeks, the multidisciplinary team decided to perform elective cesarean section on the basis of the cardiac surgery clinic “State Institution Heart Institute of the Ministry of Health of Ukraine”.
The patient has been re-hospitalized for elective caesarean section. At the time of arrival – there has been no complaints.
The preliminary diagnostics has not found any changes for the worse from the side of the heart functional state. At the time of re-hospitalization, before delivery, the patient had been taking the following therapy: acetylsalicylic acid, and beta-blockers. Clopidogrel had been canceled 5 days before delivery.
At 37 weeks of pregnancy, a planned delivery by cesarean section under epidural anesthesia, was performed. A girl with a weight of 3660 grams, a height of 51 cm and an estimate on the Apgar score of 8-9, was born. Blood loss during surgical delivery was 600 ml.
There have been no complications during anesthesia, the patient had stable hemodynamic parameter. The postpartum period proceeded without any peculiarities, the patient received therapy with beta-blockers and acetylsalicylic acid$ clopidogrel therapy was restored and statins added. On the 6th day, the patient and her child, in satisfactory condition with recommendations were discharged home.
Pregnancy causes changes in the cardiovascular system in accordance with an increase in the metabolic needs of mother and fetus [1,2,11,12]. The physiological increase of blood volume and cardiac output during pregnancy, along with pregnancy-related hypertension, is an additional threat to CA dissection or thrombotic rupture . An increase in heart rate in a woman during pregnancy can facilitate to the progression of acute coronary syndrome (ACS), by reducing the time of diastole phase and thereby reducing the effectiveness of coronary blood flow.
Changes in hemostasis, regulated by the hormonal background of the pregnant woman, cause a tendency to hypercoagulation and affect the vascular wall [1,2,11-14]. High levels of progesterone lead to degeneration of connective tissue in intima and middle layer of CA . This may become a risk factor of thrombosis or spontaneous CA dissection [13,14]. Other risk factors include: pregnancy in older age, smoking, diabetes mellitus, hypertension, hyperlipidemia, family history of ACS, preeclampsia, and obesity – all become increasingly detected in modern society and drive the development of complications [1,2,4,11,12,15,16].
In this case, the patient had the following risk factors: pregnancy in older age, smoking, obesity, and hypertension, which, in our opinion, together with the physiological changes in pregnancy, caused acute MI.
Concerning the management of MI in pregnant women, it`s worth to note that it`s identical to the principles of ACS management in non-pregnant population. However, certain physiological peculiarities of pregnancy require adaptation necessary for protection of life and health of both mother and fetus – shielding the abdomen of pregnant women and minimizing exposure to radiation during percutaneous coronary intervention (PCI) [1,2,4,11,12,14]
A patient with ACS should be transported immediately to a specialized center for PCI with subsequent revascularization in the shortest possible time [1,2].
In our opinion, in the described case, minimizing the time from the onset of symptoms to the PCI had prevented the further development of myocardial ischemia and subsequently, after rehabilitation and with adequate medical support, gave an opportunity for a woman to prolong pregnancy and give birth to a healthy, full-term child.
Certain authors note the superiority of bare-metal stent systems over drug-eluting stents [1,2,11,12,16]. The effects of these drugs on fetus haven’t been properly studied. Drug-eluting stent (DES) systems, require prolonged, up to one year, double antiplatelet therapy, whereas bare-metal stent systems require only four weeks long double antiplatelet therapy, thus reducing the risk of hemorrhagic complications [1,2,11,12,16].
In our case, a bare-metal stent system has been implanted, which allowed to safely withdraw clopidogrel five days before the elective caesarean section, which had been performed under regional anesthesia and without significant blood loss.
It is important to note that women with ACS risk factors should receive pre-conceptional counseling from cardiologist and obstetrician-gynecologist and continue monitoring throughout pregnancy with a possible extension of the number of specialists, if needed [12,16].
Thus, MI during pregnancy has its own characteristics associated with physiological changes in mother`s body, and can be successfully treated if a PCI with a revascularization is timely performed.
1. This clinical case illustrates importance of minimizing time to hospitalization of a pregnant woman with MI to a specialized center for timely complete diagnostic measures, which allows to properly choose the tactics of patient management. Timely revascularization and properly selected anticoagulation therapy are the mainstay of the successful management in this category of patients.
2. An important thing that follows from this case is the right choice of stent system for revascularization. The bare-metal stent system, along with a proper anticoagulation allows to safely prolong pregnancy and perform delivery, with the possibility of using regional anesthetic techniques.
3. More and more women in modern society are planning pregnancy after 35 years. This poses new problems for obstetricians-gynecologists, cardiologists and anesthesiologists. Such pathology, which until now wasn’t characteristic for pregnant women, increasingly poses a challenge for multidisciplinary team of physicians whose participation is required for the management of coronary heart disease during pregnancy and in the postpartum period.
MI = myocardial infarction,
ACS = acute coronary syndrome,
CVG = coronary angiography with cardiac ventriculography,
CA = coronary artery,
LAD = left anterior descending coronary artery,
RCA = right coronary artery,
PCI = percutaneous intervention.
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According to the order of the Authorship.
Conflict of interest:
The Authors declare no conflict of interest.
Yevhen M. Sulimenko
Shupyk National Medical Academy of Postgraduate Education
9 Dorogozhytska St., 04112 Kyiv, Ukraine,
Fig. 1a. Initial CVG patient P. LAD occlusion.
Fig. 1b. CVG of the patient P. after the LAD recanalization.