Page 18 - Delaware Medical Journal - August, 2016
P. 18
STEMI in Pregnancy
Erum Siddiqui, MD; Jon McGhee, DO, FACEP, FAAEM
FIGURE 1
CASE REPORT
A 39-year-old woman in her fourth pregnancy with three previous
hyperlipidemia, tobacco use, and insulin dependent diabetes presented to the hospital via EMS with a chief complaint of 30 minutes of severe chest pain. She described the pain as starting intermittently about two days prior to presenting at the hospital. The pain was waxing and waning and suddenly became severe with nausea. She described the pain as 10/10 in intensity, “severe” and “sharp,” and radiating to her back. She denied any associated shortness of breath, or radiation to neck or arms. Her vital signs on arrival were temperature of 36.6 C, heart rate of 88, blood pressure of 108/69, respiratory rate of 20, and oxygen saturation of 98 percent.
En route to the hospital, she had periods of bigeminy, and appeared pale and clammy to the medics. She was noted to be hypotensive to a systolic blood pressure of 70. Her blood pressure responded appropriately to a bolus of 500 mL of normal saline, and she was given 325 mg of aspirin.
Her last menstrual period was approximately 40 days ago and
she reported a positive home pregnancy test. She was seen by her Medic rhythm strips showed a bigeminy pattern. A 12-lead EKG was immediately obtained when the patient arrived in the room. 12-lead EKG: Normal sinus rhythm, rate = 86, normal intervals, normal QRS duration, normal axis, ST elevation in V1, V2. ST
depression in V5, V6, 1, aVL. (See Figure 1)
The cardiac catheterization lab was activated from the
emergency department. The case was discussed with the on
call interventionist from the cath lab. At the time, all of her risk factors for Acute Coronary Syndrome (ACS) were not completely elucidated and the details of the pregnancy were not certain either. The interventionist expressed concern regarding dye exposure to the fetus. He reviewed an electronic copy of the EKG and made the decision to deactivate the cardiac catheterization activation.
The ED physicians were in disagreement with this decision. An emergent echo was ordered and was completed within the hour. A different in-house cardiologist was contacted for a second review of the case. The echo showed an akinetic apex, and the second cardiologist agreed with the emergency physician’s assessment and promptly reactivated the cath lab. Cardiac catheterization demonstrated a proximal left anterior descending thrombotic occlusion. This was treated with an aspiration thrombectomy followed by placement of a drug-eluting stent.
DISCUSSION
As the societal age of pregnancy continues to increase, so too does the risk of acute coronary syndrome in the pregnancy patient. Approximately, 1 in 10,000 deliveries are complicated by ischemic heart disease.1 Risk factors in pregnancy that put
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Del Med J | August 2016 | Vol. 88 | No. 8
