Page 19 - Delaware Medical Journal - August, 2016
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CASE REPORT
a patient at higher risk for ACS include: older age, diabetes, hypertension, tobacco use, obesity, family history, and hyperlipidemia.2 Risk factors for ACS in pregnancy are similar to risk factors seen in the general population for ACS. Pregnancy diabetes, gestational hypertension, and preeclampsia/eclampsia.2 Having a pregnancy complicated by these issues leads one to have a higher risk of developing ischemic heart disease in the future. While myocardial infarction (MI) has been observed through all stages of pregnancy, it is more commonly seen later in pregnancy and is generally localized to the anterior wall of the myocardium.3,4 Furthermore, simply being pregnant makes an individual 3 to 4 times more likely to have an MI.5
Diagnosis is made by similar presentation as in a non-pregnant patient, with chest pain being the most common complaint. in comparison to other cardiac enzymes. As the heart changes
in positioning during pregnancy, there are changes that occur in electrocardiography for the pregnant patient. These changes include: lead III and AVF; left axis deviation and transient ST segment changes. However, ST elevation is not a normal variant of pregnancy.6
Increasingly, spontaneous coronary artery dissection presents as ST-Segment Elevation Myocardial Infarction (STEMI). Usually these patients do not have all of the risk factors associated with ACS. Management is generally conservative for Spontaneous coronary artery dissection (SCAD). When SCAD is not the cause the culprit is usually related to coronary embolism, vasospasm, thrombus due to a hypercoagulable state, or atherosclerosis.6 SCAD has been observed in studies in a much higher proportion of pregnant patients with ACS than the general public.5
An interdisciplinary team including a cardiologist and an obstetrician should be mobilized. When the pregnancy is viable,
a delivery plan must be established for this high-risk situation. If occurrence of MI is towards the end of pregnancy, delivery should be delayed by at least two weeks because of increased cardiac demand during this time of gestation and labor.
Maternal mortality is highest within two weeks of MI.3
Percutaneous coronary intervention (PCI) is always preferred in these patients. Fibrinolysis is not well studied and is also relatively contraindicated in pregnancy. However, if it is the only option available it should be given consideration in the critical patient. Tissue plasminogen activator (TPA) is also generally a fairly large molecule that does not cross the placenta.7
The amount of radiation exposure secondary to PCI is negligible
in comparison to other radiographic modalities employed
to assess the acutely ill pregnant patient.1 The International Commission on Radiological Protection (ICRP) indicates that the chance of congenital risk is very low when exposed to 50 mGy of radiation. If PCI is performed, an average of 3 mGy of radiation are absorbed by the fetus in an unshielded abdomen.6 Methods that are used to limit radiation exposure include: abdominal shielding, radial or brachial access for angiography, stents are also used preferentially as they limit the time the patient has to receive antiplatelet therapy.
Use of low dose aspirin, beta blockers, and nitrates is acceptable without harm to the fetus. Heparin drips are also acceptable,
but with the foreseeable complication of increased bleeding. Drugs in the statin category, ACE inhibitors, and ARB drugs are contraindicated due to the harmful effects on the developing pregnancy. Similarly, prostaglandins are employed by obstetricians, and are relatively contraindicated in ACS.3
CONTRIBUTING AUTHORS
■ ERUM SIDDIQUI, MD is a third year resident in Emergency Medicine at Christiana Care Health System in Newark, Del.
■ JON MCGHEE, DO, FACEP, FAAEM is an Emergency Medicine Physician at Christiana Care Health System and a Clinical Assistant Professor
of Emergency Medicine at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Penn.
REFERENCES
1. Dwyer BK, Taylor L, Fuller A, Brummel C, Lyell DJ. Percutaneous transluminal coronary angioplasty and stent placement in pregnancy. Obstet Gynecol. 2005;106:1162-1164.
2. McGregor AJ, Barron R, Rosene-Montella K. The pregnant heart: cardiac emergencies during pregnancy. Am J Emerg Med. 2015;33:573-579.
3. Kealey AJ. Coronary artery disease and myocardial infarction in pregnancy: A review of epidemiology, diagnosis, and medical and surgical management. Can J Cardiol. 2010;26:185-189.
4. Elkayam U, Jalnapurkar S, Barakkat MN,et al. Pregnancy-associated acute myocardial infarction: a review of contemporary experience in 150 cases between 2006 and 2011. Circulation. 2014;129:1695-1702.
5. James AH, Jamison MG, Biswas MS, Brancazio LR, Swamy GK, Myers ER. Acute myocardial infarction in pregnancy: a United States population-based study. Circulation. 2006;113:1564-1571.
6. Pradhan AD, Visweswaran GK, Gilchrist IC. Coronary angiography and percutaneous interventions in pregnancy. Minerva Ginecol. 2012t;64:345-359.
7. Pacheco LD, Saade GR, Hankins GD. Acute myocardial infarction during pregnancy. Clin Obstet Gynecol. 2014;57:835-843.
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