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Missed Myocardial Infarction Presenting as Flash Pulmonary Edema following Cesarean Section
Abstract Number: F 50
Abstract Type: Case Report/Case Series
Acute maternal myocardial infarction (MI) occurs in fewer than 10 in 100,000 deliveries in the US (1). In the immediate peripartum period, when an anesthesiologist is most likely to be present, the cause of MI in 50% of cases is acute coronary artery dissection, which carries significant morbidity and mortality (2-3). Diagnosing MI in pregnancy is challenging, as the pretest probability is low, and normal manifestations of pregnancy like epigastric pain, nausea and malaise can hinder diagnosis.
We present a case of a 35-year-old gravida 2, para 1 female who was admitted with preterm contractions at 30 weeks gestation. Eighteen hours prior to delivery, she reported substernal chest pain, at which point an ECG was obtained as shown below. The tracing contained severe baseline artifact that limited interpretation. The patient was treated for the presumed diagnosis of “heartburn.” The following day, the patient required urgent cesarean section for a non-reassuring fetal heart rate pattern. Shortly after delivery, the patient developed dyspnea, hypoxia, tachycardia, and bibasilar rales. A chest x-ray revealed pulmonary edema and a second ECG showed loss of anterior R waves. Her troponin-T level was elevated. Coronary catheterization demonstrated complete occlusion of the left anterior descending artery due to coronary dissection, which was successfully stented. She was discharged home on aspirin, clopidogrel and metoprolol.
The management of acute MI in pregnancy requires a careful and multidisciplinary approach given the medical implications of therapy and intervention to the mother and fetus. A retrospective review of the initial ECG, taken the night before surgery, demonstrated mild anterior ST elevation, shown below. This case highlights an example of cognitive blindness, the phenomenon where critical cues are unrecognized due to a variety of human and environmental factors, that played a role in delaying diagnosis and management of this uncommon but treatable complication of pregnancy.
1. James AH, et al. Circulation 2006; 113:1564-71.
2. Sahni G. Cardiol Clin 2012; 30:343-67.
3. Shahabi S, et al. Upsala J Med Sci 2008; 113:325-330.