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Obstetric Anesthetic Management of a Parturient with an Acute ST Elevation Myocardial Infarction: A Case Report
Abstract Number: F-45
Abstract Type: Case Report/Case Series
Acute myocardial infarction (AMI) is a rare occurrence during pregnancy which has been documented to occur in approximately 1 in 10,000 live births.1 Multiple etiologies have been recognized with the most common cause of AMI in this patient population being atherosclerosis with other notable causes including coronary artery thrombosis, coronary artery spasm, coronary artery dissection, vasculitis, collagen vascular disease, and pheochromoctyoma.2 Pregnancy has been noted to increase the risk of AMI 3- to 4-fold. Maternal age, maternal gravidity, stage of pregnancy, as well as progesterone-induced biochemical and structural changes have been identified as pregnancy-specific risk factors which cause an increased incidence of AMI in this population. The following case report presents a 28-year old parturient with acute onset chest pain and negative cardiac risk factors who was found to have an acute ST-elevation myocardial infarction (STEMI) in the 35th gestational week and the associated obstetric anesthetic management. Patient denied any previous past medical history and her past surgical history was only significant for a previous classical cesarean section in 2005. STAT EKG demonstrated diffuse ST-segment elevation in leads I, aVL, V2, and V3 consistent with an acute anterolateral myocardial infarction. Cardiac catheterization revealed an ostial 70 – 80% occlusion of the LAD, a 50 – 60% lesion of the mid LAD, and very high suspicion of spontaneous dissection extending from the ostial LAD to the distal LAD. Patient was subsequently medically managed per acute coronary syndrome (ACS) protocol. Cardiothoracic Surgery service was consulted and planned for a 2-vessel CABG after cesarean section. Patient was urgently delivered via repeat cesarean section secondary to labile blood pressures and irregular contractions. A General Anesthetic was chosen as the obstetric anesthetic regiment to allow for stricter control of the patient’s hemodynamics. Apart from acute hemodynamic changes involved with direct laryngoscopy, the patient did extremely well intra-operatively post delivery of the healthy newborn as well as post-operatively. On Day 6 of admission, the patient subsequently had an uneventful CABG performed and was discharged 10 days after admission.
1. Dwyer B, Taylor L, Fuller A, Brummel C, Lyell DJ. Percutaneous transluminal coronary angioplasty and stent placement in pregnancy. Obstet Gynaecol, 2005; 106: 1162-4.
2. Roth A, Elkayam U. Acute myocardial infarction associated with pregnancy. Ann Intern Med 1996; 125: 751-62.
3. Ladner HE, Danielson B, Gilbert WM. Acute Myocardial Infarction in Pregnancy and the Puerperium: A Population-Based Study. Obstet Gynaecol, 2005; 105: 480-4.
4. Manalo-Estrella P, Barker AE. Histopathologic findings in human aortic media associated with pregnancy. Arch Pathol 1967; 83: 336-41.
5-10. Roth A, Elkayam U. Acute myocardial infarction associated with pregnancy. Ann Intern Med 1996; 125: 751-62.