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A Pregnant Patient with Suspected Spontaneous Coronary Artery Dissection and Cardiac Arrest Likely Secondary to a History of Kawasaki Disease as a Child
Abstract Number: F-54
Abstract Type: Case Report/Case Series
We present a 32 year old G2P1001 at 32w4d estimated gestational age with a past medical history of gestational diabetes and an undisclosed history of Kawasaki Disease (asymptomatic since early childhood). She presented to L&D clinic with nausea and vomiting, fever, chills, and worsening malaise for 6 days. Her office vitals were BP 97/59, T 36.9, HR 100. Monitoring showed no signs of fetal distress. Rapid flu/PCR was negative. Her symptoms were attributed to a viral illness and she received IV Zofran and IVNS, after which she felt dramatically better.
The next day her symptoms returned and became progressively worse. She also began complaining of chest pain and shortness of breath. She returned to the hospital 2 days after the clinic visit and collapsed in the lobby. She was able to avoid trauma to her head. When approached the patient was AOx1 and barely able to keep her eyes open. A code blue and code pink were called. She was brought emergently to the L&D recovery area and received 2L IVNS during transport for tachycardia and hypotension. She was immediately placed in left uterine displacement.
Her vital signs were stable and she was lethargic but lucid, her neurological exam was unremarkable, and her lungs were clear to auscultation. Stat labs were sent (although the results were unknown for roughly 30 minutes), and they were significant for a metabolic acidosis and elevated troponin.
She was having ten second runs of wide-complex tachycardia roughly every 1.5 mins, which were becoming more frequent and prolonged. Fetal bradycardia was noted with each episode. TTE showed LV hypokinesis and EKG showed ventricular tachycardia.
Her blood pressure and heart rate remained normal, but with each run of VT her systolic blood pressure dropped to 70s-80s and the patient's mental status would deteriorate, but both would recover with return of sinus rhythm.
An RSI and intubation was performed with etomidate and succinylcholine in anticipation of defribrillation and potential cesarean section. Roughly thirty seconds after intubation the patient lost her pulse and the A-line flattened. She was immediately defibrillated with a return to VTach and pulselessness. CPR was initiated.
At four minutes the L&D team successfully performed a crash cesarean section, packed the abdomen, and covered the incision with Ioban.
The patient’s rhythm eventually deteriorated to ventricular fibrillation. There was never return of spontaneous circulation. After two hours of CPR the patient was declared dead.
The two leading theories of cardiovascular collapse are viral myocarditis and Kawasaki Disease contributing to spontaneous coronary artery dissection (SCAD). Due to religious concerns from the family an autopsy was unable to be performed before burial. All viral cultures were negative, but PCR for enterovirus, adenovirus, and coxsackie virus were unable to be performed. Case reports of sudden death during pregnancy due to SCAD have been described in the literature.