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Peripartum management of antiplatelet therapy in a patient with recent myocardial infarction and drug eluding stent.
Abstract Number: SU-34
Abstract Type: Case Report/Case Series
No set guidelines exist for management of antiplatelet therapy in the peripartum period. This case report highlights current evidence on treatment of cardiovascular disease during pregnancy with emphasis on management following percutaneous coronary intervention and antiplatelet therapy. A 35 y.o. G4P0030 was treated for STEMI with DES to LAD at 3w gestation. Post STEMI course was initially complicated by ischemic cardiomyopathy, with LVEF of 20-25%, with recovery to normal within two months. Dual antiplatelet therapy with aspirin and prasugrel was continued until 34w2d, at which time the patient was admitted for concern of superimposed preeclampsia. After multidisciplinary input from obstetrics, anesthesiology and cardiology, and anticipating the need for induction of labor and delivery, prasugrel was discontinued and labor was induced 14 days later allowing for neuraxial labor analgesia. Low dose aspirin was continued during the peripartum period. An epidural was placed for labor analgesia. Arrest of dilation occurred at 4cm and fetal intolerance of labor necessitated cesarean delivery, performed under epidural anesthesia. Prasugrel was restarted 12h post cesarean delivery.
While there is general agreement that time off dual antiplatelet therapy and cardiac stress during delivery should be minimized, there is no standard protocol mitigating the potential risk factors for acute myocardial infarction (AMI) during pregnancy. The 2014 ACCAHA guidelines on management of patients undergoing noncardiac surgery state that “perioperative antiplatelet therapy should be determined by a consensus of the surgeon, anesthesiologist, cardiologist, and patient, who should weigh the relative risk of bleeding versus prevention of stent thrombosis.” Recommendations on mode of delivery likewise rely on multidisciplinary consensus of the obstetrician, cardiologist and anesthesiologist.
While AMI in pregnancy is rare, occurring in 3-10 per 100,000 pregnancies, with recent mortality estimates of 5.1-7.3%, the US parturient population is becoming older and more likely to exhibit preexisting cardiac risk factors. The risk of AMI during pregnancy is strongly associated with increasing age, HTN, smoking and diabetes mellitus. Population studies identified that 38% of AMI occurred antepartum and 37% of women with AMI during pregnancy underwent angioplasty, stent placement or bypass surgery, requiring antiplatelet therapy for a period of time. Additional reports on management of AMI during pregnancy will help to devise protocols outlining effective ways to manage AMI risk factors while minimizing adverse pregnancy and labor outcomes.
James A et al. Acute myocardial infarction in pregnancy. Circulation. 2006;113:1564-71.
Ladner H et al. Acute myocardial infarction in pregnancy and the puerperium. Obstet Gynecol. 2005;105:480-84.
Yarrington C et al. Cardiovascular management in pregnancy. Circulation. 2015;132:1354-64.