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Cesarean Delivery 40 Days after STEMI with PCI and Drug Eluting Stent Placement
Abstract Number: SUN-75
Abstract Type: Case Report/Case Series
Introduction: Acute myocardial infarction is a rare event during pregnancy, with an estimated incidence of one in 16,000 pregnancies. Cardiovascular changes associated with pregnancy, labor, and delivery may precipitate myocardial ischemia. Parturients with recent myocardial infraction require careful anesthetic and physiological management of labor and delivery in order to avoid further ischemia and myocardial decompensation.
Case Description: A 28 year-old primiparous woman at 34+6 weeks gestation presented with chest pain. Her past medical history was significant for osteogenesis imperfecta and a previous right coronary artery dissection requiring three cardiac stents six years earlier. Her examination revealed EKG changes, elevated troponins, and new echocardiographic wall motion abnormality consistent with STEMI. Angiography revealed an acute dissection of the LAD coronary artery and a drug eluting stent was placed by interventional cardiology. Once stable, the patient was discharged on dual antiplatelet therapy. Coordination between cardiology, maternal fetal medicine, and anesthesiology physicians resulted in a plan for a scheduled induction of labor four weeks after cardiac stenting. A lumbar MRI was performed revealing anatomy favorable for lumbar epidural placement. The patient was instructed to stop clopidogrel seven days before the scheduled induction.
Upon planned presentation, the patient’s interval medical history was reviewed and continuous hemodynamic monitoring, including an arterial line, was initiated. Labor analgesia was achieved with a carefully titrated lumbar epidural with planned passive second stage of labor with assisted vaginal delivery in order to reduce maternal cardiac stress. However, due to arrest of fetal descent, a cesarean delivery was performed in a controlled manner under epidural anesthesia, producing a vigorous female infant with APGARs of 9/9. The patient tolerated the procedure well without any cardiac events and had an unremarkable postpartum course.
Discussion: Due to the rare nature of peripartum myocardial infarction and variable patient characteristics, there is no consensus on the optimal method of delivery for these cases. Both vaginal and cesarean deliveries are reported in the literature and each has its theoretical advantages. In this case, cesarean delivery was indicated due to fetal malposition and arrest of descent and was safely performed in a controlled manner via epidural anesthesia.
The successful management of this patient was ultimately the result of a multidisciplinary approach with close collaboration between obstetricians, cardiologists, and anesthesiologists.