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A Case of Spontaneous Coronary Artery Dissection and Subsequent Myocardial Infarction During Pregnancy
Abstract Number: T4D-2
Abstract Type: Case Report/Case Series
Introduction: Spontaneous coronary artery dissection (SCAD) is a separation of the layers within the coronary artery wall that is non-iatrogenic and not secondary to trauma. Intramural hematomas form creating a false lumen which compresses the true arterial lumen. This decreases anterograde blood flow and leads to subsequent myocardial ischemia. Up to 1 in 4 myocardial infarctions during pregnancy are the result of SCAD.
Case: A 32 yo G4P2 at 35w4d presents with chest pain. This pregnancy was complicated by an acute myocardial infarction approximately 1 month previously secondary to SCAD in the LAD. A cardiac catheterization at the time showed a focal lesion in the LAD with preserved distal flow, thus no surgical intervention was warranted at the time. Upon the current presentation, she was managed medically. The workup for ACS was negative. Given the concern for recurrence of SCAD in the pregnant state, she underwent an elective C-section at 36w1d. A radial arterial line was place prior to placement of neuraxial analgesia. An epidural was placed with slow titration of 2% lidocaine. The patient was hemodynamically stable throughout and there were no ECG changes. A healthy baby was delivered. There were no further cardiac complications and the patient was discharged on post-op day 3 on aspirin and clopidogrel and scheduled to follow up with a cardiologist.
Discussion: Although rare, SCAD is the most common cause of myocardial infarction during pregnancy and the postpartum period. SCAD should be considered in the differential of any woman presenting with chest pain during pregnancy. Currently, there is no consensus on the standard management for SCAD and evidence is lacking due to its rarity and the absence of randomized controlled trials. Blood pressure and heart rate control should be established to reduce the shear stress on the vascular walls. A C-section or a vaginal delivery with profound analgesic coverage that minimizes pushing and thus the sympathetic response would seem to be the ideal modes of delivery. This may require forceps or vacuum assistance if the delivery is to be done vaginally. In hemodynamically stable patients such as the one presented above, conservative therapy and medical management is reasonable until the time of delivery. Unstable patients may require further interventions such as a PCI if there is an identifiable lesion. Urgent surgical treatment is generally reserved for dissections with coronary occlusion with hemodynamic instability or cardiogenic shock.
Naderi, S. Spontaneous Coronary Artery Dissection and Pregnancy. Curr Treat Options Cardio Med (2017) 19:69 Rose, E et al.
Pregnancy-Related Spontaneous Coronary Artery Dissection: A Case Series and Literature Review. The Journal of Emergency Medicine. 2017 Jun; 52(6): 867-874
Franca JC et al. Unusual presentation of extensive spontaneous coronary dissection: Case report literature review. ARYA Atherosclerosis. 2017 Jan; 13(1): 46-49