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Approaching Complex Management Decisions for a Pregnant Patient Presenting with NSTEMI
Abstract Number: RF6AI-441
Abstract Type: Case Report Case Series
A 39 y.o. AA G11P5237 at 29w3d with PMHx of HTN and GDM presents with chest pain, headache, BP 215/120, and troponin elevation to 0.32. She was admitted for hypertensive urgency, superimposed pre-eclampsia with SF, and concern for demand ischemia. BP was controlled with labetalol, hydralazine, nifedipine, and magnesium. Cardiology was consulted and echo showed LVH and normal LVEF with no evidence of RWMAs. She later developed substernal chest pain with troponin elevation to 2.11 and was started on heparin gtt, ASA 325mg, and atorvastatin 40mg. Coronary angiography was considered, however patient had non-reactive NST and BPP 6/10 concerning for worsening placental function, so we proceeded with cesarean delivery prior to angiography/potential PCI. Uncomplicated CD was performed under GA with pre-induction arterial line. Post-operatively, LHC was performed showing normal coronaries, and patient was discharged to home on ASA, Coreg, Cardizem, and HCTZ.
Discussion: Acute myocardial infarction (AMI) during pregnancy is rare, estimated at 3-100 per 100,000 women in the US, but carries significant morbidity and mortality (estimated 11% maternal and 9% fetal fatality). In addition to standard risk factors for AMI, factors specific to pregnant women include pre-eclampsia and physiological changes of pregnancy such as increased cardiac output, dilutional anemia, and hypercoagulable state. Pregnant women are also at increased risk of spontaneous coronary artery dissection, possibly due to progesterone-induced degeneration of connective tissue in the coronary intima and media(1).
Management of AMI in pregnant women follows the same principles as in the general population, though fetal risk adds additional complexity to decisions. Some common AMI treatments, including ACEi/ARBs and statins, are contraindicated in pregnancy due to risk of teratogenicity(1). Coronary angiography also presents teratogenic risks from ionizing radiation and risk of fetal hypothyroidism from iodinated contrast agents, as well as the need for DAPT if PCI is performed(2). Our patient most likely had a type 2 NSTEMI secondary to hypertensive crisis precipitated by severe pre-E. Monitors showed signs of poor uteroplacental perfusion and fetal distress, indicating that the fetus was no longer tolerating pregnancy. Additionally, anticoagulation during angiography, and the possibility of PCI and DAPT, would complicate an already urgent delivery. Thus, the decision was made to deliver prior to angiography.
This case illustrates the complexity of decision-making when approaching AMI in pregnant patients. Though AMI in pregnancy carries significant morbidity, collaboration between obstetrics, anesthesiology, and cardiology in shared decision-making increase the patient’s chance for a good outcome.
1. Ismail S, et al. Clin Card. 2017;40:399-406
2. Jaiswal A, et al. Ind Heart J. 2013 Jul-Aug;65(4):464-8