Cardiac disease in pregnancy and acute myocardial infarction

Cardiac disease in pregnancy Microchapters
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Special Scenarios: I. Pre-existing Cardiac Disease: Congenital Heart Disease Repaired Congenital Heart Disease Pulmonary Hypertension Rheumatic Heart Disease Connective Tissue Disorders II. Valvular Heart Disease: Mitral Stenosis Mitral Regurgitation Aortic Insufficiency Aortic Stenosis Mechanical Prosthetic Valves Tissue Prosthetic Valves III. Cardiomyopathy: Dilated Cardiomyopathy Hypertrophic Cardiomyopathy Peripartum Cardiomyopathy IV. Cardiac diseases that may develop During Pregnancy: Arrhythmias Acute Myocardial Infarction Hypertension
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

• First reported case in 1922
• Incidence ~1/10000
• Ages range 16-45
• Most common in 3rd trimester women > 33 years of age
• Anterior wall most commonly involved
• Maternal mortality 21% (most at time of MI or within 2 weeks- usually with labor and delivery)
• Outcomes better if MI early in pregnancy
• Fetal deaths usually associated with maternal deaths

Pathophysiology

Caths in 54% of published cases:

• CAD with or without thrombus 43% (58% in prepartum period)
• Thrombus without CAD 21%
• Normal coronaries 29% (75% in peripartum period MIs)
• Coronary dissection 16% (33% in postpartum period)

Risk factors

• Family history of coronary artery disease
• Hyperlipidemia
• Low HDL
• High LDL
• Smoking
• Previous oral contraceptive use

Diagnosis

• EKG and enzymes are the gold standard
• 37% of patients undergoing elective C-section have EKG changes suggestive of MI or ischemia
• Echocardiography to assess regional wall motion abnormalities can be useful
• Nuclear imaging and diagnostic cath exposure to conceptus <0.01 Gy (0.05 Gy considered to be threshold value)

Pharmacotherapy

Check with pharmacist or Maternal Fetal Medicine Specialist before any drug administration

• ASA - low dose
• Nitrates – use low dose to prevent fetal distress
• Beta-1 selective Beta-blockers
• Magnesium
• Morphine sulfate

Drugs to be Avoided

• Avoid ACE inhibitors and warfarin due to teratogenicity
• Thrombolytics mostly untested

• Greatest experience in massive pulmonary embolism
• Streptokinase does not cross placental membrane in animals, but Ab found in neonatal spinal cord fluid
• Urokinase not teratogenic in mice/rats
• Risk for maternal hemorrhage (1 case of placental abruption reported); increased risk when given at time of delivery
• Delivery best delayed at least 2-3 weeks

References

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