Pregnancy, Myocardial Infarction and split-site hospitals: A management challenge
Case Report
A 29 weeks pregnant lady (G2, P1) presented, with chest pain, breathlessness and ST segment
depression. Echocardiogram showed good LV function with no RWMA. She was admitted to CMU
and treated for NSTEMI. Angiogram revealed dissection of left circumflex artery (LCX) and >90%
obstruction in left anterior descending artery (LAD). Provisional diagnosis of viral myo-pericarditis or
NSTEMI. An MDT agreed on following i) an elective LSCS at 33 weeks under GA or spinal ii) labour
analgesia with Entonox/ PCA /epidural, iii) Elective percutaneous coronary intervention at 3 months
postpartum or an emergency PCI if she becomes unstable. Considering that obstetric and cardiac
services are on two different sites (6 miles apart), it was decided that her elective /emergency LSCS
should be done in a cardiac theatre. At 31 weeks, patient developed a large haematoma in anterior
abdominal wall and dropped Hb to 7.7 (gm/dl). Her antiplatelet and LMWH therapy was stopped,
RBC (2 units) transfused and transferred to obstetric unit. At 32 weeks, patient went into labour and
delivered a healthy baby; labour analgesia was achieved with Entonox. On the 4th postoperative day,
patient developed chest pain and transferred to cardiac unit. Angiogram showed new dissection in
left LAD with distal thrombus. Considering she was high risk for stent thrombosis, cardiologists
decided to treat her medically. She remained haemodynamically stable and was discharged from
hospital.
Discussion
Spontaneous coronary artery dissection (SCAD) accounts for >27% of myocardial infarction cases in
pregnancy.1 Because of its rarity, evidence-base to manage this condition is non-existent. For us, the
key challenge was how to balance her cardiac needs with obstetric needs, in two different hospitals,
this was unique, and warranted a lot of thinking, planning and resource allocations. Thrombolysis is
best avoided in patients with dissection and PCI is considered the preferred management.
References
1. Roth A, Elkayam U. Acute MI associated with pregnancy. Journal of American College of
Cardiology, 2008;52:171-80
2. Appleby CE, Barolet A, Ross J, et al. Contemporary management of pregnancy-related coronary
artery dissection: A single-center experience and literature review, Experimental & Clinical
Cardiology 2009;14(1): e8–e16.