Advanced maternal age parturient: Is there reason for concern?

Abstract

Sir, The literature concerning intraoperative myocardial infarction (MI) in pregnancy is very limited (1). The most common mechanisms include coronary artery vasospasm, dissection, and hypercoagulability or plaque rupture (2). I herein report a case of a parturient with unrecognized severe 3 vessel coronary artery disease who developed acute MI during an emergent cesarean section under regional anesthesia. A 42-year-old gravida 3 para 2 previously ‘healthy’ female admitted with nonspecific chest and abdominal pain in active labor at 36 weeks' gestation required emergent cesarean section secondary to previous classical uterine incision. Preoperative electrocardiographic (ECG) evaluation revealed a nonspecific (1 mm) ST-segment depression. Invasive intra-arterial blood pressure monitoring was initiated and a T4 sensory level of spinal anesthesia was established with 12 mg of 0.75% bupivacaine, 10 µg of fentanyl and 0.2 mg of morphine. Immediately after delivering the fetus the patient developed intense chest pain, hypotenison and ST-segment depression (5 mm). A Swan-Ganz catheter (Edwards Lifesciences LLC, CA, USA) was deemed necessary to facilitate intraoperative monitoring. Chest pain was successfully treated with sublingual nitroglycerin while intravenous phenylephrine restored blood pressure to normal. Surgery was promptly completed. Thirty hours postoperatively, continuous ECG monitoring and cardiac enzymes were indicative of a non-Q wave MI. A trans-thoracic echocardiogram showed a significantly reduced (25%) left ventricular ejection fraction. Coronary angiogram demonstrated severe 3 vessel coronary artery disease. Extensive coronary artery bypass graft was successfully conducted in the immediate postpartum period. The author of this report is not aware of any reports documenting emergent, intraoperative anesthetic management of a parturient presenting with unrecognized severe coronary artery disease and an acutely evolving MI. In summary, this case should serve as a warning that, although extremely rare, evolving MI may be occasionally encountered intrapartum, particularly in ‘advanced maternal age’ (AMA) parturients. Because of the increasing incidence of pregnancy in AMA women, increased vigilance by obstetricians and obstetric anesthesiologists is required. Address for correspondence: Krzysztof M. Kuczkowski Department of Anesthesiology UCSD Medical Center 200 W. Arbor Drive San Diego CA 92103–8770 e-mail: kkuczkowski@ucsd.edu