Pregnancy-Associated Myocardial Infarction (PAMI) Post Elective Caesarean Section

Abstract

A 26-year-old female complained of chest tightness one day after elective caesarean section. The delivery was uneventful with the birth of a healthy baby and a normal postnatal recovery. She was treated for hypothyroidism but had no cardiovascular risk factors or history of recreational drug use. Initial troponin was slightly elevated at 0.066 with no ischaemic changes on ECG. CT angiography was negative for pulmonary embolism and aortic dissection. Transthoracic echocardiogram showed normal LV size and systolic function (EF∼60%) with no pericardial effusion. Persistent symptoms for four hours was associated with a peak troponin of 0.46 and evolution of transient inferolateral ST elevation of ∼1-2 mm. Vasculitic screen included C-reactive protein (CRP) 144 mg/dL, erythrocyte sedimentation rate (ESR) 71 mm/hr, antinuclear antibody (ANA) 40 IU/mL, negative extractable nuclear antigen (ENA) and negative cytoplasmic and perinuclear anti-neutrophil cytoplasmic antibodies (c and p-ANCAs). Urgent coronary angiography revealed normal coronary arteries and normal LV function with no evidence of spontaneous coronary artery dissection or plaque rupture. The interventional cardiologist's impression was possible transient coronary vasospasm however super-imposed thrombosis in a small vessel or autoimmune vasculitis could not be excluded. Conclusion: This case describes a rare presentation of pregnancy-associated myocardial infarction (PAMI) with an unremarkable coronary angiogram. A review of 132 PAMI case studies, revealed only 11% had normal coronary anatomy, with cases more commonly associated with coronary dissection (43%) and atherosclerotic disease (27%) [[1]Elkayam U. Jalnapurkar S. Barakkat M.N. Khatri N. Kealey A.J. Mehra A. et al.Pregnancy-Associated Acute Myocardial Infarction: A Review of Contemporary Experience in 150 Cases Between 2006 and 2011.Circulation. 2014; 129: 1695-1702Crossref PubMed Scopus (236) Google Scholar]. Future research should investigate triggers such as oxytocin for transient presentations suggestive of myocardial infarction in pregnancy [[2]Srivastava U. Chauhan N. Gupta V. Singh T.K. Kumar A. Incidence of electrocardiographic changes indicating myocardial ischaemia during caesarean sections under spinal anesthesia.Journal of Obstetric Anaesthesia and Critical Care. 2015; 5: 73-77Crossref Google Scholar].