Pregnancy complicated by myocardial infarction

Abstract

A 37-year-old woman with a coronary thrombosis was transferred to the obstetricward because shewas in the 33rdweek of pregnancy. The thrombosis was indicated by a creatine phosphokinase MB fraction of 38 ng/mL, along with an ST-segmentelevation in leadsV1 throughV3on theelectrocardiogram. We detected the blockage of a thin anterior interventricular artery on coronography, which was immediately performed, and ventriculography revealed important anteroapical akinesia. Following a right interventricular transluminal angioplasty, the patient was treated with 200 mg per day of metoprolol, 20 mg of furosemide twice per day, and 160 mg per day of salicylic acid, and remained stable. The maximal concentration of creatine phosphokinase was measured 7 hours after treatment initiation. Corticosteroid therapy was initiated for lung maturation even though the fetal signs were reassuring. The findings of a clinical examination were all within normal limits a week later, but a control electrocardiogram showed a Q wave infarction and a control echocardiography showed a small anteroapical area of akinesia. The ejection fraction of the left ventricle was 40%. The remainder of the pregnancy was uneventful, with satisfactory maternal and fetal vitality, and vaginal delivery was allowed. The patient gave birth at 36 weeks to a female neonate weighing 2700 g with an Apgar score of 10 at 5 minutes. She returned home 10 days postpartum with the same pharmacologic treatment. Coronary thrombosis can arise at any age and in all phases of pregnancy, but mostly during the third trimester. The coronary affection frequently affects only 1 vessel. Most maternal deaths arise at the time of infarction or in the 2 weeks following infarction, which often coincide with delivery. Fetal death in utero is often concomitant with maternal death, and maternal and fetal mortality from maternal myocardial infarction is 35% and 34%, respectively [1]. Diagnosis is generally delayed in pregnant women because of a low threshold of suspicion for myocardial infarction during pregnancy, even though the clinical signs are the same for pregnant women and the general population. Once myocardial infarction has been evoked as a possibility, diagnosis is confirmed by an electrocardiogram, the measurement of myocardial necrosis enzymes, and magnetic resonance imaging [2]. As a rule, pregnancy does not affect the diagnostic and therapeutic plans. In cases of arterial obstruction, early reperfusion by transluminal coronary angioplasty is the preferred option because it has fewer contraindications than thrombolysis [3]. The choice between angioplasty and thrombolysis will depend on team experience, time since the infarction, extent and severity of the infarct, and pregnancy duration. The remainder of the pregnancy is most often uneventful, with normal fetal development, which makes a cesarean delivery unwarranted in most cases. Outside of obstetric indications, a cesarean delivery is necessary in women with an unstable cardiac function or a hemorrhagic syndrome [4]. Women who experience myocardial infarction during pregnancy will benefit from a cardiovascular evaluation after delivery to assess the left ventricular function. At that ⁎ Corresponding author. 7 Rue de l'Arabie Saoudite, 4011 HammamSousse, Tunisia. Tel.: +216 72 285 633; fax: +216 73 21 94 86. E-mail address: youssef_benbrahim@yahoo.fr (Y.B. Brahim). ava i l ab l e a t www.sc i enced i r ec t . com