Spontaneous Coronary Artery Dissection in Pregnancy

Abstract

Spontaneous coronary artery dissection is a major cause of myocardial infarction in pregnancy and the postpartum period. It occurs predominantly in young women with few or no conventional risk factors for atherosclerosis and has been clinically underrecognized. Treatment differs from that of myocardial infarction as a result of atherosclerosis and the diagnosis should be considered in all parturient and postpartum patients with acute coronary syndrome. Complications of spontaneous coronary artery dissection include recurrence, congestive heart failure, and death. Thus, specialist obstetrician-gynecologists and maternal-fetal medicine specialists need to gain knowledge of spontaneous coronary artery dissection to improve outcomes.

Mode of Delivery for a Term Patient with Spontaneous Coronary Artery Dissection

“…There appears to be a consensus in the literature that conservative medical management is the most appropriate mode of treatment for clinically stable patients 4,[11][12][13]17 . In contrast to this, there is very little data on the best mode of delivery for patients who have suffered from SCAD during the pregnancy.…”

“…Recommendations from many years of experience with cardiac patients who are pregnant have focused on decreasing the risk to the mother during delivery. Early epidural placement is recommended for all women with cardiac history as it will decrease the sympathetic stimulation in response to pain, thereby decreasing myocardial oxygen consumption during labor 4,18,[21][22] . The second stage of labor is associated with an increase in hemodynamic and oxidative cardiac stress, likely secondary to strenuous Valsalva necessary for fetal expulsion 4,18,21 .…”

“…Early epidural placement is recommended for all women with cardiac history as it will decrease the sympathetic stimulation in response to pain, thereby decreasing myocardial oxygen consumption during labor 4,18,[21][22] . The second stage of labor is associated with an increase in hemodynamic and oxidative cardiac stress, likely secondary to strenuous Valsalva necessary for fetal expulsion 4,18,21 . Operative vaginal delivery and a shortened second stage will reduce the amount of Valsalva necessary for delivery, thereby reducing the oxidative stress on the heart 4,18,21,23 .…”

“…Additionally, after delivery of the placenta there is a 500 cc autotransfusion that occurs which may not be tolerated by the patient with cardiac decompensation 21 . It is recommended that delivery be postponed at least two weeks from the time of infarction if possible to allow for some amount of cardiac healing after the ischemic event 4,[18][19][20] . Maternal mortality is higher if delivery is sooner than two weeks from the ischemic event, possibly due to increase in hemodynamic requirements during labor which increase the myocardial demand and the risk of recurrent myocardial ischemia in a heart that has not had sufficient time to heal from the initial ischemic event [18][19][20] .…”

“…In the Mayo clinic SCAD registry, 49% of patients presented with ST elevation myocardial infarction (STEMI), 44% presented with non-ST elevation myocardial infarction (NSTEMI) and 7% presented with unstable angina 3 . Among pregnant women, the most common time for presentation was in the late third trimester, intrapartum or postpartum 4 .…”