Subsequent Pregnancy in a Patient With Spontaneous Coronary Artery Dissection

Abstract

Spontaneous coronary artery dissection (SCAD) is an exceedingly rare condition that primarily affects women in late pregnancy and post partum period. While rare, the mortality in the acute episode may approach 38%. In the literature there are several reports of SCAD in pregnancy and the post partum period but none describe the management of such patients in a subsequent pregnancy. We report a case of SCAD in the post partum period requiring coronary intervention with placement of four stents. The patient presents for prenatal care for a subsequent unplanned but desired pregnancy. Multidisciplinary care was instituted, including close cardiology follow-up. She remained asymptomatic throughout the pregnancy and post partum period. SCAD as a rare cause of acute coronary syndrome carries a significant mortality especially if there is a delay in diagnosis, and management. It should be an important part of the differential diagnoses for a clinician working up a female patient with chest pain in late pregnancy and post partum period. While our patient had a favorable outcome during the subsequent pregnancy, delivery and post partum periods, close follow-up and comanagement with cardiology is important in the care of such patients. Given the lack of available clinical information, management recommendations are suggested using expert opinion and tangential data.

Pregnancy-Associated Spontaneous Coronary Artery Dissection in Women: A Literature Review

“…* P-SCAD cases NP-SCAD cases Fibromuscular dysplasia (complete screens) (n = 63) 17 (27) (n = 411) 233 (56.7) Fibromuscular dysplasia (including all screens) (n = 63) 17 (27) (n = 750) 550 (73.3) Systemic inflammatory condition (n = 54) 1 (1.8) (n = 664) 35 (5.3) Connective tissue disorder (n = 23) 2 (8.7) (n = 664) 27 (3.6) ⁎ Values are presented as n (%). Sources: Saw et al, 11 Havakuk et al, 12 Tweet et al, 13 Tweet et al, 14 Faden et al, 15 Elkayam et al, 16 Cade et al, 17 Numasawa et al, 18 Manasrah et al, 19 Yogeswaran et al, 20 Lee et al, 21 Sharma et al, 22 Davis et al, 23 and Elshatanoufy et al 24 …”

“…The findings pertaining to SCAD onset are reported in Table 3 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 in P-SCAD patients (n = 510). The largest occurrence of P-SCAD occurred during pregnancy or within 30 days after delivery.…”

“… ⁎ Values are presented as n (%). Sources: Saw et al, 11 Havakuk et al, 12 Tweet et al, 13 Tweet et al, 14 Faden et al, 15 Elkayam et al, 16 Cade et al, 17 Numasawa et al, 18 Manasrah et al, 19 Yogeswaran et al, 20 Lee et al, 21 Sharma et al, 22 Davis et al, 23 and Elshatanoufy et al 24 …”

“…Given the potentially devastating consequences of SCAD, especially during pregnancy, its recurrence was also investigated, 6 , 12 , 13 , 14 , 21 , 22 , 23 , 24 , 25 , 26 , 27 and the findings are reported in Table 8 . Although very few authors reported these data based on a limited number of cases, including SCAD patients from the Mayo Clinic SCAD registry with child-bearing potential, it appears that the risk is relatively low, but does increase after 2 years following delivery in women who have previously had SCAD or P-SCAD.…”

“…* Postpartum Tweet et al 13 (n = 54) Tweet et al 14 (n = 23) Davis et al 23 and Elshatanoufy et al 24 (n = 2) ≤12 wk after delivery 4 (7.4) 0 (0) 0 (0) >12 wk after delivery 0 (0) 0 (0) 0 (0) >13 mo after delivery 0 (0) 0 (0) 0 (0) >2 y after delivery 4 (7.4) 2 (8.7) 2 (100) ⁎ Values are presented as n (%). Sources: Saw et al, 11 Hayes et al, 6 Tweet et al, 13 Tweet et al, 14 Lee et al, 21 Sharma et al, 22 Davis et al, 23 Elshatanoufy et al, 24 Clare et al, 25 Tweet Eleid et al, 26 and Saw et al 27 . …”