Ischemic heart disease in pregnancy


Prevalence of IHD in pregnancy is 1:10,000
Incidence of M.I in pregnancy is 7.5:100,000
Over all mortality rate is 37%


Risk factors
diabetes
smoking
family history of myocardial infarction before age 60
hypercholesrolaemia
history of chronic hypertension
Kawasaki disease,
hypertrophic cardiomyopathy
cocaine use

atherocelerosis accounts for less than 50% of cases but dissection of coronary arteries is relatively common.



ECG
normal pregnancy-left-axis deviation and non-specific ST and T wave
changes.Serial ECG is important in diagnosis

Chest X ray-enlargement of the heart, straightening of the left
heart border, and increased vascular markings


CK-MB correlates with non pregnant state by usage is limited in labour & delivery

Troponin-I is the marker of choice as the level is not affected by pregnancy,labour or obstetric anaesthesia.

Echocardiography helps to check  abnormal ventricular wall motion.




Differential diagnosis
1.Acute pulmonary embolism
2.Aortic dissection


Management of MI is similar to non pregnant patients

Setting : Coronary care unit

Drugs:
1.Oxygen
2.Morphine
3.Nitrates
4.Aspirin
5.Beta blockers
6.heparin

Multidisciplinary care -cardiologist,obstetrician,anaethesiologist

Primary PCI(percutaneus coronary intervention) is the treatment of choice but if it isn't feasible thrombolysis should be considered.Anticoagulation is considered if embolus  is demonstrated in angiography,otherwise risk of thrombolysis slightly outweighs the benefit.Large molecular weight Tissue plasminogen activator wouldn't cross the placenta but there is a risk of premature labour & haemorrhage.



Streptokinase
no reports linking to congenital defects.
Minimal amount crosses plancenta,so no fibrinolytic effects on fetus.

Urokinase

It isn't teratogenic in animal studies.It is n't known whether it crosses placenta but there are proteinase inhibitors in the placenta which inactivates urokinase.

angioplasty and systemic and local thrombolytic therapy has been
described.'fragile'nature of coronary vessels in pregnancy should be kept in mind when considering angioplasty or angiography.


Radiation exposure to fetus during cardiac catheterisation & interventional procedure is less than 0.01 Gy


Use of clopidogrel also seems to be safe.

 

Delivery

Caesarean section is indicated for Obstetric reasons & It doesn't improve the survival.Second can be limited with forceps.
Delivery with in the first two weeks after ischemic heart disease should be avoided if possible.ECG monitoring should be done in labour.Epidural anakgesisa is recommended.

Third stage -avoid ergometrine as it can cause coronary spasm


Good outcomes have been reported  from subsequent pregnancies in patients with left ventricular aneurysm and also in patients who suffered cardiac arrest during MI.   


Future pregnancy

There is no evidence to suggest that pregnancy predisposes for anothe episode of MI but if the aetiology had been a coronary  embolus the risk of recurrence should be carefully considered.

poor prognostic features
1.left ventricular dysfunction
2.persistence of ischaemia


statins should be discontinued preconception as there is a risk of fetal anomalies(CNS & Limb defects)

Useful article

 

1.Nelson-Piercy C. Handbook of Obstetric Medicine, Second Edition. 2nd ed. Taylor & Francis; 2001.

2.Swiet MD. Medical Disorders in Obstetric Practice. 4th ed. Wiley-Blackwell; 2002

3.	Fayomi O, Nazar R. Acute myocardial infarction in pregnancy: a case report and subject review. Emerg Med J. 2007 Nov 1;24(11):800-801.