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 Table of Contents 
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 5  |  Page : 2528-2530  

Pregnancy-associated myocardial infarction following elective caesarean section for two previous caesarean sections and myomectomy


1 Department of Family Medicine, Garki Hospital Abuja; Department of Hospital Services, Federal Ministry of Health Abuja, Nigeria
2 Department of Family Medicine, Garki Hospital Abuja, Nigeria
3 Department of Internal Medicine, Garki Hospital Abuja, Nigeria
4 Department of Obstetrics and Gynecology, Garki Hospital Abuja, Nigeria

Date of Submission06-Feb-2020
Date of Decision13-Mar-2020
Date of Acceptance07-Apr-2020
Date of Web Publication31-May-2020

Correspondence Address:
Dr. Adaeze Chidinma Oreh
Department of Hospital Services, Federal Ministry of Health, Abuja 900211
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_225_20

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  Abstract 


A 39-year-old woman, gravida 4, para 2 + 1 (2 alive) for elective second repeat caesarean delivery on account of two previous caesarean sections and one open myomectomy. Following the caesarean section, she developed sudden cardiac failure and was transferred to the intensive care unit for mechanical ventilation support. Congestive cardiac failure secondary to non ST segment elevation myocardial infarction (NSTEMI) was subsequently diagnosed following an electrocardiogram (ECG), echocardiography, and cardiac enzyme assay. The presented case demonstrates the importance of skilled delivery and efficient referral services in developing countries to minimize poor maternal and fetal outcomes in pregnancy-related heart disease.

Keywords: Congestive cardiac failure, myocardial infarction, NSTEMI, pregnancy


How to cite this article:
Oreh AC, Imagbenikaro EoU, Adelaja AM, Ezeogu L. Pregnancy-associated myocardial infarction following elective caesarean section for two previous caesarean sections and myomectomy. J Family Med Prim Care 2020;9:2528-30

How to cite this URL:
Oreh AC, Imagbenikaro EoU, Adelaja AM, Ezeogu L. Pregnancy-associated myocardial infarction following elective caesarean section for two previous caesarean sections and myomectomy. J Family Med Prim Care [serial online] 2020 [cited 2020 Sep 19];9:2528-30. Available from: http://www.jfmpc.com/text.asp?2020/9/5/2528/285098




  Introduction Top


Maternal cardiovascular disease is rare, affecting only 1–4% of pregnancies but causing up to 10–15% of maternal deaths.[1],[2]

Acute myocardial infarction (AMI) is a clinical or pathological event due to myocardial injury or necrosis.[3] Maternal deaths due to AMI have been increasingly reported, however, data from sub-Saharan Africa hardly exists.[1],[2] Although rare in obstetric patients (incidence 3 to 10 per 100,000 deliveries), pregnant women have a three- to four-fold higher relative risk compared to the non pregnant women of reproductive age with mortality rates between 5.1% and 38%.[4],[5]

In pregnancy, risk is heightened by increased myocardial oxygen demand, anxiety, pain, or enhanced venous return following uterine contractions or evacuation of the pregnant uterus.[5]

The commonest cause is coronary atherosclerosis and higher parity (>3), followed by maternal age of above 35 years, pre existing hypertension, diabetes or ischemic heart disease; smoking, obesity, strong family history, dyslipidemia, pre eclampsia, eclampsia, thrombophilia, migraines, postpartum infections, and blood transfusions are risk factors.[4],[6] Awareness of this is therefore vital to primary care practice.

We present a patient who developed cardiorespiratory failure following an elective caesarean section. She was diagnosed with congestive cardiac failure secondary to non ST segment elevation myocardial infarction following ECG, echocardiography, and cardiac enzyme assays. After acute cardiac life support, spontaneous circulation returned, and oxygen saturation stabilized. Institutional ethical clearance was obtained from the Federal Capital Research Ethics Department to report this case.


  Case History Top


A 39-year-old woman, gravida 4, para 2+1 at 37 weeks and two days of gestation, presented at our facility as scheduled for an elective second repeat caesarean delivery on account of two previous caesarean sections and one previous open myomectomy.

The patient had an uneventful medical history prior to and in the index pregnancy. She had no history of hypertension, diabetes, or family history of cardiac disease or sudden cardiac death. Two hours after caesarean delivery under spinal anesthesia with bupivacaine, she developed sudden onset desaturation with chest tightness, tachycardia, and tachypnea.

Bilateral mild lower leg edema was observed. Blood pressure was 114/80 mmHg; pulse rate 132 beats/minute; respiratory rate 28 cycles/minute; temperature 36.2°C, and oxygen saturation 83–86% on 6 L/minute intranasal oxygen delivered via face mask. Fine crepitations were heard in the entire left lung fields. Despite 6–8 L/minute of intranasal oxygen, the patient continued to desaturate (oxygen saturation 78–80%), prompting her immediate transfer from the recovery ward to the intensive care unit (ICU). She was swiftly intubated with mechanical ventilation support.

Laboratory investigations were promptly ordered and completel blood count, serum electrolytes, clotting profile, fasting lipid profile, and fasting blood glucose were within normal limits and urine and blood cultures yielded no bacterial growth. Troponin I, Troponin T and plasma D-Dimer were all elevated (see [Table 1] below). Chest radiography showed the features of interstitial edema. Electrocardiography demonstrated sinus tachycardia and ST segment depression in leads V4-V6. Echocardiography revealed mild left ventricular systolic dysfunction, an ejection fraction of 45%, mild pulmonary regurgitation, mild aortic regurgitation, and mild pulmonary hypertension.
Table 1: Laboratory Investigations at admission into ICU

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A diagnosis of congestive cardiac failure secondary to acute non ST elevation myocardial infarction (NSTEMI) was made.

Diuretics (intravenous frusemide 80 mg 12-hourly), β-blockers (tablets bisoprolol 2.5 mg daily), angiotensin receptor blockers (tablets losartan 25 mg daily), and tablets spironolactone 25 mg daily were administered for cardiac failure; and fluid restriction with nasogastric tube insertion for medication and feeding was initiated. She was also administered subcutaneous enoxaparin 40 mg 12-hourly, tablets aspirin 75 mg daily, tablets clopidogrel 75 mg daily. By the fourth post operative day, her condition was assessed to have improved, and she was extubated. She returned to the general ward on the seventh post operative day and was subsequently discharged home on day eight. Follow up echocardiography done six months post discharge showed an improved ejection fraction of 55%.


  Discussion Top


Little information from low- and middle-income countries exists regarding sudden onset pregnancy-related cardiac disease.[7] Considering a vast majority of births occur at primary care level, availability of skilled obstetric care with efficient referral services would significantly lower the cases of maternal mortality and fetal compromise due to cardiac disease.

The patient presented in this case was regular with antenatal appointments and showed no features that would have raised the suspicion of a cardiac condition. In the index pregnancy and prior antenatal visits, clinical assessments and investigations were uneventful. Her sudden cardio-respiratory compromise necessitated an urgent ECG that showed features of myocardial infarction. Echocardiography though not a routine diagnostic requirement for MI is said to be helpful when a patient presents with the symptoms or signs of MI and the diagnosis is uncertain given the ambiguity of the features of heart failure in peripartum women.[8]

Ideally, the care of the patient with pregnancy-associated myocardial infarction (PAMI) requires a critical care setting with a multidisciplinary team including obstetrician, internist cardiologist, family physician, and anesthetist.[9]

Medical management includes oxygen administration, pain relief, nitrates, aspirin, unfractionated or low molecular weight heparin to prevent further thrombosis, beta-blockers to decrease myocardial oxygen demand and clopidogrel for additional antiplatelet effect.[6]

Previous MI is not an absolute contraindication to subsequent pregnancies; however, pre-conception care must involve full cardiac evaluation with electrocardiogram, stress test, echocardiography, and possibly assessment of the coronary arteries to determine risk.[7]

Pre-conception counseling is thus required to advise patients of risks associated with pregnancy, labor, and delivery. Once pregnancy is diagnosed, patients' physical activity and cardiac symptoms should be reviewed and activities should be restricted where necessary.[7],[9] Regular follow-up should ideally occur in facilities with access to specialist care, as patients remain at a risk of ischemia and associated complications as pregnancy advances.



Few cases of pregnancy-related AMI are reported, and those recorded are often associated with high maternal and infant mortality.[10] Vigilance by a multi-specialist team is therefore crucial ante-, intra-, and postpartum.[9]

The reported patient following cardiorespiratory failure due to AMI after elective cesarean section received prompt care and was recovered. Skilled delivery and efficient referral services for immediate transfer to emergency specialist care whenever necessary are a hallmark of quality primary care. This case highlights the critical role of the primary care practitioner in providing comprehensive and coordinated care across multiple specialties where needed, to avert increased morbidity and mortality especially in developing settings.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Adedapo AD. Rising trend of cardiovascular diseases among South-Western Nigerian female patients. Nig J Cardiol 2017;14:71-4.  Back to cited text no. 1
  [Full text]  
2.
Roos-Hesselink J, Baris L, Johnson M, De Backer J, Otto C, Marelli A, et al. Pregnancy outcomes in women with cardiovascular disease: Evolving trends over 10 years in the ESC Registry of Pregnancy and Cardiac disease (ROPAC). Eur Heart J 2019; 40:3848-55.  Back to cited text no. 2
    
3.
Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al. (ESC Scientific Document Group). Fourth universal definition of myocardial infarction (2018). Eur Heart J 2019;40:237-69.  Back to cited text no. 3
    
4.
Elkayam U, Jalnapurkar S, Barakkat MN, Khatri N, Kealey AJ, Mehra A, et al. Pregnancy-associated acute myocardial infarction a review of contemporary experience in 150 cases between 2006 and 2011. Circulation 2014;129:1695-702.  Back to cited text no. 4
    
5.
Wuntakal R, Shetty N, Ioannou E, Sharma S and Kurian J. Myocardial infarction and pregnancy. Obstet Gynaecol 2013;15:247-55.  Back to cited text no. 5
    
6.
Sliwa K and Böhm M. Incidence and prevalence of pregnancy-related heart disease. Cardiovasc Res 2014;101:554-60.  Back to cited text no. 6
    
7.
Edupuganti MM, Ganga V. Acute myocardial infarction in pregnancy: Current diagnosis and management approaches. Indian Heart J 2019;71:367-74.  Back to cited text no. 7
    
8.
Weissman NJ, Ristow B, Schiller NB. Role of echocardiography in myocardial infarction. Up to Date 2019. Available from: https://www.uptodate.com/contents/role-of-echocardiography- in-acute-myocardial-infarction. [Last accessed on 2019 Oct. 26].  Back to cited text no. 8
    
9.
Meng-Han C, Hsin-Hui H, Yu-Ju L, Kwei-Shuai H, Yu-Chi W, Her-Young S. Cardiac arrest during emergency caesarean section for severe pre-eclampsia and peripartum cardiomyopathy. Taiwan J Obstet Gynecol 2016;55:125-7.  Back to cited text no. 9
    
10.
Gibson P, Narous M, Firoz T, Chou D, Barreix M, Say L, et al. (WHO Maternal Morbidity Working Group). Incidence of myocardial infarction in pregnancy: A systematic review and meta-analysis of population-based studies. Eur Heart J Qual Care Clin Outcomes 2017;3:198-207.  Back to cited text no. 10
    



 
 
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