RECOGNIZING THE UNUSUAL STEMI IN A 40 YEARS OLD PREGNANT:STEMI IN PREGNANCY IS A DIFFERENT ENTITY

Albana Mihali1, Thupten Gyaltsen2, Sundara Kesiraju2, Harrit Desai, Ekaterina Vypritskaya2, 1Resident, Trenton, NJ; 2NJ

Meeting: Hospital Medicine 2019, March 24-27, National Harbor, Md.

Abstract number: 850

Categories: Adult, Clinical Vignettes, Hospital Medicine 2019

Keywords: , , , ,

Case Presentation: We present the case of a 40-year-old previously healthy female, G5 P2, approximately 26 weeks pregnant. The patient presented with midsternal chest pain radiating to the neck and shoulder. Antacids and rehydration had failed to relieve the pain and finally she called 911 as her pain was worsening. Pre-hospital EKG showed a 3 mm ST-segment elevation in the inferior leads. She was given aspirin 325 mg en route to the hospital. Nitroglycerin and heparin drip were started. Emergent cardiac catheterization confirmed complete occlusion of distal LAD, and a bare metal stent was placed. Even though patient developed congestive heart failure with a reduced EF (40%) she was placed only on aspirin, clopidrogel, and betablockers. The next morning, after approximately 10 hours EKG showed resolution of the ST segments. The patient recovered well and fetal vital signs were reassuring. She was discharged on aspirin, clopidogrel and metoprolol with planned elective c- section delivery at term. Patient was followed up closely by primary care physician, cardiology and OBGYN. Patient had an uneventful vaginal delivery at full term. She delivered a healthy baby boy. In the pregnancy, statins and ACE inhibitors are contraindicated, hence the standardized treatment were resumed after the baby was delivered. Both mom and baby are doing well.

Discussion: The risk of MI during pregnancy is 3 to 4 fold compared to non-pregnant women with an incidence of 6.2 per 100 000 pregnancies. Multiparity is associated with increased risk of MI. Mechanisms include atherosclerotic plaque rupture, coronary artery dissection, coronary vasospasm and thromboembolism. The management of these patients differs from standard protocol as some conventional medications can be harmful in this setting. In pregnant women, bare metal stents are preferred. There is limited data on Clopidrogel, a class B medication in pregnancy. Placing a bare metal stent gave us the advantage of being able to keep our patient on clopidrogel for only 30 days and avoiding clopidogrel long before delivery. Aspirin, beta blockers, and nitrates have been used during pregnancy without apparent harmful effects. Heparin does not cross placenta and thus does not affect the fetus. ACE-I, ARBs and statins are contraindicated in pregnancy. The fetus should be closely monitored and there should be a plan for delivery if sudden maternal or fetal deterioration arises.

Conclusions: Learning points: 1) Atherosclerotic CAD, the most common cause of AMI in the non- pregnant population, is responsible for only a third of PAMI cases; the majority of patients develop their AMI by other mechanisms.
2) Having high index of suspicion when it comes in evaluating a pregnant or child bearing age as MI is of increasing rate
3) Management of MI in pregnant women is different and needs to be individualized as the needs of the mother and child may conflict. Many of the appropriate diagnostic and therapeutic intervention may pose a risk to the fetus

IMAGE 1: ECG at presentaton

IMAGE 2: ECG after 10 hours

To cite this abstract:

Mihali, AB; Gyaltsen, T; Kesiraju, S; Desai, H; Vypritskaya, E. RECOGNIZING THE UNUSUAL STEMI IN A 40 YEARS OLD PREGNANT:STEMI IN PREGNANCY IS A DIFFERENT ENTITY. Abstract published at Hospital Medicine 2019, March 24-27, National Harbor, Md. Abstract 850. https://www.shmabstracts.com/abstract/recognizing-the-unusual-stemi-in-a-40-years-old-pregnantstemi-in-pregnancy-is-a-different-entity/. Accessed January 19, 2020.

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