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SIMULTANEOUS CAESAREAN SECTION

AND CORONARY ARTERY BYPASS GRAFTING (CABG)

Our case study reports the multidisciplinary management of a patient with ST-elevation myocardial infarction (STEMI) and spontaneous coronary artery dissection.  The patient presented to the OB Triage area at 34 weeks gestation complaining of chest pain, shortness of breath, nausea and diaphoresis.  She reported having a history of  a myocardial infarction six years prior so she was immediately given aspirin.  IV access was established and cardiac enzymes were drawn.  A stat EKG showed ST elevation so the patient was transferred immediately to the main emergency department.  An OB nurse accompanied her to continue fetal monitoring.  Nitroglycerine therapy was initiated and she was sent for an emergency cardiac catheterization.

Prior to the cardiac catheterization, our OB OR team (staffed by L&D nurses) was notified that this patient may need to have a C-Section performed in the emergency room.  The decision was made to delay the C-Section until after the cardiac catheterization was completed.  Continuous electronic fetal monitoring continued during this period.  The cardiac catheterization showed a dissection of the left main coronary artery that extended to the left anterior descending artery and the left circumflex artery.  The patient was then transferred to CVICU where she underwent a transesophageal echocardiogram which ruled out aortic dissection.  The OB team was on stand-by in the event of a stat C-Section.

After much deliberation between the obstetricians, the cardiologist, the cardiac surgeon, the anesthesiologist and the nurses, the decision was made to deliver the patient by caesarean section in the main operating room.  All of the equipment normally necessary for a caesarean section and newborn resuscitation was transported to the cardiac surgery operating room. The OB team and the cardiac surgery team both prepared for the case simultaneously.  The OB team performed a primary caesarean section and a live female was delivered.  As soon as the abdominal incision was closed, the OB team stepped back from the OR table and the cardiac team stepped forward to perform the coronary artery bypass grafting.

The patient recovered well postoperatively and was discharged after five days.  The newborn was discharged from the Newborn Intensive Care Unit twenty-three days after birth.

Myocardial infarction, spontaneous coronary artery dissection, and coronary artery bypass grafting are all very rare in pregnancy.  There are no published statistics for perinatal survival of all three.  The maternal mortality rate associated with myocardial infarction alone is estimated to be as high as 37%.  We present a difficult case with a successful outcome that was achieved through careful consideration of the unique needs of both mother and fetus by a multidisciplinary team that worked very well together.