Myocardial infarction during pregnancy is rare. There is an estimated incidence rate of approximately 1 in 16,000 pregnancies and case fatality rate of 11%. Though uncommon, pregnant women are at increased risk of MI due to normal physiologic adaptations of pregnancy, including increased circulating volume and other hemodynamic changes. Additional risk factors include hypertension, diabetes, preeclampsia, advanced maternal age, obesity, multiparity, and smoking. Management of MI during pregnancy is complicated by consideration for the effect of interventions on the developing fetus. 

Case:

A 41 year old multigravida patient presented to Labor and Delivery at 35 weeks gestation complaining of chest pain radiating down her left arm. A stat ECG and cardiac enzymes labs were obtained, and the patient went to CT to rule out dissecting aortic aneurysm. The initial ECG showed normal sinus rhythm, but elevated troponin levers were indicative of an acute myocardial infarction. A cardiac catheterization determined the extent of the infarction, and the patient was diagnosed with single-vessel coronary artery disease of the left anterior descending coronary artery. The patient was treated medically with heparin and scheduled for a repeat cesarean section two weeks after the initial attack. However, approximately five days after the episode, the patient experienced another ischemic event increasing the urgency for delivery. A multidisciplinary team including the patient’s obstetrician, house obstetrician, cardiologist, neonatologist, interventional radiologist, representative from blood bank, clinical nurse specialist, and L&D charge nurse met and planned for the delivery. Nine days after the initial insult, the patient delivered a viable baby girl via repeat cesarean section under general anesthesia. After the surgery, the patient was transferred to ICU for recovery. Over the next several days, the patient’s hemoglobin and hematocrit dropped requiring several blood transfusions, and a CT scan revealed two large rectal sheath hematomas. Heparin therapy was temporarily suspended until bleeding stabilized, and the patient experienced no other complications. She was discharged home on post-op day six. 

Conclusion:

As the prevalence of obesity and advanced maternal age increase, the incidence of MI during pregnancy is expected to rise. Recognition of signs and symptoms of MI in pregnant patients are essential to early detection and intervention. Nurses serve a crucial role in facilitating a multidisciplinary team approach to promote effective, evidence-based care of critically ill mothers and their babies. 

Keywords:

Pregnancy, myocardial infarction, maternal morbidity, high risk pregnancy, coronary artery disease.