Pregnancy in a patient with a history of myocardial infarction and coronary artery bypass grafting

Pregnancy in women with pre-existent ischaemic heart disease: a systematic review with individualised patient data

INTRODUCTION

Studies on pregnancy risk in women with ischaemic heart disease (IHD) have mainly excluded pregnancies in women with pre-existent IHD. There is a need for better information about the pregnancy risks in these women and their offspring.

METHODS

We performed a systematic review searching the PubMed/MEDLINE public database for pregnancy in women with pre-existent IHD analysing the cardiac, obstetric and fetal/neonatal outcome of pregnancy in women with pre-existing IHD. Individual patient data were requested from large series. The primary outcome endpoints was a composite of ischaemic complications including maternal death, acute coronary syndrome and ventricular tachycardia.

RESULTS

116 women with pre-existent IHD had 124 pregnancies including one twin pregnancy. They had a 21% chance of having an uncomplicated pregnancy (completed pregnancy without cardiovascular, obstetric or fetal/neonatal complications, n=26). Primary (ischaemic) endpoints occurred in 9% (n=11). Women with atherosclerosis had more cardiovascular complications compared with pregnancies in women with other underlying pathology for IHD (50%vs23%, P=0.02) but no significant difference in occurrence of primary endpoints (13% vs 9%, P=0.53). There were two maternal cardiac deaths (2%), one of which occurred in the 18th week of pregnancy and the other postpartum. Obstetric complications occurred in 58% (n=65) of pregnancies and fetal/neonatal complications in 42% (n=47).

CONCLUSION

Pregnancies in women with pre-existing IHD are high-risk pregnancies. These women have a high risk of ischaemic cardiovascular complications including 2% maternal mortality. The risk of ischaemic complications is especially high among women with atherosclerotic coronary artery disease.

The parturient with coronary heart disease

Cardiac disease is one of the leading indirect causes of maternal mortality in the UK, exceeding numbers of direct deaths from thromboembolism and hypertension combined. Over one year in our unit we managed six women with coronary heart disease. In this series five women had stable coronary heart disease. Three delivered electively by caesarean section under combined spinal-epidural anaesthesia, a further two women had spontaneous vaginal deliveries, one planned under epidural analgesia, the second unplanned after a rapid labour. The sixth woman had unstable angina requiring percutaneous coronary intervention in the 28th week of pregnancy and went on to deliver by caesarean section under general anaesthesia. Regional anaesthesia was avoided in this case because of antiplatelet and anticoagulant medication. There is a lack of level-one evidence to direct the management of these women. Clinical decisions were directed by guidelines for the perioperative management of patients with cardiac disease in non-cardiac surgery and the management of all cardiac disease in the obstetric population. A multi-disciplinary approach was taken, with a collaborative plan made for each pregnancy and delivery. A thorough clinical history and examination together with transthoracic echocardiography allows risk stratification of women with coronary heart disease at risk of peripartum cardiac events. Further investigation specific to each woman's management can then be undertaken.

Acute coronary artery dissection during pregnancy

Acute coronary artery dissection is a rare complication of pregnancy usually identified at postmortem examination. We report a case of myocardial infarction apparently caused by acute dissection of the left main coronary artery in a 24-year-old woman being treated for preterm labor with terbutaline. Hemodynamic deterioration necessitated emergency cesarean delivery and coronary bypass surgery.

Anaesthetic considerations in a parturient with critical coronary artery disease and a drug-eluting stent presenting for caesarean section

A parturient presented with her first symptoms of coronary artery disease at 18 weeks' gestation. Following an angiogram, a drug-eluting stent was inserted, resulting in resolution of her symptoms. The patient was prescribed anti-platelet medication including clopidogrel. She was delivered by elective caesarean section at 35 weeks under general anaesthesia. The anaesthetic management is discussed and a review of the literature presented.

Successful pregnancy after coronary artery bypass grafting for Kawasaki disease

A 13-year-old girl with a history of Kawasaki disease underwent coronary artery bypass grafting because of angina pectoris due to a giant coronary artery aneurysm on the left main trunk artery. Nine years after the operation, the patient had an uneventful pregnancy followed by a normal vaginal delivery. This is the first case of a successful pregnancy after coronary artery bypass grafting for Kawasaki coronary artery disease.

Pregnancy after myocardial infarction and a coronary artery bypass graft

The authors report a pregnancy in a 34 year old patient who previously experienced a myocardial infarction. The pregnancy ended at 39 weeks in the birth of a healthy girl weighting 3040 g, by cesarean section under epidural anesthesia. A review of the literature revealed 33 similar cases, 16 of which were adequately documented.

Pregnancy after myocardial infarction

The occurrence of pregnancy in a patient after myocardial infarction remains a dilemma for both the cardiologist and the obstetrician. The majority of obstetricians and cardiologists are very reticent about pregnancy in a woman suffering from coronary disease.

AIMS

The aims of this study are to evaluate the risks, the prognosis of pregnancy for women who had suffered from myocardial infarction and to propose guidelines for pre-pregnancy counselling and medical supervision of the pregnancy and delivery.

METHODS

A review of literature has revealed 30 cases, 14 of which are sufficiently documented. Only one of these patients requested pre-pregnancy counselling. We add to this experience the case of a patient who, having had an infarction, was authorized to begin pregnancy.

RESULTS

Most of the pregnancies in these patients evolve satisfactorily if the more frequent cardiovascular complications are diagnosed and treated rapidly. During the pregnancy, rest is the rule and any situation which risks to increase the myocardial work-load should be avoided. Normal vaginal delivery with epidural anesthesia is the preferred method.

CONCLUSION

The maternal and fetal prognosis is good on condition of performing a pre-pregnancy examination and of setting up a multi-discipline surveillance of the pregnancy. The review of the literature does not confirm the surrounding pessimism concerning the patients becoming pregnant after myocardial infarction.

Caesarean section in a diabetic patient with a recent myocardial infarction

This is a report of a 38-yr-old parturient with multiple medical problems including diabetes mellitus, bronchial asthma, chronic myelogenous leukaemia, pre-eclampsia and a recent myocardial infarction. After medical management in the coronary care unit, it was decided to proceed with a Caesarean section. The choice of anaesthetic was made by the patient and had to be modified in accordance with her medical condition. Cardiovascular monitoring included PA catheterisation and transoesophageal echocardiography. A general anaesthetic was performed using fentanyl, thiopentone and succinylcholine. The outcome was satisfactory for both parturient and baby.

The obstetrical anaesthesia assessment clinic: a review of six years experience

We reviewed the out-patient consultation notes of 136 pregnant women seen at the Ottawa Civic Hospital from 1985 to 1991 to evaluate the efficacy of an Obstetric Anaesthesia Assessment Clinic (OAC). In addition, their anaesthetic records from labour and delivery were reviewed. For each patient the reason for referral was recorded according to the involved organ system. The anaesthetic management at delivery was compared with the proposed anaesthetic plan by the OAC consultant (obstetric anaesthetist). The majority of women 84 (62%) had complaints related to the musculo-skeletal system. In addition, 18 patients were referred because of previous anaesthetic problems, ten with a history of cardiac disease, and eight with neurological disease. Lumbar epidural analgesia (LEA) was a safe and effective choice for parturients with low back pain, history of lumbar fractures or single level discectomies without lumbar fusion. Parturients with posterior instrumentation experienced an increased incidence of inadequate pain relief from LEA. Individualized anaesthetic management plans were executed for parturients with spina bifida occulta, neurological, cardiac, and haematological disease as well as for women, with a history of adverse drug reactions and previous problems with regional or general anaesthesia. It is concluded that the OAC has provided a valuable service to obstetricians and anaesthetists for the anaesthetic management of pregnant women with co-existing disease. The OAC gave an opportunity for patient education regarding anaesthetic options for labour and delivery. The attending anaesthetist was provided with a risk assessment and anaesthetic management plan which was adhered to with only two exceptions. Finally, the obstetrician was given consistent advice regarding anaesthesia management that may affect obstetrical decisions.

The cardiac, obstetric, and anesthetic management of pregnancy complicated by acute myocardial infarction

Myocardial infarction (MI) occurring during pregnancy is a rare but potentially lethal event for both mother and fetus, particularly when it occurs in the third trimester or peripartum period. The authors report two cases of MI occurring in the third trimester of pregnancy and review the literature. Management of the acute infarct and the medical, obstetric, and anesthetic considerations in such patients during labor and delivery are discussed. Successful use of percutaneous transluminal coronary angioplasty is described in a patient with evolving MI and ongoing pain. The preferred method of delivery in the pregnant MI patient is addressed, with emphasis on the need for individualization of care and coordination between the cardiac, obstetric, and anesthetic teams. Finally, the authors review the risks of subsequent pregnancy in this patient population.

Pregnancy after aortofemoral bypass grafting in a diabetic patient

A case of pregnancy after an aortofemoral bypass graft for atherosclerosis in an insulin-dependent diabetic is described. Pregnancy after this type of surgery in a diabetic patient has not been described previously.

Anaesthetic management of a parturient with prior myocardial infarction and coronary artery bypass graft

An increasing number of parturients suffering from ischaemic heart disease require anaesthetic care for labour and vaginal delivery. We present the case of a 42-year-old gravida who had previously suffered a myocardial infarction and undergone coronary artery bypass grafting. Management was directed toward prevention of haemodynamic instability by alleviation of pain and stress while minimizing the risk of anaesthetic complications. Monitoring included a central venous catheter, pulse oximetry, and an automated blood pressure cuff. A judiciously administered segmental lumbar extradural block was instituted early, utilizing local anaesthetics with the narcotic fentanyl.

Pre-eclampsia in a parturient with a history of myocardial infarction. A case report and literature review

A mother with pre-eclamptic toxaemia and severe coronary artery disease was managed with epidural analgesia accompanied by invasive cardiovascular monitoring. Caesarean section was carried out uneventfully using the epidural. The literature is reviewed.