Acute myocardial infarction during pregnancy: a clinical checkmate

Subchronic exposure to fenpyroximate causes multiorgan toxicity in Wistar rats by disrupting lipid profile, inducing oxidative stress and DNA damage

BACKGROUND

Fenpyroximate (FEN) is an acaricide that inhibits the complex I of the mitochondrial respiratory chain in mites. Data concerning mammalian toxicity of this acaricide are limited; thus the aim of this work was to explore FEN toxicity on Wistar rats, particularly on cardiac, pulmonary, and splenic tissues and in bone marrow cells.

METHODS

rats were treated orally with FEN at 1, 2, 4, and 8 mg/Kg bw for 28 days. After treatment, we analyzed lipid profile, oxidative stress and DNA damage in rat tissues.

RESULTS

FEN exposure increased creatinine phosphokinase (CPK) and lactate dehydrogenase (LDH) activities, elevated total cholesterol (T-CHOL), triglycerides (TG), and low-density lipoprotein cholesterol (LDL-C) concentrations, while decreasing high-density lipoprotein cholesterol (HDL-C). It inhibited acetylcholinesterase (AChE) activity, enhanced lipid peroxidation, protein oxidation, and modulated antioxidant enzymes activities (superoxide dismutase, catalase, glutathione peroxidase, and glutathione S-transferase). Comet assay indicated that FEN induced a dose-dependent DNA damage, contrasting with the micronucleus test showing no micronuclei formation. Nonetheless, FEN exhibited cytotoxicity to bone marrow cells, as evidenced by a reduction in the number of immature erythrocytes among total cells.

CONCLUSION

FEN appears to carry out its genotoxic and cytotoxic activities most likely through an indirect pathway that involves oxidative stress.

Acute myocardial infarction in twin pregnancy after assisted reproduction: A case report

BACKGROUND

Acute myocardial infarction (AMI) during pregnancy is rare, especially in twin pregnancy, and it can endanger the lives of the mother and children. Except for conventional cardiovascular risk factors, pregnancy and assisted reproduction can increase the risk of AMI during pregnancy. AMI develops secondary to different etiologies, such as coronary spasm and spontaneous coronary artery dissection.

CASE SUMMARY

A 33-year-old woman, with twin pregnancy in the 31^st week of gestation, presented to the hospital with intermittent chest tightness for 12 wk, aggravation for 1 wk, and chest pain for 4 h. Combined with the electrocardiogram and hypersensitive troponin results, she was diagnosed with acute ST-elevation myocardial infarction. Although the patient had no related medical history, she presented several risk factors, such as age greater than 30 years, assisted reproduction, and hyperlipidemia. After diagnosis, the patient received antiplatelet and anticoagulant treatment. Cesarean section and coronary angiography performed 7 d later showed stenosis and thrombus shadow of the right coronary artery. After receiving medication, the patient was in good condition.

CONCLUSION

This case suggests that, with the widespread use of assisted reproductive technology, more attention should be paid to perinatal healthcare, especially when chest pain occurs, to facilitate early diagnosis and intervention of AMI, and the etiology of AMI in pregnancy needs to be differentiated, especially between coronary spasm and spontaneous coronary artery dissection.

Antiplatelet therapy in pregnancy: A systematic review

OBJECTIVE

To systematically review contemporary data on the safety of clopidogrel and newer antiplatelet agents in pregnant women, with particular attention to maternal and neonatal complications.

METHODS

The review protocol was published via PROSPERO (ID 42020165235) and conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Databases were searched using MeSH and free text terms encompassing the included antiplatelets, relevant indications, and pregnancy. Included studies reported the drug dose, the stage of pregnancy at which it was administered, and at least one primary or secondary outcome relating to pregnancy. The primary outcome was reporting of complications associated with antiplatelet use in pregnancy.

RESULTS

The search yielded 5271 results. 39 publications were included, incorporating 42 live births. The mean age of women was 34.6 years. Seven different antiplatelet agents were described, clopidogrel being most frequent (n = 37). 14 women received antiplatelet therapy in the first trimester. 14 women had regional anaesthesia (12 while taking clopidogrel), all without complication. Two women developed bleeding post caesarean section. There were no recorded neonatal delivery complications. Two neonates had congenital anomalies not felt to be related to maternal antiplatelet use.

CONCLUSIONS

This systematic review describes outcomes for both mothers and neonates when exposed to clopidogrel at varying durations throughout gestation, and does not suggest higher than acceptable risk, with a congenital anomaly rate comparable to background risk. Evidence for other antiplatelet agents remains limited. Regional anaesthesia should be offered, with recommendation to stop prior to delivery in line with national guidance and in the context of individualised decision making.

Management of a decompensated acute-on-chronic intracranial venous sinus thrombosis

A 34-year-old female patient presented during the 10th week of her second gravidity with headache, nausea and vomiting 2 weeks before admission. Her medical history was remarkable for a heterozygous factor V Leiden mutation, elevated lipoprotein A, and a cerebral venous thrombosis (CVT) after oral contraceptive intake 15 years before. Magnetic resonance imaging (MRI) suggested acute and massive intracranial sinus thrombosis. Despite full-dose anticoagulation, the patient deteriorated clinically and eventually became comatose. Now, MRI/magnetic resonance angiography revealed vasogenic edema of both thalami, of the left frontal lobe, and of the head of the caudate nucleus, with venous stasis and frontal petechial hemorrhage. She was referred for endovascular treatment. Diagnostic angiography confirmed a complete superficial and deep venous sinus occlusion. Endovascular access to the straight and superior sagittal sinus was possible, but neither rheolysis nor balloon angioplasty resulted in recanalization of the venous sinuses. Monitored heparinization was continued and antiaggregation was initiated. The patient remained comatose for another 5 days and MRI showed progress of the cytotoxic edema. On day 6, infusion of eptifibatide at body-weight-adapted dosage was started. The following day, the patient improved and slowly regained consciousness. MRI confirmed regression of the edema. The eptifibatide infusion was continued for a total of 14 days. Thereafter two doses of 180 mg ticagrelor per os (PO) daily were started. The patient remained on acetylsalicylic acid (ASA), ticagrelor, and enoxaparin on an unchanged dosage regimen. She was discharged home 26 days after the endovascular treatment without serious neurological deficit, with the pregnancy intact. At the 30th week of pregnancy the dosage of ASA was reduced to 300 mg once PO daily. Cesarian delivery was carried out at the 38th week of pregnancy. The newborn was completely healthy. Ultima ratio therapeutic options for severe intracranial venous sinus thrombosis refractory to anticoagulation are discussed, with an emphasis on platelet-function inhibition.

A case of cardiopulmonary arrest due to spontaneous coronary artery dissection in a pregnant woman

We present the case of a young pregnant woman with cardiopulmonary arrest due to acute coronary syndrome. Emergent coronary angiography (CAG) and intravascular ultrasound (IVUS) showed extensive coronary artery dissection in the left anterior descending artery, which was treated with primary percutaneous coronary intervention. After managing the heart failure and disseminated intravascular coagulation, a dead fetus was delivered via caesarean section 4 days after admission to the hospital. Follow-up CAG and IVUS at 18 months showed persistent dissection in the non-stented site; hence, another stent was implanted. Dual antiplatelet therapy was discontinued 6 months later; however, aspirin and beta-blockers were continued lifelong.

Dilemma in Timing of Delivery in a Patient with an Acute Myocardial Infarction

Introduction. Acute myocardial infarction (AMI) in a pregnant woman is rare. When occurring, AMI is a major cause of maternal and neonatal death. By presenting the following case we describe the dilemma concerning the timing of delivery.Case. A 36-year-old, multiparous women, at 35 6/7 weeks of gestation, suffered from an AMI due to an acute blockage of the left anterior descending artery (LAD). This was treated by angiographic thrombosuction and biodegradable stent placement. Within 5 hours after this procedure, a cesarean section (CS) was performed because of a nonreassuring fetal condition. A healthy son with an Apgar score of 9/10 was born. The patient’s postoperative course was complicated by a big wound hematoma, a hemoglobin drop, and heart failure.Discussion. In case of AMI during pregnancy, the cardiological management has absolute priority. The obstetrical management is not outlined. In a nonreassuring fetal condition, delivery is indicated after stabilization of the mother. However, delivery after recent AMI and angiography will bring new risks of cardiologic stress and bleeding complications. The limited literature available tends to an expectant obstetrical management, but this case emphasizes the difficulty of waiting in suspected fetal distress.