Myocardial infarction during pregnancy is rare with an estimated incidence rate of approximately 1 in 16,000 pregnancies and a case fatality rate of 11%. Though uncommon, pregnant women are at increased risk of myocardial infarction due to normal physiological adaptations of pregnancy, including increased circulating blood volume and other hemodynamic changes. Additional risk factors include hypertension, diabetes, preeclampsia, advanced maternal age, obesity, multiparity, and smoking. Management of myocardial infarction during pregnancy is complicated by the potential effects of intervention on the developing fetus.
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 electrocardiogram and cardiac enzymes tests were obtained, and the patient had a computed tomography scan (CT scan) to rule out dissecting aortic aneurysm. The initial electrocardiogram showed normal sinus rhythm, but elevated troponin levels 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 2 weeks after the initial attack. However, approximately 5 days after the episode, she 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 labor and delivery charge nurse met and planned for the birth. Nine days after the initial insult, the patient delivered a viable female infant via repeat cesarean under general anesthesia. After the surgery, the patient was transferred to the intensive care unit 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 on day 6.
As the prevalence of obesity and advanced maternal age increase, the incidence of myocardial infarction during pregnancy is expected to rise. Recognition of signs and symptoms of myocardial infarction in pregnant patients is 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 infants.