A 35 year old woman presented with chest pain at 34+3 weeks gestation of an IVF pregnancy. ECG revealed anterior ST elevation (Figure 1), and the catheterisation laboratory was activated after discussion with her obstetrician. Radial coronary angiography performed with minimal contrast (70 mL), minimal radiation (skin dose 88mGy), and abdominal shielding demonstrated a spontaneous dissection (SCAD) of the distal left anterior descending artery. The decision was made for conservative management. Echocardiography showed anterior hypokinesis with ejection fraction (LVEF) of 40%, and probable LV thrombus. Foetal cardiotocography (CTG) was normal. Our patient commenced aspirin, clopidogrel, metoprolol and a heparin infusion, with daily CTGs. ECG evolved to show anterior Q waves, and troponin peaked at 40,494ng/L (normal <16ng/L). After six days, our patient was discharged home with therapeutic clexane, then readmitted at 38+0 weeks' gestation for elective Caesarean section. This was successfully performed under spinal anaesthesia (with clopidogrel cessation one week prior), with delivery of a healthy female singleton. Post-partum, our patient commenced ramipril and warfarin, with agreement not to breastfeed. 7 days later, our patient returned home with her daughter, stable with NYHA I symptoms. This case highlights the challenges of managing an acute coronary syndrome (ACS) in pregnancy. SCAD is the aetiology of approximately 25% of ACS in pregnancy, and confers high mortality (approximately 40%). Radiation minimisation during angiography, safety and evidence for appropriate cardiac medications, timing and mode of delivery, and safety of breastfeeding are multiple unique issues which must be addressed in a holistic manner between cardiac and obstetric teams.
Paratz, E., Kao, C., & Somaratne, J. (2016). Dissection Then C-section: Spontaneous Coronary Artery Dissection, Heart Failure and Left Ventricular Thrombus in An Elderly Primigravida with an IVF Pregnancy. Heart, Lung and Circulation, 25, S42. https://doi.org/10.1016/j.hlc.2016.06.093