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Acute Myocardial Infarction in Pregnancy and the Puerperium: A Population-Based Study
Abstract
To estimate the population-based incidence and pregnancy outcomes of acute myocardial infarction (MI) in pregnancy.
Maternal and newborn hospital discharge records were linked to birth/death certificates for the 10-year period January 1, 1991, to December 30, 2000, for the majority (98%) of deliveries in California. This database was searched for the diagnosis of acute MI, demographic characteristics, and pregnancy outcomes. Patients were divided into 4 groups: antenatal diagnosis, intrapartum diagnosis, up to 6-week postpartum diagnosis, and those without the diagnosis of acute MI. All groups were compared by Student t test or chi(2) or both, where appropriate.
A total of 151 women had an acute MI during the antepartum (38%), intrapartum (21%), or 6-week postpartum (41%) period, giving an incidence rate of 1 in 35,700 deliveries. The incidence rate increased over the study period. The maternal mortality rate was 7.3%, and maternal death only occurred in women with an acute MI before or at delivery (P < .01). Compared with women who did not have an acute MI, those with one were more likely to be older (30% were older than 35 years compared with 10%), multiparous (78% compared with 61%), non-Hispanic white (40% compared with 35%) or African Americans (15% compared with 7%). All measures of maternal and neonatal morbidity were increased in the acute MI group compared with those without an acute MI. Multivariate analysis identified chronic hypertension, diabetes, advancing maternal age, eclampsia, and severe preeclampsia as independent risk factors for acute MI.
Acute MI during pregnancy remains a rare event, with significant maternal, fetal, and neonatal morbidity and mortality and maternal mortality limited to the antepartum and intrapartum period.
... Recent data suggest ischemic heart disease, which accounts for <2% of cardiovascular disease in pregnancy [2,3], and pregnancy-associated myocardial infarction (PAMI), are leading causes [1][2][3][4]. Acute coronary syndrome (ACS) is 3 to 4 times more likely to affect women during pregnancy than similarly aged, non-pregnant women [5], and is estimated to affect 3-10 of every 100,000 pregnancies [5][6][7][8][9][10]. MI during pregnancy is also associated with higher mortality than in non-pregnant women [5,8]. ...
... One of the strongest risk factors is advanced maternal age (>30 years of age) [5,7,8]. Women with traditional atherosclerotic risk factors, including hypertension, hyperlipidemia, and type 2 diabetes, are also at higher risk of PAMI, but these risk factors are present in only a minority of women [5,6,8]. There are also sex-specific risk factors for PAMI, including preeclampsia [6] and gestational diabetes [12,16]. ...
... Women with traditional atherosclerotic risk factors, including hypertension, hyperlipidemia, and type 2 diabetes, are also at higher risk of PAMI, but these risk factors are present in only a minority of women [5,6,8]. There are also sex-specific risk factors for PAMI, including preeclampsia [6] and gestational diabetes [12,16]. Black women have higher rates of PAMI than white women, as do women of lower socioeconomic status [5][6][7]. ...
Cardiovascular disease is the leading cause of maternal mortality in the United States. Acute coronary syndrome (ACS) is more common in pregnant women than in non-pregnant controls and contributes to the burden of maternal mortality. This review highlights numerous etiologies of chest discomfort during pregnancy, as well as risk factors and causes of ACS during pregnancy. It focuses on the evaluation and management of ACS during pregnancy and the post-partum period, including considerations when deciding between invasive and non-invasive ischemic evaluations. It also focuses specifically on the management of post-myocardial infarction complications, including shock, and outlines the role of mechanical circulatory support, including veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Finally, it offers additional recommendations for navigating delivery in women who experienced pregnancy-associated myocardial infarction and considerations for the post-partum patient who develops ACS.
... 3 Pregnancy is associated with a three-fold increase in the risk of acute myocardial infarction compared to non-pregnant women of similar age group. 4 Previous studies have demonstrated cardiovascular risk factors in the majority of these patients, however, in some cases, no well-defined cardiovascular risk factors are found. 4 Common underlying mechanisms implicated in PAMI are atherosclerotic coronary artery disease, coronary thrombosis with hypercoagulabilty and coronary artery dissection. ...
... 4 Previous studies have demonstrated cardiovascular risk factors in the majority of these patients, however, in some cases, no well-defined cardiovascular risk factors are found. 4 Common underlying mechanisms implicated in PAMI are atherosclerotic coronary artery disease, coronary thrombosis with hypercoagulabilty and coronary artery dissection. 3 Spontaneous coronary artery dissection (SCAD) is a rare but often lethal complication of pregnancy. ...
... 1-2 However, there is increased risk during pregnancy as compared with non-pregnant women. 4 Incidence of PAMI is about 0.7 per 100,000 deliveries in the United Kingdom and 6.2 per 100,000 deliveries in the United States. [2][3][4][5][6][7][8][9] There are increasing cases globally. ...
Cardiovascular diseases are recognised complications of pregnancy, however, pregnancy-associated acute myocardial infarction (PAMI) is uncommon. Pregnancy is known to increase risk of myocardial infarction even in the absence of traditional risk factors for atherosclerotic vascular disease. Our patient presented with acute chest pain two weeks after delivery and her electrocardiogram was in keeping with STelevation myocardial infarction (STEMI). Coronary angiography revealed coronary artery dissection and she was managed conservatively. Various pathophysiological mechanisms of PAMI have been described in literature including spontaneous coronary artery dissection (SCAD) found in our case. The diagnosis is often missed and earlier reported cases were diagnosed at autopsy. Therefore, we report this case as a learning tool. Also, there is a need for a high index of suspicion in pregnant patients presenting with features suggestive of aortic dissection, and its diagnosis should be thought of in peripartum women presenting with acute chest pain.
... вагітних [3]. Найчастіше ІМ реєструється в допологовому періоді або під час пологів (59 %), рідше (41 %) -після них [9]. ...
... пологів, смертність від ІМ -0,35 на 100 тис. пологів [9]. Часто-та гострого коронарного синдрому (ГКС) під час вагітності оцінюється на рівні 1:10000 вагітностей [8,9]. ...
... пологів [9]. Часто-та гострого коронарного синдрому (ГКС) під час вагітності оцінюється на рівні 1:10000 вагітностей [8,9]. ...
... 4 The incidence of PAMI varies from 3 to 10 per 100 000 pregnancies. [4][5][6][7] In addition, PAMI has become a common cause of maternal mortality in the United States. 8 Studies have shown significant ethnic variations in the incidence of PAMI and the presence of nontraditional mechanisms. ...
... 15,23 High incidence of PAMI in Black patients is attributable to high prevalence of cardiovascular risk factors at a younger age, which include preeclampsia, hypertension, diabetes, and physical inactivity. 7,24,25 Being in the lower-income quartile was a risk factor for PAMI. These patients have been shown to have a high likelihood of cardiovascular risk factors, poorer pregnancy outcomes, poor access to health care, and the lowest medication compliance rates. ...
Background
The objective of this study was to evaluate the temporal trends in pregnancy‐associated myocardial infarction (PAMI) in the State of California and explore potential risk factors and mechanisms.
Methods and Results
The California State Inpatient Database was analyzed from 2003 to 2011 for patients with International Classification of Diseases, Ninth Revision ( ICD‐9 ) codes for acute myocardial infarction and pregnancy or postpartum admissions; risk factors were analyzed and compared with pregnant patients without myocardial infarction. A total of 341 patients were identified with PAMI from a total of 5 266 380 pregnancies (incidence of 6.5 per 100 000 pregnancies). Inpatient maternal mortality rate was 7%, and infant mortality rate was 3.5% among patients with PAMI. There was a nonsignificant trend toward an increase in PAMI incidence from 2003 to 2011, possibly attributable to higher incidence of spontaneous coronary artery dissection, vasospasm, and Takotsubo syndrome. PAMI, when compared with pregnant patients without myocardial infarction, was significant for older age (aged >30 years in 72% versus 37%, P <0.0005), higher preponderance of Black race (12% versus 6%, P <0.00005), lower socioeconomic status (median household income in lowest quartile 26% versus 20%, P =0.04), higher prevalence of hypertension (26% versus 7%, P <0.0005), diabetes (7% versus 1%, P <0.0005), anemia (31% versus 7%, P <0.0001), amphetamine use (1% versus 0%, P <0.00005), cocaine use (2% versus 0.2%, P <0.0001), and smoking (6% versus 1%, P =0.0001).
Conclusions
There has been a trend toward an increase in PAMI incidence in California over the past decade, with an increasing trend in spontaneous coronary artery dissection, vasospasm, and Takotsubo syndrome as mechanisms. These findings warrant further investigation.
... 3,[26][27][28][29][30][31] Myocardial infarction during pregnancy is an uncommon event with multiple possible etiologies for the condition, which may occur in the presence of normal or atherosclerotic coronary arteries. 15,16,[32][33][34] Possible etiologies for myocardial infarction include coronary atherosclerosis with or without associated thrombus, coronary artery dissection, localized hematoma, and coronary artery spasm. 15,16,[32][33][34] NSTEMI may occur in approximately 25%-30% of pregnant patients who experience myocardial infarction, and our patient had typical chest pain and TNI elevation consistent with NSTEMI. ...
... 15,16,[32][33][34] Possible etiologies for myocardial infarction include coronary atherosclerosis with or without associated thrombus, coronary artery dissection, localized hematoma, and coronary artery spasm. 15,16,[32][33][34] NSTEMI may occur in approximately 25%-30% of pregnant patients who experience myocardial infarction, and our patient had typical chest pain and TNI elevation consistent with NSTEMI. 16,32 TNI elevation can occur as a result of hypertensive complications in pregnancy, including pre-eclampsia, but was not present in our patient. ...
Transcatheter aortic valve replacement (TAVR) within a severely stenotic native aortic valve or previously placed surgical biologic aortic valve replacement (SAVR) is a rare occurrence in pregnant patients. The short- and long-term procedural outcomes for future pregnancies in these women or any woman of child bearing age who have received prior TAVR or TAVR in SAVR, are unknown. We describe the first result of a repeat pregnancy outcome in a woman with a history of prior TAVR in SAVR. Both maternal and fetal outcomes were favorable, but maternal cardiac complications observed in the third trimester emphasize our concerns regarding risk for cardiac complications in subsequent pregnancies in patients with a prior TAVR in SAVR. Despite the maternal complications that occurred during repeat pregnancy in this patient, a successful pregnancy outcome reaffirms our recommendation to utilize a multidisciplinary team for pregnancy management in patients with prior TAVR or TAVR in SAVR and to help in the management of any cardiac complications that may occur during or shortly after pregnancy.
... 11 According to the guideline definition of ACS, we have included unstable angina pectoris in our study as a coronary ischemic event, which could explain why our incidence of ACS is slightly higher than that found in the systematic review, although this might not be a significant difference In accordance with the current literature, the vast majority of women suffered from ACS in the third trimester. 12,13 Possibly the increase in cardiac output during pregnancy gradually increases the myocardial oxygen demand, peaking in the third trimester. 14 Also, the integrity and constitution of the coronary artery wall may be affected by hormonal alterations in the last stages of pregnancy, leading to changes in collagen and thus an increased risk of coronary dissection. ...
... 14 Also, the integrity and constitution of the coronary artery wall may be affected by hormonal alterations in the last stages of pregnancy, leading to changes in collagen and thus an increased risk of coronary dissection. 12 Maternal smoking status seems to be important for predicting the ACS risk during pregnancy in women with preexisting IHD. While former smoking was not a predictor of ACS in our study, smoking during pregnancy was most strongly associated with the occurrence of ACS in women with preexisting IHD. ...
Background
The prevalence of ischemic heart disease (IHD) in women of child‐bearing age is rising. Data on pregnancies however are scarce. The objective is to describe the pregnancy outcomes in these women.
Methods and Results
The European Society of Cardiology‐EURObservational Research Programme ROPAC (Registry of Pregnancy and Cardiac Disease) is a prospective registry in which data on pregnancies in women with heart disease were collected from 138 centers in 53 countries. Pregnant women with preexistent and pregnancy‐onset IHD were included. Primary end point were maternal cardiac events. Secondary end points were obstetric and fetal complications. There were 117 women with IHD, of which 104 had preexisting IHD. Median age was 35.5 years and 17.1% of women were smoking. There was no maternal mortality, heart failure occurred in 5 pregnancies (4.8%). Of the 104 women with preexisting IHD, 11 women suffered from acute coronary syndrome during pregnancy. ST‐segment‒elevation myocardial infarction were more common than non‒ST‐segment‒elevation myocardial infarction, and atherosclerosis was the most common etiology. Women who had undergone revascularization before pregnancy did not have less events than women who had not. There were 13 women with pregnancy‐onset IHD, in whom non‒ST‐segment‒elevation myocardial infarction was the most common. Smoking during pregnancy was associated with acute coronary syndrome. Caesarean section was the primary mode of delivery (55.8% in preexisting IHD, 84.6% in pregnancy‐onset IHD) and there were high rates of preterm births (20.2% and 38.5%, respectively).
Conclusions
Women with IHD tolerate pregnancy relatively well, however there is a high rate of ischemic events and these women should therefore be considered moderate‐ to high‐risk. Ongoing cigarette smoking is associated with acute coronary syndrome during pregnancy.
... Acute myocardial infarction in women during childbearing age is rare (1 per 36,000 births) [1] [2]. Pregnancy, however, has been shown to increase the risk of acute myocardial infarction 3 to 4 folds [1] [3] [4]. ...
... Acute myocardial infarction in women during childbearing age is rare (1 per 36,000 births) [1] [2]. Pregnancy, however, has been shown to increase the risk of acute myocardial infarction 3 to 4 folds [1] [3] [4]. The importance of the thrombotic component is attached to the hypercoagulability of pregnancy. ...
... Acute myocardial infarction accounts for the majority of deaths and is most commonly due to coronary atherosclerosis, although coronary artery dissection and consequent occlusion is also relatively frequent [19]. The risk of an acute myocardial infarction during pregnancy is small but increasing, with an estimated incidence of one in 35,700 deliveries between 1991 and 2000 [20] and one in 16,100 deliveries between 2000 and 2002 [21]. Pregnancyinduced cardiomyopathy is a disorder in which left ventricular systolic dysfunction and heart failure present in the last month of pregnancy and the first 5 months postdelivery, in the absence of all other causes of dilated cardiomyopathy with heart failure. ...
Introduction: In women with heart disease, maternal mortality is reported to be much higher than average and the risk appears to be increasing. In western countries heart disease is the major cause of maternal death. The full spectrum of structural heart disease including congenital heart disease (CHD), valvular heart disease (VHD), and cardiomyopathy (CMP), and also ischemic heart disease (IHD) may be encountered in pregnant women. Aim of the study: The aim of this study was to determine the impact of ischemic heart diseases on maternal adverse outcome during pregnancy. Methods: This was a retrospective cohort study and was conducted in the Department of Gynaecology and Obstetrics of Kushtia General Hospital, Kushtia, Bangladesh during the period from January, 2021 to January, 2022. There was total 100 women in our study. This study was conducted among pregnant women with ischemic heart disease. The study population was categorized into two; namely, Group A -women with IHD(n=50) and Group B - women without IHD (n=50). Result: In total 100 patients from both the groups completed the study. In our study we found the mean ± SD age of pregnant mothers in Group A was (30.01 ± 5.00) and in Group B (27.05 ± 5.04) respectively. The mean± SD of BMI for women in Group A was (27.47 ± 4.40) and in Group B (28.34 ± 5.67) respectively. The prevalence of Hypertension was found in 41(82%) & 21 (42%) and DM was 68% & 36%among Group A & B respectively. Transient Ischemic Attack & Stroke was found 46% & 16 % in Group A respectively. Arrythmia was only found in Group A by 36% & 28%. Conclusion: In our study, we found that the incidence of adverse maternal outcomes was higher among women with IHD. Pregnant women with IHD have a higher risk of maternal and fetal complications compared with women without HD. Cardiomyopathy, hypertension, and arrhythmias were independently associated with higher rates of major adverse maternal events was found in our study.
... AMI may occur at any stage of pregnancy, as 22% of the pregnancy-related AMI cases occur during pregnancy itself, and the rest (i.e. 78%) occur from 10 to 12 weeks postpartum, with the peak incidence being during the first 2 weeks postpartum [3,4]. The characterization of the coronary arteries after autopsy or angiography during pregnancy and the postpartum period has shown that 40% of the patients with pregnancy-related AMI have had atherosclerosis with or without intracoronary thrombosis, while there has been no evidence of atherosclerosis in only 8% of the cases [4]. ...
Introduction: Atherosclerotic coronary artery disease is the most common form of heart disease that is associated with high rates of acute myocardial infarction (AMI) and death in young people. Methods: Given the importance of pregnancy and the postpartum period and the fact that AMI is associated with poor maternal outcomes in postpartum, the present study reports acute myocardial infarction due to dissection of the coronary arteries associated with premature atherosclerosis in late postpartum. Results: The case was the maternal death of a 34-year-old woman at 42 days postpartum without any history of underlying diseases or symptoms, whose autopsy report read AMI due to coronary artery dissection associated with atherosclerosis. Conclusions: This report emphasizes the importance of postpartum care and attention to any symptoms witnessed during this period.
... It has been found in about 0.2% to 4% of acute coronary syndrome (ACS) patients who have undergone invasive angiography [1]. Moreover, coronary artery disease (CAD) incidence in women of childbearing age is low, and AMI is uncommon [2][3]. However, pregnant women have about three times higher risk of AMI when compared to that non-pregnant women [4]. ...
Spontaneous coronary artery dissection (SCAD) is a non-traumatic spontaneous separation of a coronary wall that can present as acute myocardial infarction. Pregnant females are already at a considerably higher risk of acute myocardial infarction when compared to non-pregnant women of child-bearing age, and dissection explains the majority of these cases. Here, we present a 36-year-old female at 36-weeks gestation who experienced ventricular fibrillation arrest after ST-segment elevation myocardial infarction (STEMI) secondary to spontaneous dissection of the left anterior descending (LAD) coronary artery.
... Pregnancy can also lead to APOs such as preeclampsia, which can further exacerbate known diabetes complications such as retinopathy and nephropathy [25,31,32]. Women with pregestational diabetes are at increased risk for acute myocardial infarction and symptomatic coronary artery disease during pregnancy, particularly those with comorbidities such as nephropathy and hypertension [33,34]. ...
Purpose of Review
Internationally, cardiovascular disease (CVD) is the leading cause of death in women. With risk factors for CVD continuing to rise, early identification and management of chronic diseases such as hypertension, diabetes, and obstructive sleep apnea is necessary for prevention. Pregnancy is a natural stress test for women with risk factors who may be predisposed to CVD and offers a unique opportunity to not only recognize disease but also implement effective and long-lasting strategies for prevention.
Recent Findings
Prevention begins before pregnancy, as preconception screening, counseling, and optimization of chronic diseases can improve maternal and fetal outcomes. Throughout pregnancy, women should maintain close follow-up, continued reevaluation of risk factors, with counseling when necessary. Continued healthcare engagement during the “fourth trimester,” 3 months following delivery, allows clinicians to continue monitoring the evolution of chronic diseases, encourage ongoing lifestyle counseling, and connect women with primary care and appropriate specialists if needed. Unfortunately, this postpartum period represents a major care gap, as a significant proportion of most women do not attend their scheduled visits. Social determinants of health including decreased access to care and economic instability lead to increased risk factors throughout pregnancy but particularly play a role in poor compliance with postpartum follow-up. The use of telemedicine clinics and remote monitoring may prove to be effective interventions, bridging the gap between physicians and patients and improving follow-up for at-risk women.
Summary
While many clinicians are beginning to understand the impact of CVD on women, screening and prevention strategies are not often implemented until much later in life. Pregnancy creates an opportunity to begin engaging women in cardiovascular protective strategies before the development of the disease.
... Pregnancy increases the risk of having a MI by three to four-fold (Ladner et al., 2005;416 James et al., 2006). Our data failed to find an association between pregnancy and a history of MI 417 or CHD diagnoses, although this difference could be explained by a smaller sample size. ...
Cardiovascular disease has been the leading cause of death worldwide over the last decades (Roth et al., 2015; WHO, 2021a). In countries with middle or elevated gross domestic product indices, stroke and myocardial infarction represent the prevalent causes of death. Over the years, the scientific community has identified significant cognitive and emotional impacts on survivors of coronary heart disease and cardiovascular disease. We know that ageing populations and high-stress levels associated with contemporary lifestyles play a crucial role in the prognosis and recovery of individuals with myocardial infarction. These factors are associated with an increased societal burden related to survivors’ care. As they age, a higher proportion of women than men are affected by coronary heart disease, including myocardial infarction. Nonetheless, women remain under-represented in studies addressing trajectories of recovery associated with myocardial infarction. The arching goal of this thesis is to expand the knowledge on the association of various environmental and physical factors with a history of myocardial infarction in a sample of Canadian women. The accomplished research is presented in the form of two empirical studies carried out on samples of Canadian women with and without a history of myocardial infarction, as well as two systematic reviews of the literature.
The first study established the state of knowledge on the Trier Social Stress Test paradigm, a tool that we later used in our laboratory study. Through an in-depth examination of the protocols used by different research groups, this systematic review identified essential elements for valid conclusions and proposed a set of recommendations for standardizing the use of the Trier Social Stress Test in research. The second systematic review updated the current scientific knowledge concerning the cognitive consequences of women with a history of coronary heart disease. Despite cardiovascular disease, including coronary heart disease, remains understudied in women, the last decade has seen an emergence of research supporting cognition to be affected. Our findings support subtle cognitive impairments in women with a history of coronary heart disease. Our literature review was conducted to facilitate interpreting the results obtained in a sample of women with a history of MI in this thesis’ fourth study.
Regarding data collection, an online questionnaire validated the presence of specific risk factors and symptoms associated with myocardial infarction in a sample of middle-aged Canadian women (N = 366). Finally, a laboratory study measured alterations in the physiological responses (i.e., heart rate variability and salivary cortisol secretion) associated with exposure to a social stressor (i.e., Trier Social Stress Test) in women with a history of myocardial infarction and age-matched controls (N = 29).
This body of data and analytic reviews contribute to expanding the knowledge of physiological and cognitive impairments in women with a MI history. Our research also helps improve testing paradigms to examine deficits and identify areas where further research is needed. Our findings support women experiencing different symptoms than those described in men, and it pleads for these to be no longer described as "atypical." Our work highlights a similar prevalence of certain factors (e.g., hypertension) in Canadian women and women from other parts of the world. In terms of the laboratory study, our results indicate subjective/perceived levels of stress intensity to be comparable between the myocardial infarction and non-myocardial infarction women groups. However, we only found tendencies in changes related to measured physiological variables.
... Nevertheless, global mortality has shown a decreasing trend since the 1980s, improving from 37 and 21% in 1985 and 1996, respectively, to 7.3% in the 1990s and 5.1% in 2000-2002 [66,[68][69][70]. This probably follows significant improvements in diagnosis and treatment over time and bias in collecting data mainly from severe or fatal cases in older reports. ...
Pregnancy-related acute myocardial infarction is a rare and potentially life-threatening cardiovascular event, the incidence of which is growing due to the heightened prevalence of several risk factors, including increased maternal age. Its main aetiology is spontaneous coronary artery dissection, which particularly occurs in pregnancy and may engender severe clinical scenarios. Therefore, despite frequently atypical and deceptive presentations, early recognition of such a dangerous complication of gestation is paramount. Notwithstanding diagnostic and therapeutic improvements, pregnancy-related acute myocardial infarction often carries unfavourable outcomes, as emergent management is difficult owing to significant limitations in the use of ionising radiation—e.g. during coronary angiography, potentially harmful to the foetus even at low doses. Notably, however, maternal mortality has steadily decreased in recent decades, indicating enhanced awareness and major medical advances in this field. In our paper, we review the recent literature on pregnancy-related acute myocardial infarction and highlight the key points in its management.
... The exact incidence of coronary artery disease (CAD) in women of child-bearing age is poorly defined. 35 Acute coronary syndromes are overall rare (1.7-6.2/100 000 pregnancies) but are responsible for 20% of cardiovascular mortality during pregnancy. ...
The growing population of women with heart disease of reproductive age has been associated with an increasing number of high-risk pregnancies. Pregnant women with heart disease are a very heterogeneous population, with different risks for maternal cardiovascular, obstetric, and foetal complications. Adverse cardiovascular events during pregnancy pose significant clinical challenges, with uncertainties regarding diagnostic and therapeutic approaches potentially compromising maternal and foetal health. This review summarizes best practice for the treatment of common cardiovascular complications during pregnancy, based on expert opinion, current guidelines, and available evidence. Topics covered include heart failure (HF), arrhythmias, coronary artery disease, aortic and thromboembolic events, and the management of mechanical heart valves during pregnancy. Cardiovascular pathology is the leading cause of non-obstetric morbidity and mortality during pregnancy in developed countries. For women with pre-existing cardiac conditions, preconception counselling and structured follow-up during pregnancy are important measures for reducing the risk of acute cardiovascular complications during gestation and at the time of delivery. However, many women do not receive pre-pregnancy counselling often due to gaps in what should be lifelong care, and physicians are increasingly encountering pregnant women who present acutely with cardiac complications, including HF, arrhythmias, aortic events, coronary syndromes, and bleeding or thrombotic events. This review provides a summary of recommendations on the management of acute cardiovascular complication during pregnancy, based on available literature and expert opinion. This article covers the diagnosis, risk stratification, and therapy and is organized according to the clinical presentation and the type of complication, providing a reference for the practicing cardiologist, obstetrician, and acute medicine specialist, while highlighting areas of need and potential future research.
... p < 0.001) [6]. It is estimated that women who experience MI during pregnancy have a mortality rate of up to 5-7% [7,8]. Preconception planning with a cardioobstetrics team is critical [9••]. ...
Purpose of Review
In this review, we discuss strategies for managing dyslipidemia in pregnant women with ASCVD.
Recent Findings
Cardiovascular disease (CVD) is the leading cause of mortality in women as well as the leading cause of pregnancy-related mortality in the USA. It is paramount to screen, identify, counsel, and treat women of childbearing age who have existing atherosclerotic disease to mitigate the risks of complications and mortality. Dyslipidemias, including hypercholesterolemia and hyperlipidemia, can further enhance the risk for future CVD events.
Summary
Treating hypercholesterolemia during pregnancy is crucial, and this is an opportune time for cross-collaboration of subspecialties in cardiology, obstetrics, and gynecology.
... There is up to a 4fold higher risk of MI during pregnancy and while MI is a rare event, it is associated with a high in-hospital mortality rate [28•]. Risk of MI in pregnancy was estimated at 3-10/ 100,000 deliveries or 1/12,400 hospitalizations in the NIS and the in-hospital maternal fatality rate was astoundingly high at 4.5-5.1% and up to 7.3% in a California-based cohort [28•, 29,30]. ...
Purpose of Review
Cardiovascular disease is an escalating cause of maternal morbidity and mortality. Women are at risk for acute myocardial infarction (MI), and more are living with risk factors for ischemic heart disease (IHD). The purpose of this review is to describe the evaluation and management of women at risk for and diagnosed with IHD in pregnancy.
Recent Findings
Pregnancy can provoke MI which has been estimated as occurring in 1.5–10/100, 000 deliveries or 1/12,400 hospitalizations, with a high inpatient mortality rate of approximately 5–7%. An invasive strategy may or may not be preferred, but fetal radiation exposure is less of a concern in comparison to maternal mortality. Common medications used to treat IHD may be continued successfully during pregnancy and lactation, including aspirin, which has an emerging role in pregnancy to prevent preeclampsia, preterm labor, and maternal mortality. Hemodynamics can be modulated during pregnancy, labor, and postpartum to mitigate risk for acute decompensation in women with IHD.
Summary
Cardiologists can successfully manage IHD in pregnancy with obstetric partners and should engage women in a lifetime of cardiovascular care.
... M aternal mortality in the United States continues to rise, partly related to increases in cardiovascular disease. 1 Cardiovascular conditions ranked as the leading cause of pregnancy-related deaths in the United States and accounted for 15.1% of all pregnancy-related deaths from 2011 to 2015. 1 Of the cardiovascular diseases contributing to morbidity and mortality in the pregnant population, acute myocardial infarction (AMI) may have a substantial role. 2 Although its incidence is uncommon relative to other cardiovascular diseases affecting women of childbearing potential, pregnancy can increase the risk of myocardial infarction 3-to 4-fold, 3 and maternal mortality related to AMI in pregnancy has been reported to be as high as 37%. [4][5][6] Pregnancy-associated myocardial infarction is on the rise, 6 for reasons that are likely multifactorial. This Balgobin et al Acute Myocardial Infarction in Pregnancy rise is perhaps related to increases in detection and increases in traditional cardiovascular risk factors such as diabetes mellitus, hypertension, obesity, hyperlipidemia, and tobacco abuse (or combinations thereof) in women of childbearing potential. ...
Background
Pregnancy increases the risk of acute myocardial infarction (AMI). The purpose of this study was to examine timing and risk factors for AMI in pregnancy and poor outcome.
Methods and Results
National Inpatient Sample (2003–2015) was screened in pregnancy, labor and delivery, and postpartum. There were 11 297 849 records extracted with 913 instances of AMI (0.008%). One hundred eleven (12.2%) women experienced AMI during labor and delivery, 338 (37.0%) during pregnancy and most during the postpartum period (464; 50.8%). The prevalence of AMI in pregnancy has increased ( P =0.0005). Most major adverse cardiovascular and cerebrovascular events occurred in the postpartum period (63.5%). Inpatient mortality was 4.5%. Predictors of AMI include known coronary artery disease (odds ratio [OR], 517.4; 95% CI, 420.8–636.2), heart failure (OR, 8.2; 95% CI, 1.9–35.2), prior valve replacement (OR, 6.4; 95% CI, 2.4–17.1), and atrial fibrillation (OR, 2.7; CI, 1.5–4.7; P <0.001). Risk factors of traditional atherosclerosis including hyperlipidemia, obesity, tobacco history, substance abuse, and thrombophilia were identified ( P <0.001). Gestational hypertensive disorders (eclampsia OR, 6.0; 95% CI, 3.3–10.8; preeclampsia OR, 3.2; 95% CI, 2.5–4.2) were significant risk factors in predicting AMI. Risk factors associated with major adverse cardiovascular and cerebrovascular events included prior percutaneous coronary intervention (OR, 6.6; 95% CI, 1.4–31.2) and pre‐eclampsia (OR, 2.3; 95% CI, 1.3–3.9).
Conclusions
AMI is associated with modifiable, nonmodifiable, and obstetric risk factors. These risk factors can lead to devastating adverse outcomes and highlight the need for risk factor modification and public health resource initiatives toward the goal of decreasing AMI in the pregnant population.
This chapter presents multiple‐choice question‐and‐answers on the topic of heart disease and pregnancy in cardiology. It is written for the primary purpose of helping candidates prepare for the American Board of Internal Medicine subspecialty certification. It will be very useful for those preparing for initial and recertification exams in Cardiology. Each of the questions is followed by few answers to choose from and the discussions address not only the rationale behind picking the right choice, but also fills in information around the topic so that important key concepts are clearly laid out. The questions address all areas of cardiology, some of which include: physical examination, ECG section with high resolution images, and non‐invasive and invasive imaging. The chapter also facilitates comprehensive and critical review of cardiovascular medicine to enhance one's diagnostic and therapeutic skills.
Background
It has been suggested that chronic hypertension is a risk factor for negative maternal and fetal outcomes during pregnancy and postpartum. We aimed to estimate the association of chronic hypertension on adverse maternal and infant outcomes and assess the impact of antihypertensive treatment and these outcomes.
Methods and Results
Using data from the French national health data system, we identified and included in the CONCEPTION cohort all women in France who delivered their first child between 2010 and 2018. Chronic hypertension before pregnancy was identified through antihypertensive medication purchases and by diagnosis during hospitalization. We assessed the incidence risk ratios (IRRs) of maternofetal outcomes using Poisson models. A total of 2 822 616 women were included, and 42 349 (1.5%) had chronic hypertension and 22 816 were treated during pregnancy. In Poisson models, the adjusted IRR (95% CI) of maternofetal outcomes for women with hypertension were as follows: 1.76 (1.54–2.01) for infant death, 1.73 (1.60–1.87) for small gestational age, 2.14 (1.89–2.43) for preterm birth, 4.58 (4.41–4.75) for preeclampsia, 1.33 (1.27–1.39) for cesarean delivery, 1.84 (1.47–2.31) for venous thromboembolism, 2.62 (1.71–4.01) for stroke or acute coronary syndrome, and 3.54 (2.11–5.93) for maternal death postpartum. In women with chronic hypertension, being treated with an antihypertensive drug during pregnancy was associated with a significantly lower risk of obstetric hemorrhage, stroke, and acute coronary syndrome during pregnancy and postpartum.
Conclusions
Chronic hypertension is a major risk factor of infant and maternal negative outcomes. In women with chronic hypertension, the risk of pregnancy and postpartum cardiovascular events may be decreased by antihypertensive treatment during pregnancy.
Purpose:
Rigorous perinatal epidemiologic research depends on population-based parental and neonatal sociodemographic and clinical data. Here we describe the creation of linked birth cohort files (LBCF), an enriched data source that combines information from vital records with maternal delivery and infant hospital encounter records.
Methods:
Probabilistic linkage techniques were used to link vital records (i.e., birth and fetal death certificates) from the California Department of Public Health with hospital inpatient, ambulatory surgery and emergency department encounter data for mothers and infants from the California Department of Health Care Access and Information.
Results:
From 2012 to 2018, 95% of live birth records were successfully linked to maternal and newborn hospital records while 85% of fetal death records were linked to a maternal delivery record. Overall, 93% of postnatal hospital encounters of infants (i.e., <1 year old) were matched to a linked record.
Conclusion:
The LBCF is a rich resource opening many possibilities for understanding perinatal health outcomes and opportunities for linkage to longitudinal, social determinant, and environmental data. To optimally use this file for research, analysts should evaluate possible shortcomings or biases of the data sources being linked.
From atrial septal defects to cardiac tamponade, the management of the myriad cardiac conditions that can complicate pregnancy follows a consistent approach: optimizing preload, optimizing afterload, and monitoring for the development of arrhythmia and pulmonary edema. This chapter addresses the majority of cardiac conditions that can complicate pregnancy and highlights the specific considerations for each.
Aim
To investigate the incidence and outcomes of acute high-risk chest pain diseases, including acute myocardial infarction (AMI), aortic dissection (AD), and pulmonary embolism (PE) during pregnancy and puerperium.
Methods
The National Inpatient Sample was queried to identify pregnancy-related hospitalizations from January 1, 2008 to December 31, 2017. Temporal trends in the incidence and mortality of AMI, AD and PE were extracted.
Results
Among 41,174,101 hospitalizations, acute high-risk chest pain diseases were diagnosed in 40,285 (0.098%). The incidence increased from 79.92/100,000 in 2008 to 114.79/100,000 in 2017 (P trend < 0.0001). The most frequent was PE (86.5%), followed by AMI (9.6%) and AD (3.3%). The incidence of PE in pregnancy decreased after 2014 and was lower than AMI and AD, while its incidence in puerperium was higher than AMI and AD consistently (P trend < 0.0001). Subgroup analysis showed the incidence of these diseases was higher in black women, lowest-income households, and elderly parturients (P trend < 0.0001). The mortality decreased from 2.24% in 2008 to 2.21% in 2017 (P trend = 0.0240), exhibiting 200-fold higher than patients without these diseases. The following factors were significantly associated with these diseases: aged ≥ 45 years (OR, 4.25; 95%CI, 3.80–4.75), valvular disease (OR, 10.20; 95%CI, 9.73–10.70), and metastatic cancer (OR, 9.75; 95%CI, 7.78–12.22). The trend of elderly parturients increased from 14.94% in 2008 to 17.81% in 2017 (P trend < 0.0001), while no such up-trend was found in valvular disease and metastatic cancer.
Conclusion
The incidence of acute high-risk chest pain diseases, especially PE in puerperium, increased consistently. Although mortality has shown a downward trend, it is still at a high level. We should strengthen monitoring and management of acute high-risk pain diseases in pregnancy and puerperium, especially for black women, lowest-income households, and elderly parturients in the future.
As the average maternal age advances with increasing concurrent cardiovascular disease risk factors, more women are entering pregnancy with or at risk for various cardiovascular conditions. Although rare, pregnant patients may require various cardiac interventions in the catheterization laboratory. An understanding of indications for intervention in pregnant patients with conditions such as myocardial infarction, severe valvular disease, and cardiogenic shock is critical to optimizing both fetal and maternal outcomes. This document highlights the most common cardiovascular conditions that may be encountered during pregnancy that may require intervention and highlights indications for intervention and periprocedural considerations to facilitate favorable maternal and fetal outcomes.
Cardiovascular disease, and particularly ischemic heart disease, is a leading cause of maternal morbidity and mortality in high-income countries. The incidence of acute myocardial infarction (AMI) has been rising over the past two decades due to increasing maternal age and a higher prevalence of cardiovascular risk factors in the pregnant population. Causes of AMI in pregnancy are diverse and may require specific considerations for their diagnosis and management. In this narrative review, we provide an overview of physiologic changes, risk factors, and etiologies leading to AMI in pregnancy, as well as diagnostic tools, reperfusion strategies, and pharmacological treatments for this complex population. In addition, we outline considerations for labor and delivery planning and long-term follow-up of patients with AMI in pregnancy.
Objective:
This study aims to examine the incidence of pregnancy-related cardiometabolic conditions and severe cardiovascular outcomes, and their relationship in US Medicaid-funded women.
Methods:
Medicaid is a government-sponsored health insurance programme for low-income families in the USA. We report the incidence of pregnancy-related cardiometabolic conditions (hypertensive disorders and diabetes in, or complicated by, pregnancy) and severe cardiovascular outcomes (myocardial infarction, stroke, acute heart failure, cardiomyopathy, cardiac arrest, ventricular fibrillation, ventricular tachycardia, aortic dissection/aneurysm and peripheral vascular disease) among Medicaid-funded women with a birth (International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis code O80 or O82) over the period January 2015-June 2019, from the states of Georgia, Ohio and Indiana. In this cross-sectional cohort, we examined the relationship between pregnancy-related cardiometabolic conditions and severe cardiovascular outcomes from pregnancy through to 60 days after birth using multivariable models.
Results:
Among 74 510 women, mean age 26.4 years (SD 5.5), the incidence per 1000 births of pregnancy-related cardiometabolic conditions was 224.3 (95% CI 221.3 to 227.3). The incidence per 1000 births of severe cardiovascular conditions was 10.8 (95% CI 10.1 to 11.6). Women with pregnancy-related cardiometabolic conditions were at greater risk of having a severe cardiovascular condition with an age-adjusted OR of 3.1 (95% CI 2.7 to 3.5).
Conclusion:
This US cohort of Medicaid-funded women have a high incidence of severe cardiovascular conditions during pregnancy. Cardiometabolic conditions of pregnancy conferred threefold higher odds of severe cardiovascular outcomes.
Importance:
Pregnant patients over age 40 often have unique risk factors and potential complications before and during pregnancy that play a role in their counseling and management.
Objective:
To provide practitioners an overview on how to approach preconception evaluation and counseling, prenatal care, and management of associated comorbidities, as well as potential complications, in pregnant patients over age 40.
Evidence acquisition:
Literature review was performed using OVID and PubMed, with further relevant information queried from guidelines of professional organizations.
Results:
Pregnant patients over age 40 should receive preconception evaluations by their obstetrician-gynecologist and other appropriate specialty care providers as they pertain to preexisting medical comorbidities. In the preconception period, attention should be given to managing and optimizing preexisting medical conditions and associated pharmacotherapeutics. Referral to specialists in assisted reproductive technologies or maternal-fetal medicine should be considered if indicated for appropriate evaluation and counseling. During pregnancy, accurate dating and counseling on aneuploidy screening, with consideration for early diabetes screening, should be performed in the first trimester. A detailed anatomy scan and fetal echocardiogram should be completed by 22 weeks' gestation, along with routine and high-risk (if indicated) prenatal care. Close attention should be given to the development of pregnancy-related complications associated with advancing age. Third-trimester fetal surveillance can be considered. Given that no contraindications exist, these patients should be encouraged to pursue a vaginal delivery with consideration for induction at 39 to 40 weeks' gestation.
Conclusions and relevance:
Pregnancy rates are increasing in persons over age 40. As a result, preconception evaluation and counseling tailored to that demographic are essential. In addition to standard prenatal care, they should have early screening and diligent monitoring for pregnancy-related comorbidities associated with advancing age.
Relevance statement:
With the increased pregnancy-associated comorbidities in patients over age 40, providers should be familiar with how to evaluate, counsel, and manage them during the preconception and pregnancy periods.
PANDUAN TATA LAKSANA PENYAKIT KARDIOVASKULAR PADA KEHAMILAN. Guidelines for the Management of Cardiovascular Diseases During Pregnancy yang dikeluarkan oleh European Society of Cardiology (ESC) menjadi acuan utama dalam buku ini. Panduan ini dibuat untuk pertama kali, dengan harapan dapat memberi acuan tentang tata laksana yang tidak hanya dititikberatkan pada kondisi ibu, tetapi juga memperhatikan kesejahteraan janin, sehingga angka kematian ibu hamil dan janin/bayi dapat diturunkan.
Coronary events in pregnancy are a rare but growing cause of maternal morbidity and mortality. Pregnancy presents unique challenges across a broad spectrum of disciplines and requires a multidisciplinary approach to optimize maternal and fetal outcomes. The early involvement of the "cardio-obstetrics" team in pre-pregnancy counselling, the antenatal period, delivery and post-partum is vital to ensuring better outcomes for patients at high risk of coronary pathology. The overall risk for coronary events complicating pregnancy is increasing due to a number of factors including advancing maternal age and increases in traditional cardiac risk factors; contributing to higher rates of maternal morbidity and mortality. The majority of pregnant women experiencing a coronary event do not have prior coronary disease, and the pathological mechanisms involved are predominantly non-atherosclerotic. Diagnosis and management should follow standard guideline-based practices for acute coronary syndrome (ACS), including the use of diagnostic coronary angiography to guide percutaneous intervention when needed. Management of ACS should not be delayed to facilitate delivery, which can proceed following stent implantation and dual antiplatelet therapy. The timing and mode of delivery should be based on assessment of maternal and fetal status, but vaginal delivery is preferred when possible. This review aims to provide an overview of the major etiologies, risk factors, diagnosis and management strategies for patients at risk of or presenting with coronary events in pregnancy.
Pregnant women with heart disease are vulnerable to many adverse cardiovascular events (AE). AEs during and after pregnancy continue to be important causes of maternal mortality and morbidity worldwide, with huge variations in burden in different countries and regions. These AEs are classified as having direct or indirect causes, depending on whether they are directly caused by pregnancy or due to some pre-existing disease and/or non-obstetric cause, respectively. The risks continue throughout pregnancy and even after childbirth. Apart from immediate complications during pregnancy, there is increasing evidence of a significant link between several events and the risk of cardiovascular disease (CVD) later in life. A significant number of pregnancy-related deaths caused by cardiovascular disease are preventable. This prevention can be realized through increasing awareness of cardiovascular AE in pregnancy, coupled with the application of strategies for prevention and treatment. Knowledge of the risks associated with CVD and pregnancy is of extreme importance in that regard. We discuss the global distribution of cardiovascular maternal mortality, adverse events during and after pregnancy, their predictors and risk stratification. In addition, we enumerate possible solutions, particularly the role of cardio-obstetric clinics.
Acquired cardiovascular conditions are a leading cause of maternal morbidity and mortality. A growing number of pregnant women have acquired and heritable cardiovascular conditions and cardiovascular risk factors. As the average age of childbearing women increases, the prevalence of acute coronary syndromes, cardiomyopathy, and other cardiovascular complications in pregnancy are also expected to increase. This document, the third of a 5-part series, aims to provide practical guidance on the management of such conditions encompassing pre-conception through acute management and considerations for delivery.
The objective of this literature review was to explore the long-term cardiovascular effects of preeclampsia in women. The primary goal was to determine which organs were most commonly affected in this population. Although it was previously believed that preeclampsia is cured after the delivery of the fetus and the placenta current evidence supports an association between preeclampsia and cardiovascular disease later in life, many years after the manifestation of this hypertensive pregnancy related disorder. Therefore preeclampsia may be emerging as a novel cardiovascular risk factor for women, which requires long-term follow up.
Clinical Case
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A 34-year-old, G1P1, asymptomatic woman, who grew up in Ethiopia presents for preconception counseling. She has a history of rheumatic heart disease resulting in mitral stenosis as a child.
She has no cardiac symptoms, at rest or with exertion. On physical exam, she has a regular rate and rhythm, with a loud S1, and normal S2. There is an opening snap followed by a 2/6 diastolic murmur at the left ventricular apex. No other extracardiac sounds are present. Lungs are clear to auscultation. Her current echocardiogram demonstrates a mitral valve area by pressure half-time method of 1.2 cm², mean gradient across the valve of 7 mmHg at a heart of 70 beats per minute, and a mitral valve score of 8, with trace mitral regurgitation. What are her pregnancy-associated risks and how do we optimize her preconception?
Abstract
Maternal mortality in the United States is rising and cardiovascular disease causes 26.5% of these pregnancy-related deaths. The rising trend appears to be secondary to acquired heart disease with many factors contributing, including increasing maternal age, rise in multifetal pregnancies, and the increased burden of preexisting cardiovascular risk factors in the pregnant population. Pregnancy itself causes a significant hemodynamic burden and may cause decompensation in a patient with preexisting cardiovascular disease. Risk stratification for pregnancy should ideally occur preconception and there are several risk assessment tools that can aid decision making.
The care of the pregnant woman with heart disease also implicates several stakeholders including obstetrics, obstetric anesthesia, and cardiology. Unlike many cardiovascular diseases, there are no randomized controlled data to support decision making, and guidelines are largely built on expert consensus. It is therefore vital for cardiologists to continue to build on their knowledge on the management of cardiovascular disease during pregnancy and work in a multidisciplinary fashion to improve care.
The reported incidence of ischemic heart disease in pregnancy is 2.8 to 6.2 per 100,000 pregnancies. Although additional factors, such as maternal diabetes, obesity, and hypertension, are risk factors for ischemic heart disease, pregnancy itself more than doubles the risk for acute myocardial infarction. Given the increasing clinical importance of ischemic heart disease during pregnancy, this article addresses underlying pathophysiology, risk stratification, screening, and diagnosis of ischemic heart disease, as well as recommendations for management of acute myocardial infarction during pregnancy and the early postpartum period.
Cardiac arrest is rare in pregnancy. Therefore, most intensivists will have limited experience with post-cardiac arrest care in pregnancy. Intensive care should be tailored to the state of pregnancy while adhering to general guidelines on post cardiac arrest care whenever possible. Accurate details regarding cardiac arrest and resuscitation (in particular information regarding delays and initial rhythm) are important for identifying the cause of the arrest and assessing the risk of hypoxic-ischaemic brain injury. Fever is common after return of spontaneous circulation and has been shown to be detrimental. Thus, targeting a temperature of 33–36 °C is paramount. Haemodynamic, oxygenation, ventilation and sedation goals follow general recommendations. Prolonged unconsciousness requires a multimodal prognostication strategy. Both patient and family commonly require support and counselling given the traumatic nature of such events.
Acute coronary syndromes (ACS) represent a major cause of morbidity and mortality worldwide and are mostly related to coronary artery disease (CAD). Acute myocardial infarction (AMI) has historically been regarded as a men’s disease and, for many years, women have been underdiagnosed and mistreated, especially at a young age. Relevant disparities still exist in the diagnosis, management and outcomes of ACS between men and women, especially during the pre-menopausal age. Moreover, although CAD is uncommon among young patients due to the low prevalence of atherosclerosis related risk factors, ACS may have destructive effects on their lifestyle and prognosis. Here we describe three frequent causes of ACS and AMI or conditions mimicking it, with a specific focus on women with absent or non-critical CAD: spontaneous coronary artery dissection (SCAD), AMI with non-obstructive coronary arteries (MINOCA) and Takotsubo cardiomyopathy (TTS). These conditions are rare but potentially life-threatening and are frequently underdiagnosed or misdiagnosed, since presenting symptoms and signs are atypical and not always overt and since most affected subjects have always been considered at low risk of having ACS. Due to difficulties in the diagnostic process and their potential devastating consequences, it is important to raise awareness on the prevalence and on clinical features of ACS in this class of patients.
Introduction: The article presents information about the peculiarities of the course of pregnancy and childbirth in women with a syphilitic infection in the anamnesis. The peculiarities of the state of newborn babies born from mothers who have suffered syphilis are described. To date, the incidence of syphilis in Ukraine has a clear tendency to decline, but still remains quite high. The maximum incidence of syphilis is observed in women aged 15-20 years. The combination of pregnancy and syphilitic infection in an anamnesis is an unfavorable factor in regard to high risk of perinatal complications, the frequency of which does not tend to decrease. The aim - study the features of the course of pregnancy and childbirth in women with a syphilitic infection in the anamnesis, the evaluation of the state of newborns. Materials and methods: A prospective examination of 57 healthy women and their newborns (control group) and 60 pregnant women with a history of syphilitic infection (the main group) had been conducted. All pregnant women had undergone ultrasound examination, including feto- and placentometry, an estimate of the amount of amniotic fluid. The effect of the transferred syphilis on the state of the newborn had been assessed in accordance with the results of the clinical examination of an anthropometric data, including an Apgar score. Results: It is stated that the incidence of latent (41,66%) and forms with a prolonged course (20,00%) of syphilitic infection. The threat of premature childbirth was almost 3,5 times higher than in women with syphilis, cases of an anemia in pregnant women – 2 times, hypertensive disorders of pregnant women were 2,4 times more common in women of the main group, fetal development retardation syndrome 6,4 times, while a greater percentage of this disorder was recorded among women in the main group who were ill with latent forms and suffered secondary recurrent syphilis (35%). In 20% of the cases, pregnancy in women with syphilis has been completed by the cesarean section, an abnormality of the contractile capacity of the uterus was significantly higher – 23,33%. The adaptive capacity of the newborns in the main group has been significantly lower, compared to the control group. Conclusions: Syphilitic infection in the anamnesis complicates the course of pregnancy with numerous pathological conditions. Syphilitic infection, borne before pregnancy, affects not only the course of pregnancy, but also the course of childbirth and the postpartum period. The pathological conditions in infants are due to a decrease in resistance to birth stress, early depletion of adaptive resources of newborns under the influence of a syphilitic infection of the mother. In children who have experienced chronic intrauterine hypoxia, the risk of hemorrhagic syndrome is significantly higher due to increased permeability of the vascular wall. Such children have a tendency to develop neurological disorders and respiratory system lesions.
Introduction: There have recently been increasingly frequent reports of myocardial infarction (MI) in pregnancy and in the postpartum period. Pertinent and timely treatment affect maternal and fetal morbidity and mortality. Clinical case: We are reporting about a 42 years old woman at the 19th week of gestation, with complains of chest pain with irradiation into the left arm, and shortness of breath. It was known from the history of present illness, that at the time of the event ventricular fibrillation was recorded and resuscitation measures with cardioversion were performed. Subsequently, after an additional examination in the hospital, a diagnosis of MI has been determined. Coronary angiography with cardiac ventriculography (CVG) has been performed and stenosis of left anterior descending coronary artery (LAD) and right coronary artery (RCA) detected. A revascularization with the insertion of the bare-metal stent system has performed and double antiplatelet therapy prescribed. At 37 weeks of gestation, the patient gave birth to a healthy child by caesarean section. Conclusions: This clinical case illustrates the importance of minimizing the time to hospitalization of a pregnant woman with a MI to a specialized center for timely and complete diagnostic measures, which, in turn, allow to properly choose the tactics of patient management. Timely revascularization and properly selected anticoagulation are the key factors of the successful management in this category of patients.
Introduction: Human health depends on various factors that have a different physical origin, degree of influence on the human body, methods of manifestation and other characteristics. Within public health, their research is carried out implementing an integrated approach and understanding the causation of the factors that influence each other as well as their effects on the human body. The natural environment, namely its state in general and individual natural objects, in particular, is one of the elements having both direct and indirect effects on human health. The aim: To analyze the legal basis for the regulation of the impact of the natural environment as a component of public health. Materials and methods: The study examines provisions of international documents and scientists’ attitudes. The article analyzes generalized information from scientific journals by means of scientific methods from a medical and legal point of view. This article is based on dialectical, comparative, analytic, synthetic and comprehensive research methods. Within the framework of the system approach, as well as analysis and synthesis, the concepts of public health, health and influence of the natural environment on them are researched. Review: As a result of the study of a particular range of problems, it may be noted that human health depends on a number of factors that allow it to be adequately addressed. The environmental component, namely, the state of the natural environment affecting the human body both directly and indirectly, is not the least of them. Proper legal settlement of the above-mentioned range of problems will allow a comprehensive approach to understanding the causation of human health and the natural environment. Conclusions: when researching the impact of the natural environment within public health, it can be noted that the legal basis for the multidimensional regulation of the notion of health in general, as well as its individual components, in particular, has been formed and reflected in a number of regulatory legal acts. In turn, inadequate implementation of the systematic approach with an in-depth understanding of the real and potential factors that affect human condition in one way or another does not allow the fullest possible determination of their causation both on the positive and negative sides.
Introduction: A significant part of patients with HIV / AIDS develops damage to the nervous system. There are also cases where opportunistic infections of the nervous system, especially herpes viral origin, can hide the underlying disease, making it difficult diagnosis. The aim: To show the possibility of HIV infection mimicry a neurological pathology. Clinical case: A 41-years-old female presented to The Cеntег of Infectious disorders of the Nervous System (Kyiv, Ukraine) in August, 2018 after developing acute fever following by a left side hemiparesis, violation of coordination. Tuberculosis and HIV denied. Her physical examination showed tremor in her hands during a Barre-probe. She performed the coordination tests with intent, staggering in the Romberg pose. A small brain lesion was revealed at MRI. Antibodies to HSV1/2, CMV, Tox. gondii were found in the CSF and blood. Blood PCR was reported to be positive for EBV DNA, and HCV RNA. A rapid HIV test was negative. A repeated blood test performed 10 days after admission showed low level of CD4+ T cells (36 cells /1 μl), and HIV RNA (850,104 cp / ml). HIV antibodies were also revealed. As a result, patient was transferred to a specialized department for further treatment. Conclusion: Considering high clinical polymorphism of HIV/AIDS, physicians of all specialties should be alert for the possible neurologic manifestations of this disease to timely examine patients.
Pregnancy-associated myocardial infarction is a primary contributor to maternal cardiovascular morbidity and mortality. Specific attention to the cause of myocardial infarction, diagnostic evaluation, treatment strategies, and postevent care is necessary when treating women with pregnancy-associated myocardial infarction. This review summarizes the current knowledge, consensus statements, and essential nuances.
Pregnancy-related maternal mortality and morbidity rates continue to increase in the United States despite global improvements in maternal outcomes. The unique hemodynamic and physiological changes of pregnancy results in a 3- to 4-fold increased risk of acute myocardial infarction (AMI) which causes a substantial proportion of all maternal cardiac deaths. In addition to atherosclerosis, pregnancy-associated AMI is commonly caused by nonatherosclerotic etiologies such as spontaneous coronary artery dissection, embolus to the coronary artery, and coronary vasospasm. Herein, the epidemiology, etiologies, presentation, diagnosis, and management of AMI in pregnancy is discussed along with future directions for multidisciplinary care.
As a summary of this guideline, Table 21 shows the frequency of each examination, treatment, and lifestyle guidance according to the severity classification of KD. Authors would be pleased if it could be used as a reference for medical staff who handle the remote stage of KD. On the other hand, the higher the severity, the more likely it is that various disorders will be complicated, and specialists are required to manage each case individually. Keeping in mind that the policy shown in this guideline is general, authors would like readers to deal with each case with the best policy. Most of the long-term treatment and management of KD still have a low level of evidence, and the treatments that could show strong recommendation level in this guideline are very limited. Authors would like to emphasize that the accumulation of evidence is urgent in the future.
Pregnancy is a special situation in a woman’s life, and emergencies arising in pregnant women require a particularly specialized approach. Due to the concerns of potential radiation risk to the developing fetus, imaging requiring ionizing radiation should be used judiciously. Ultrasound and magnetic resonance imaging play a substantial role in evaluating pregnant patients in general; however, their role is much more limited in thoracic emergencies due to the inherent limitations of these technologies. Chest radiography and computed tomography are the mainstay when it comes to the imaging of thoracic emergencies, in non-pregnant and in pregnant patients. Due to changes in physiology, pregnant patients are more predisposed to certain thoracic emergencies, including pulmonary embolism and peripartum cardiomyopathy. In this chapter, we will discuss the more common thoracic emergencies potentially arising in pregnant patients, and we will discuss the most appropriate imaging evaluation, the imaging findings, and patient management.
Cardio-obstetrics has emerged as an important multidisciplinary field that requires a team approach to the management of cardiovascular disease during pregnancy. Cardiac conditions during pregnancy include hypertensive disorders, hypercholesterolemia, myocardial infarction, cardiomyopathies, arrhythmias, valvular disease, thromboembolic disease, aortic disease, and cerebrovascular diseases. Cardiovascular disease is the primary cause of pregnancy-related mortality in the United States. Advancing maternal age and preexisting comorbid conditions have contributed to the increased rates of maternal mortality. Preconception counseling by the multidisciplinary cardio-obstetrics team is essential for women with preexistent cardiac conditions or history of preeclampsia. Early involvement of the cardio-obstetrics team is critical to prevent maternal morbidity and mortality during the length of the pregnancy and 1 year postpartum. A general understanding of cardiovascular disease during pregnancy should be a core knowledge area for all cardiovascular and primary care clinicians. This scientific statement provides an overview of the diagnosis and management of cardiovascular disease during pregnancy.
Coronary insufficiency is uncommon during pregnancy, occurring in approximately one in 10 000 pregnancies. With the increasing age of mothers, the incidence of coronary insufficiency in pregnancy is likely to increase. The most common cause of acute myocardial infarction are atherosclerotic disease, thrombosis, coronary artery dissection, coronary artery spasm. Coronary insufficiency constitutes an important problem for the treating physician and the patient, because the selection of diagnostic and therapeutic approaches is influenced not only by maternal, but also by fetal safety. Even less is known about the use of thrombolytics, percutaneous coronary intervention and optimal medical management of coronary insufficiency during pregnancy. The epidemiology, diagnosis, medical and surgical treatment of coronary insufficiency are the subject of the given article.
The need for cardiac surgery during pregnancy is rare. Only 1% to 4% of pregnancies are complicated by maternal cardiac disease and most of these can be managed with medical therapy and lifestyle changes. On occasion, whether due to natural progression of the underlying cardiac disease or precipitated by the cardiovascular changes of pregnancy, cardiac surgical therapy must be considered. Cardiac surgery is inherently dangerous for both, the mother and fetus with mortality rates near 10% and 30%, respectively. For some conditions, percutaneous cardiac intervention offers effective therapy with far less risk to the mother and her fetus. For others, cardiac surgery, including procedures that mandate the use of cardiopulmonary bypass, must be entertained to save the life of the mother. Given the extreme risks to the fetus, if the patient is in the third trimester, strong consideration should be given to delivery before surgery involving cardiopulmonary bypass. At earlier gestational ages when this is not feasible, modifications to the perfusion protocol including higher flow rates, normothermic perfusion, pulsatile flow, and the use of intraoperative external fetal heart rate monitoring should be considered.
In the present review the world literature on pregnancy complicated by myocardial infarction is summarized, and two additional cases are presented. It is apparent that the majority of pregnant women who have died after myocardial infarction did so at the time of initial infarction, and maternal mortality was greatest if the infarction was late in pregnancy. Moreover, delivery within two weeks of infarction was associated with increased mortality as was reinfarction during labor. These results suggest that the increasing cardiovascular stresses of late pregnancy, especially when intensified by parturition, seriously compromise women with ischemic heart disease. Efforts should therefore be made to limit myocardial oxygen demand/consumption throughout pregnancy, and particularly during parturition. Although principles of management can be generalized, these high risk patients require individualization of care by a multidisciplinary team of cardiologists, anesthesiologists, and obstetricians.
The purpose of this review is to analyze the possible parameters that lead to the devel opment of what is a rare event—acute myocardial infarction (AMI) during pregnancy and puerperium. Through the Index Médicus, 109 publications on the subject were obtained. Since the first well-documented case by Katz in 1922, 136 patients have been reported, and from these reports the following data have been gathered: the average age was 32.1 years. This event is more frequent during the third trimester and puerperium of the first and second pregnancies. In 42.6% of the patients no coronary risk factors were observed, but when present, hypertension and cigarette smoking were the most common. The anterior wall along or in combination with any other anatomic area was affected in 73% of cases. Coronary angiograms, when taken, appeared normal in 47%. The maternal mortality rate was 26/136 (19.1%) and was higher during the third trimester, labor, and puerperium. Eight patients (8/26) (30.7%) had sudden death. In 5 of these, (62.5%) coronary thrombosis was found. In 18/26 deaths, an autopsy was performed; 9/18 (50%) had coronary thrombus formation and in 7/18 (39%) variable degrees of atherosclerosis were detected. On the other hand, the fetal mortality rate was 16.9%; however, in only 52% was death coincidental with that of the mother. Coronary artery spasm associated with a probable hypercoagulability state was the most likely mechanism in the majority of these patients, followed by atherosclerotic heart disease and coronary dissection—the last being secondary most likely to hormonal changes.
During the AMI these patients should be studied by a medical team composed of a cardiologist, gynecologist, and anesthesiologist. A complete cardiologic work-up should be made to decide individually about further pregnancies.
To review available information on the epidemiology, cause, diagnosis, prognosis, and treatment of acute myocardial infarction during pregnancy or in the early postpartum period and to develop guidelines for the management of this condition.
MEDLINE and Index Medicus searches and a manual search of bibliographies from reviewed articles.
Published reports of well-documented acute myocardial infarction during pregnancy or the early postpartum period or potentially relevant information.
125 well-documented cases of myocardial infarction were identified.
The highest incidence seems to occur in the third trimester and in multigravidas older than 33 years of age. Acute myocardial infarction during pregnancy is most commonly located in the anterior wall. The maternal death rate was 21%; death occurred most often at the time of acute myocardial infarction or within 2 weeks of the infarction and was usually related to labor and delivery. Most fetal deaths were associated with maternal deaths. Coronary artery morphology was studied in 54% of described patients. Coronary atherosclerosis with or without intracoronary thrombus was found in 43% of patients, coronary thrombus without atherosclerotic disease in 21%, coronary dissection in 16%, and normal coronary arteries in 29%.
Acute myocardial infarction during pregnancy or the early postpartum period is rare but may be associated with high risk. Although atherosclerosis can be documented in many cases, coronary dissection and arteries that are normal on angiography are common, especially in acute myocardial infarction occurring in the peripartum or postpartum period. Early diagnosis is often hindered by the normal changes of pregnancy and low level of suspicion. Management should follow the usual principles of care for acute myocardial infarction. However, selection of diagnostic and therapeutic approaches may be greatly influenced by fetal safety.
To determine whether the rate of cardiovascular disease is different among parous women with a general practitioner reported history of toxaemia of pregnancy than among those not reported to have experienced toxaemia, or among nulliparous women.
Prospective cohort study.
1400 general practitioners throughout the United Kingdom.
Women who had never used oral contraceptives who were recruited to the Royal College of General Practitioners' oral contraception study (original cohort about 23000).
Age, social class, and smoking standardised incidence rates for hypertensive disease, acute myocardial infarction, other acute ischaemic heart disease, other chronic ischaemic heart disease, angina pectoris, total ischaemic heart disease, total cerebrovascular disease, and total venous thromboembolic disease in the three groups.
Compared with parous women with no history of toxaemia, those who had experienced toxaemia had a significantly increased risk of hypertensive disease (relative risk (RR) 2.35), acute myocardial infarction (RR 2.24), chronic ischaemic heart disease (RR 1.74), angina pectoris (RR 1.53), all ischaemic heart disease (RR 1.65), and venous thromboembolism (RR 1.62). The rates for all cerebrovascular disease and peripheral vascular disease were also increased but not significantly. Nulliparous women were more likely to develop hypertension or all cerebrovascular disease later in life than parous women without a history of toxaemia.
A history of toxaemia of pregnancy increases the risk of several distinct cardiovascular conditions later in life. Although causality cannot be inferred (other characteristics of the women may account for both an increased risk of toxaemia and a risk of subsequent vascular disease), the findings merit further research because of their potential importance.
A methodology for linking vital statistics linked birth/death data and hospital discharge data is described. The resulting data set combines information on a neonate's sociodemographic characteristics, prenatal care, and mortality aspects and connects it to detailed health outcome and resource utilization data, thus establishing an extensive database for epidemiological studies. In the absence of a universal identifier common to both databases, our linkage strategy relied on using a virtual identifier based on variables common to both data sets. In the case of multiple incidences of the same virtual identifier we used secondary health status information to optimize the likelihood of linking low birth weight or premature infants in one database to infants of similar health status in the other while randomizing cases in which no secondary information was present. Applying our method to the 1992 California birth cohort, we could link 563,114 out of 571,189 eligible births (98.59%). Of these links, 91.2% were established on the basis of unique virtual identifiers. The link was internally consistent and no bias was evident when comparing variable distributions for all single live births in the vital statistics linked birth/death file and linked births in the linked vital statistics linked birth/death and hospital discharge file. Multiple imputation techniques showed that the prediction error incurred by randomization was negligible. Even though computationally intensive, our method for linking the vital statistics linked birth/death file and the hospital discharge file appeared to be effective. However, it is important to be aware of the limitations of the resulting data set, in particular the fact that it cannot be used for tracking individual cases. The method provides a database suitable for a variety of perinatal epidemiological analyses, such as descriptive studies of disease distribution in neonates, studies of the geographic distribution of disease, and studies of the relationship between risk and outcome.
To examine pregnancy outcomes in women age 40 or older.
We used data from the California Health Information for Policy Project, which consists of linked records from the birth certificate and the hospital discharge record of both mother and newborn of all births that occurred in acute care civilian hospitals in California between January 1, 1992, and December 31, 1993. The study population consisted of all women who delivered at age 40 or over. The control population was women who delivered between age 20 and 29 years during this 2-year period. We reviewed gestational age at delivery, birth weight, mode and type of delivery, discharge summary and birth certificate demographics, birth outcome, pregnancy, and delivery data.
Approximately 1,160,000 women delivered during the study period, and 24,032 (2%) of these women were age 40 or older. Of this latter group, 4777 (20%) were nulliparous. The cesarean delivery rate for nulliparous women in the study population was 47.0%, and the rate for multiparous patients in this group was 29.6%. The cesarean delivery rate was 22.5% for nulliparous and 17.8% for multiparous women in the control group. In the older group, the operative vaginal delivery rate (forceps and vacuum) was 14.2% for nulliparous women and 6.3% for multiparous women. Rates of birth asphyxia, fetal growth restriction, malpresentation, and gestational diabetes were significantly higher among older nulliparas (6, 2.5, 11, and 7%, respectively) compared with rates among control nulliparas (4, 1.4, 6, and 1.7%, respectively), and there were similar significant increases among older multiparas (3.4, 1.4, 6.9, and 7.8%, respectively), compared with younger multiparous controls (2.4, 1, 3.7, and 1.6%, respectively). Mean (+/- standard error) birth weight of infants delivered by older nulliparous women was 3201+/-10 g, significantly lower than that among nulliparous controls (3317+/-1 g), whereas mean birth weight in the group of older multiparas (3381+/-5 g) was no different than that among younger multiparous controls (3387+/-1 g). Gestational age at delivery was significantly lower among older nulliparas (273.4+/-0.4 days), compared with nulliparous controls (278.5+/-0.05 days), and similarly lower among older multiparous women (274.0+/-0.2 days), compared with multiparous controls (278.3+/-0.05 days). More white women age 40 or over than younger white women were having a first child (64 and 39%, respectively).
Nulliparous women age 40 or over have a higher risk of operative delivery (cesarean, forceps, and vacuum deliveries: 61%) than do younger nulliparous women (35%). This increase occurs in spite of lower birth weight and gestational age and may be explained largely by the increase in other complications of pregnancy. The increased frequency at which white women are having their first child at age 40 or over may reflect career choices that involve delaying childbirth until the fifth decade of life. These data will allow us better to counsel patients about their pregnancy expectations and possible outcomes.
To evaluate the validity of racial/ethnic information in California birth certificate data.
Computerized birth certificate data and postpartum interviews with California mothers. STUDY DESIGN AND DATA COLLECTION: Birth certificates were matched with face-to-face structured postpartum interviews with 7,428 mothers to compare racial/ethnic information between the two data sources. Interviews were conducted in Spanish or English during delivery stays at 16 California hospitals, 1994-1995.
The sensitivity of racial/ethnic classification in birth certificate data was very high (94 percent to 99 percent) for African Americans, Asians/Pacific Islanders, Europeans/Middle Easterners, and Latinas (Hispanics). For Native Americans, however, the sensitivity was only 54 percent. The positive predictive value of birth certificate classification of race/ethnicity was high for all racial/ethnic groups (96 percent to 97 percent).
Despite limited training of birth clerks, the maternal racial/ethnic information in California birth certificate data appears to be a valid measure of self-identified race and Hispanic ethnicity for groups other than Native Americans.
Acute myocardial infarction in pregnancy and puerperium is an uncommon event with substantial morbidity and mortality rates. Atherosclerosis may be the cause, but often the coronary arteries are healthy at angiography. In such cases, the suggested mechanism is a decreased coronary perfusion related to coronary spasm or in situ thrombosis. Most pregnant women who died after myocardial infarction did so at the time of initial infarction, and maternal mortality was greatest if the infarction was late in pregnancy. Increasing cardiovascular stresses of late pregnancy, especially when intensified by parturition, seriously compromise women with ischemic heart disease. Therefore, there should be efforts to limit myocardial oxygen demand throughout pregnancy, and particularly during parturition. It is important for diagnosis to have increased awareness of its possible occurrence. Although principles of management can be generalized, it is necessary to provide individualized care for these high-risk patients by a multidisciplinary team of cardiologists, anesthesiologists, and obstetricians.