Case report of myocardial infarction in labor Nicole E. Menegakis, MD, and Marvin S. Amstey, MD Rochester, New York Substernal and epigastric pain occurring during labor was not considered important until the first postpartum day when an obvious myocardial infarction was diagnosed in a 37-year-old woman. Angiography revealed normal coronary arteries, and the myocardial infarction was postulated to be due to arterial spasm in association with smoking, oxytocin, ephedrine, and epidural anesthesia. (AM J OSSTET GYNECOL 1991;165:1383-4.)

Key words: Pregnancy, infarction, oxytocin, arterial spasm

Myocardial infarction during pregnancy and the puerperium is rare; its diagnosis is often overlooked because of its rarity and vague clinical presentation.

Case report A 37-year-old white primigravid woman at 39 weeks' gestation was seen in early labor. The patient's medical history was unremarkable except for smoking one pack of cigarettes per day. She had no history of hypertension, cardiac disease, or hypercholesterolemia. She had no history of cocaine use. There were no prenatal complications when she was seen over a period of nine visits. On admission, she was in good general health with ruptured membranes and mild uterine contractions every 5 minutes. Blood pressure was 130/S0 mm Hg and pulse was 100 beats/ min and regular. A grade 1/6 systolic ejection murmur was heard at the upper left sternal border. All routine laboratory data were normal. Intravenous oxytocin (Pitocin) infusion was started S hours after admission and reached a maximum dose of S mU Imino She experienced "heartburn" 21/2 hours later. This was thought to be secondary to gastroesophageal reflux and resolved with a suspension of aluminum and magnesium hydroxides (Maalox) and emesis. She received a total of S70 mU of oxytocin over this time. The infusion was stopped for an epidural anesthetic to be administered (15 ml of 0.25% bupivacaine hydrochloride [Marcaine]). Blood pressure dropped to SO/50 mm Hg with a pulse of SO beats/min 10 minutes after the anesthetic was given; this was followed by further episodes of emesis. She was given 25 mg promethazine hydrochloride and 20 mg of ephedrine sulfate intravenously, and blood pressure returned to 100/60 mm Hg. Intravenous oxytocin was restarted, and there were no further episodes of chest pain. At From the Department of Obstetrics and Gynecology, Highland Hospital, University of Rochester School of Medicine and Dentistry. Received for publication March 5, 1991,. revised March 21.1991,. accepted April 24, 1991. Reptint requests: Marvin Amstey, MD, Department of Obstetrics and Gynecology, Highland Hospital. Universitv of Rochesta School of Medicine, Rochester, NY 14620. 6/1 130689

12:30 AM she was spontaneously delivered of a 7 pound 5 ounce male infant with Apgar scores of Sand 9 at 1 and 5 minutes, respectively. At 1:30 AM, 2 days post partum, she complained of severe "heartburn" radiating to the back and left arm and "a large weight on her chest." She denied shortness of breath and dizziness but was diaphoretic. On physical examination, blood pressure was 150/90 mm Hg, pulse SO beats/min and regular, respirations 16 breaths/min, and a 2/6 systolic ejection murmur at the upper left sternal border, but no third or fourth heart sounds were heard. She was treated with aluminum hydroxide and magnesium trisilicate (Mylanta) and acetaminophen and codeine phosphate (Tylenol #3). The pain, which resolved after 1 hour, was believed initially to have been esophagitis or musculoskeletal pain. However, an electrocardiogram done at 10:00 AM revealed an anterolateral myocardial infarction with Q waves in leads III and V2-V5, inverted T waves in lead AVL, and significant ST elevations in leads V2-V5. Echocardiogram demonstrated hypokinesis ofthe left ventricle. The cardiac enzyme pattern confirmed the diagnosis and suggested that the infarction had occurred 2 to 3 days previously (presumably during labor). The second episode of chest pain was presumed to be postinfarction angina. Coronary angiography was done 5 days after infarction; normal coronary arteries were demonstrated. Blood cholesterol was 250 mg/dl. The patient was treated with rest, anticoagulant therapy, warfarin sodium (Coumadin), and calcium-channel blockers (diltiazem hydrochloride). She was discharged on the eighth hospital day.

Comment A recent review by Hankins et al. I found 70 cases of myocardial infarction in pregnancy reported in the world literature. Mortality attributable to myocardial infarction in pregnancy and the puerperium is estimated to be 30% to 37%. Unfortunately, because of the rarity of the event and the age and sex of the patient, the symptoms of an impending infarction are often mistaken for more common and benign conditions typically associated with pregnancy. The most common risk factor in young patients with

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myocardial infarction is cigarette smoking. The risk of myocardial infarction in women

Case report of myocardial infarction in labor.

Substernal and epigastric pain occurring during labor was not considered important until the first postpartum day when an obvious myocardial infarctio...
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