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Oral Presentation WACPFAM2 Clinical Case Report Acute MI Following Elective

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Conference Paper · July 2021

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WACP/FAM2
CLINICAL CASE REPORT:
Acute myocardial infarction
following elective caesarean
section
Oreh AC1,2, Imagbenikaro EU1, Adelaja AM3, Ezeogu L4
PRESENTING AUTHOR: DR ADAEZE C OREH FWACP(Family Medicine)

PRESENTATION AT THE 44TH & 45TH

ANNUAL SCIENTIFIC CONFERENCE
AND GENERAL MEETING OF
WEST AFRICAN COLLEGE OF PHYSICIANS NIGERIA CHAPTER

KEYWORDS

01 02 03
PREGNANCY CONGESTIVE CARDIAC MYOCARDIAL
FAILURE INFARCTION

04 05
NON-ST SEGMENT PREGNANCY-ASSOCIATED
MYOCARDIAL MYOCARDIAL
INFARCTION (NSTEMI) INFARCTION (PAMI)

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INTRODUCTION
Acute myocardial infarction (AMI) is a clinical or
pathological event caused by myocardial injury
or necrosis.

Maternal deaths due to AMI have been

increasingly reported, however, little data on
pregnancy-related cardiovascular disease in
Nigeria and other low- and middle-income
countries exists.

Considering a vast majority of births occur in

rural and semi-urban areas with little access to
skilled obstetric care and efficient referral
services, this may significantly contribute to
maternal mortality and foetal compromise.

INTRODUCTION

Pregnant
women
Relatively have a
Rare three- to
occurrence four-fold
in obstetrics higher
relative risk
of AMI
Incidence of 3 to Mortality rates
10 per 100,000 range between
deliveries 5.1% and 38%

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INTRODUCTION
Coronary atherosclerosis is the commonest cause and risk factors
include:
o Higher parity (>3)
o Increasing maternal age (>35 years)
o Pre-existing hypertension, diabetes or ischaemic heart disease
o Smoking
o Obesity
o Strong family history
o Dyslipidaemia
o Pre-eclampsia/eclampsia
o Thrombophilia
o Migraines
o Postpartum infections and
o Blood transfusions

PATIENT
INFORMATION

AGE PARITY MODE OF DELIVERY

39-year-old woman Gravida 4, para 2+1 (2 Elective second repeat
alive) caesarean delivery on
at 37 weeks and 2 days of account of two previous
gestation caesarean sections and
one myomectomy

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PATIENT MEDICAL HISTORY

No history of Personal
hypertension or
diabetes

No family history of Family

cardiac disease or
sudden cardiac death

Two hours after caesarean delivery in Garki Present

Hospital Abuja under spinal anaesthesia
with bupivacaine, she developed sudden
onset desaturation with chest tightness,
hypotension, tachycardia and tachypnoea.

CLINICAL PRESENTATION
● Bilateral mild lower leg oedema
● Blood pressure was 114/80 mmHg
● Pulse rate 132 beats/minute
● Respiratory rate 28 cycles/minute
● Temperature 36.2°C
● Oxygen saturation 83–86% on 6L/minute intranasal oxygen
delivered via face mask.
● Fine crepitations were heard in the entire left lung fields.

Despite 6-8L/minute of intranasal oxygen, the patient continued to

desaturate (oxygen saturation 78-80%), prompting her immediate
transfer from the recovery ward to the intensive care unit (ICU).

She was swiftly intubated with mechanical ventilation support.

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HAEMATOLOGY, INVESTIGATIONS
CHEMISTRY &
MICROBIOLOGY
Full blood count, serum
CARDIAC ENZYMES
electrolytes, clotting Troponin I 1.8ng/dL,
profile, fasting lipid Troponin T
profile, fasting blood 236.2pg/mL and D-
Dimer >4000ng/mL
glucose were within
normal limits and urine CHEST
and blood cultures RADIOGRAPHY
yielded no bacterial Showed features of
interstitial oedema
growth

ECHOCARDIOGRAPHY Mild Left

Ventricular
FINDINGS Systolic
Dysfunction
Ejection
Fraction 45%
Mild
pulmonary
regurgitation

Mild
pulmonary
Mild aortic
hypertension
regurgitation

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MANAGEMENT
● Diuretics (intravenous frusemide 80mg 12-hourly)
● β-blockers (tablets bisoprolol 2.5mg daily)
● Angiotensin receptor blockers (tablets losartan 25mg daily)
● Tablets spironolactone 25mg daily were administered for
cardiac failure
● Fluid restriction with nasogastric tube insertion for medication
and feeding initiated.
● Subcutaneous enoxaparin 40mg 12-hourly
● Tablets aspirin 75mg daily
● Tablets clopidogrel 75mg daily.

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MANAGEMENT
UPDATE
By the 4th post-operative day, her
condition was assessed to have
improved, and she was
extubated.

She returned to the general ward

on the 7th post-operative day and
was subsequently discharged
home on Day 8.

Follow up echocardiography done

6 months post-discharge showed
an improved ejection fraction of
55%.
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CONCLUSIONS
Few cases of pregnancy-
related AMI are reported, and
those reported are often
associated with high maternal
and infant mortality.

Vigilance by a multi-specialist
team is therefore crucial ante-,
intra- and postpartum.

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CONCLUSIONS
This sudden occurrence of cardiac
failure following a ‘routine’ elective
caesarean section highlights the
importance of skilled delivery and
efficient referral services in
developing countries for immediate
transfer to emergency specialist care
when necessary.

If this case had not been managed in

a centre with access to critical care
facilities, the patient may have ended
up another unfortunate mortality as is
quite common in this environment.

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REFERENCES
1. Adedapo AD. Rising trend of cardiovascular diseases among South-Western
Nigerian female patients. Nig J Cardiol 2017;14(2):71 – 4.

2. Roos-Hesselink J, Baris L, Johnson M, De Backer J, Otto C, Marelli A, Jondeau G

et al. Pregnancy outcomes in women with cardiovascular disease: evolving
trends over 10 years in the ESC Registry of Pregnancy and Cardiac disease
(ROPAC). Eur Heart J 2019; 40(47):3848-3855.

3. Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA and White HD
(ESC Scientific Document Group). Fourth universal definition of myocardial
infarction (2018). Eur Heart J 2019; 40(3):237-269.

4. Elkayam U, Jalnapurkar S, Barakkat MN, Khatri N, Kealey AJ, Mehra A and Roth
A. Pregnancy-Associated Acute Myocardial Infarction A Review of
Contemporary Experience in 150 Cases Between 2006 and 2011. Circulation 2014;
129:1695-702.

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REFERENCES
5. Wuntakal R, Shetty N, Ioannou E, Sharma S and Kurian J. Myocardial Infarction
and Pregnancy. Obstet Gynaecol 2013; 15:247–55.

6. Sliwa K and Böhm M. Incidence and prevalence of pregnancy-related heart

disease. Cardiovasc Res 2014; 101(4):554–60.

7. Meng-Han C, Hsin-Hui H, Yu-Ju L, Kwei-Shuai H, Yu-Chi W and Her-Young S.

Cardiac arrest during emergency caesarean section for severe pre-eclampsia and
peripartum cardiomyopathy. Taiwan J Obstet Gynecol 2016; 55(1):125-7.

8. Gibson P, Narous M, Firoz T, Chou D, Barreix M, Say L and James M (WHO

Maternal Morbidity Working Group). Incidence of myocardial infarction in
pregnancy: a systematic review and meta-analysis of population-based studies. Eur
Heart J Qual Care Clin Outcomes 2017; 3(3): 198-207.

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OUR TEAM

DR ADAEZE DR ETIN-OSA DR ADEREMI DR LAWRENCE

OREH IMAGBENIKARO ADELAJA EZEOGU
Family Medicine Family Medicine Internal Medicine Obstetrics &
Gynaecology

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CONFLICT OF INTEREST
The authors declare no conflict of interest.

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13/07/2021

“Women are not dying because of

untreatable diseases. They are dying because
society is yet to make the decision that their
lives are worth saving.”
- PROF MAHMOUD FATHALLHA

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THANK YOU FOR YOUR ATTENTION

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