P036: MULTIDISCIPLINARY MANAGEMENT OF SUSPECTED PREGNANCY-RELATED SPONTANEOUS CORONARY ARTERY DISSECTION: ANESTHETIC AND OBSTETRIC CONSIDERATIONS IN A HIGH-RISK PARTURIENT
Justin Scuorzo, DO; Marisol Perales, MD; Benjamin Houseman, MD, PhD
Memorial Healthcare System
Background: Spontaneous coronary artery dissection (SCAD) is an uncommon but increasingly recognized cause of acute coronary syndrome (ACS) in parturients, accounting for up to 43% of pregnancy-associated myocardial infarctions. Pregnancy-related SCAD most commonly in the third trimester or postpartum period and is attributed to hormonal and hemodynamic changes that weaken arterial walls, leading to intimal tears and coronary obstruction. ¹ Peripartum anesthetic management of these high-risk patients must be tailored to minimize maternal cardiovascular stress while optimizing fetal outcomes.
Case Description: A 26-year-old G1P1001 woman with a BMI of 37 and chronic hypertension initially presented to another medical facility at 29 weeks of gestation with acute chest pain, dyspnea, and headache. Initial evaluation revealed significantly elevated troponin levels (peak 4.6 ng/mL). Despite negative findings on echocardiography, computed tomography pulmonary embolism protocol (CTPE), chest X-ray (CXR), and electrocardiogram (ECG), a presumptive diagnosis of SCAD was made based on biomarker elevation and clinical presentation. Conservative management with dual-antiplatelet therapy (aspirin and clopidogrel) and metoprolol was initiated without OB or OB anesthesia involvement.
At 38 weeks, the patient presented to our facility for induction of labor. Our team was able to quickly navigate her in a multidisciplinary manner with cardiac, OB, and OB Anesthesia involvement. A multidisciplinary decision was made to proceed with a trial of labor under continuous cardiovascular monitoring, as vaginal delivery is preferred over cesarean section in stable SCAD patients to minimize surgical stress and thrombotic risk. ¹ On admission, she had discontinued clopidogrel 24 hours prior but remained on aspirin and metoprolol. Repeat echocardiography confirmed preserved ejection fraction (EF 60–65%) without new abnormalities.
Labor analgesia with remifentanil was utilized to optimize hemodynamic stability. ¹ Neuraxial anesthesia was avoided due to the patient's use of clopidogrel. The patient tolerated labor well and she delivered a healthy male infant vaginally. Postpartum, she remained hemodynamically stable with no recurrent cardiac symptoms. Given the risk of postpartum cardiovascular exacerbation, clopidogrel was restarted, and she was scheduled for close follow-up with serial blood pressure monitoring and laboratory assessments (preeclampsia labs and troponin levels) at 3 days, 1 week, and 2 weeks postpartum all of which are still pending.
Discussion: Pregnancy-related SCAD presents unique anesthetic, obstetric, and cardiovascular challenges. While conservative management is preferred in stable patients, individualized labor and delivery planning is critical. In our case, remifentanil-based analgesia effectively maintained hemodynamic stability, aligning with evidence suggesting careful intrapartum management is key to preventing myocardial ischemia. ¹ The decision to resume dual-antiplatelet therapy postpartum reflects the importance of continued cardiovascular protection in patients with prior ACS.¹
This case underscores the necessity of a multidisciplinary planning involving anesthesiology, cardiology, maternal-fetal medicine, and obstetrics. With increasing recognition of pregnancy-related SCAD, future research should focus on optimizing peripartum management protocols and improving long-term maternal cardiovascular outcomes.
References
1.https://doi.org/10.1186/s12872-023-03323-7
Figure 1 ECHO 1/12/25 technical limited study due to body habitus LV: Normal left ventricular systolic function. Left ventricular cavity size is normal. LVEF 60-65%. Normal wall thickness of the left ventricle.