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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 2, March/April 2018

e8

AFRICA

Case Report

Ischaemic heart disease and pregnancy: the tale of two

stories

Mamotabo R Matshela

Abstract

Ischaemic heart disease (IHD) is presumed to be rare in preg-

nancy. Based on that assumption, patients go undiagnosed or

undertreated. IHD in pregnancy frequently occurs as a result

of an unusual aetiology, therefore each patient needs to be

managed individually since each may present differently. This

may pose challenges to the consulting clinician. Pregnancy

itself is a risk factor for cardiovascular disease, due to its

associated hypercoagulable state. From current reports, the

prevalence of IHD in females is increasing due to lifestyle

changes, including cigarette smoking, diabetes and stress. In

our modern societies, women delay childbearing until they

are older, allowing time for risk factors to cluster. Although

presumed to be rare in pregnant women, IHD is currently

estimated to occur three to four times more often during

pregnancy in middle- and high-income women, warranting

an extensive review highlighting cases of IHD in pregnancy.

Keywords:

pregnancy, ischaemic heart disease

Submitted 17/8/17, accepted 7/11/17

Published online 27/3/18

Cardiovasc J Afr

2018;

29

: e8–e12

www.cvja.co.za

DOI: 10.5830/CVJA-2017-050

In the developing world, hypertension and rheumatic disease

are the commonest heart diseases encountered in pregnancy.

However, the prevalence of adult congenital heart disease and

other cardiovascular diseases is increasing. Pregnancy itself

is a risk factor for cardiovascular disease due to its associated

hypercoagulable state.

1,2

The era of human immunodeficiency virus and improved

socio-economic lifestyles has ushered in a rise in the frequency

of ischaemic heart disease (IHD) in pregnancy. However,

many patients go undiagnosed and undertreated due to the

assumption that IHD is rare in pregnancy. IHD, particularly

acute myocardial infarction in pregnancy, frequently occurs due

to an unusual aetiology and as a result, each patient needs to be

managed accordingly.

Cardiac disease in pregnancy remains a minor yet significant

cause of maternal mortality worldwide. Since rheumatic fever is

uncommon in affluent societies, most cases in the Western world

are the result of congenital heart disease. In the developing

world, rheumatic heart disease remains the major cause of

cardiac disease in pregnancy.

3-7

The National Committee on

Confidential Enquiries into Maternal Deaths lists cardiac disease

as one of the five major causes of maternal death in southern

Africa.

8,9

Until recently, IHD or coronary artery disease (CAD) in

pregnancy has been described as a rare occurrence. In southern

Africa, there have been a few reports on IHD, including acute

myocardial infarction (AMI)/acute coronary syndrome (ACS)

in pregnancy. The purpose of this article is to describe the

challenges one encounters regarding clinical presentation and

management of IHD in pregnancy, particularly AMI. We shall

also highlight each patient’s clinical presentation and some

challenges encountered by cardiologists and obstetricians to

provide appropriate care.

Case reports

Patient 1 was a 42-year-old white female primigravid who

presented at 33 weeks of gestation complaining of Canadian

Society class (CCS) II angina and New York Heart Association

(NYHA) grade II dyspnoea. In addition, she had a past history

of an inferior wall ST-segment elevation myocardial infarction

six months prior to her pregnancy and she was also epileptic. Her

additional risk factors for CAD included type 1 diabetes mellitus

and hypertension. The clinical examination was unremarkable

and her initial transthoracic electrocardiogram revealed sinus

rhythm with poor R-wave amplitude in lead III and T-wave

inversion in leads III and V1 (Fig. 1).

A transthoracic echocardiogram revealed preserved left

ventricular (LV) function with an ejection fraction of 58%,

and basal septal wall hypokinesia. An emergency caesarean

section was performed during her admission due to worsening

symptoms and recurrent episodes of seizures, and foetal distress.

The peri-operative period was uneventful and she delivered a

1.8-kg female baby with dimorphism, in keeping with trisomy 21.

Patient 2 was a 34-year-old female of Indian descent, gravida

2 and para 1, who presented at 20 weeks of gestation, with a

past history of an extensive anterior and inferior myocardial

infarction at the age of 25 years. The patient had suffered a

spontaneous dissection of the mid-left anterior descending

(LAD) artery during her first pregnancy, which was confirmed

by an intravascular ultrasound. Her symptoms during her

University of KwaZulu-Natal, Durban; Mediclinic Heart

Hospital, Pretoria, South Africa; London School of

Economics and Political Science, London, UK

Mamotabo R Matshela, MB ChB, PhD, FESC,

mamotabomatsh@gmail.com