Cardiovascular Journal of Africa: Vol 29 No 2 (March/April 2018)

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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
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,