EP12.02: Spontaneous coronary artery dissection in late third trimester of pregnancy

Acute coronary syndrome due to non-atherosclerotic non-traumatic or iatrogenic spontaneous coronary artery dissection (SCAD) is a rare clinical scenario that affects mostly young women of reproductive age. We present a rare case of SCAD during pregnancy. A 35-year-old G2P2 woman at 36 weeks of gestation with no previous medical history was admitted to the hospital with acute-onset chest pain and respiratory distress. A CTPA was ordered and excluded pulmonary embolism or other pulmonary morbidities, however bilateral pleural effusions were evident. There were also EKG alterations and cardiac enzyme elevation. The woman underwent a coronary artery percutaneous angiography that revealed spontaneous artery dissection of all three coronary vessels. Interestingly bedside heart echo was normal. An emergency Caesarean section was performed and the patient was treated in the Cardio ICU with beta blockers, diuretics and anti-hypertensive medication. Anti-platelets and anticoagulants were administered too. Acute cardiac events antenatally are rare but could be life-threatening. Chest pain in pregnant women needs further clinical investigation. Differential diagnosis include pericarditis or myocarditis, pneumonia, pulmonary embolism, aortic dissection, peripartum cardiomyopathy, SCAD, myocardial infarction, spontaneous pneumothorax or even gastrointestinal disorders. Mortality rates are high for pregnancy related SCAD with myocardial infarction. Although, almost 40% of the acute heart conditions during pregnancy and postpartum are due to SCAD, this condition still remains under-diagnosed in many cases. Final diagnosis is only made via coronary artery angiography. The reason why SCAD is mainly treated conservatively is due to the risk of expanding the hematoma during a coronary artery intervention technique. It is of great importance for a pregnant patient to be assessed by a multidisciplinary team.