By Dr Aswin Babu
Dr Dawn Adamson delivered one of the most exhilarating talks at this year’s BCS conference. Acute coronary syndrome (ACS) in pregnancy can be a frightening experience both for the patient and the doctor! Data from the MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries) registry suggests that cardiac disease is the leading cause of death in pregnant women with ischaemic heart disease accounting for the majority of these (24%)1. Yet, given the large morbidity and mortality associated with ACS in pregnancy, UKOSS (UK Obstetric Surveillance System) data demonstrates that only 60% of pregnant women undergo invasive coronary angiography 2. Dr Adamson laid out some key expert pearls in a relatively evidence free area regarding the management of these complex patients. Here are a few of the take home points:
- Treat a pregnant woman with ACS as you would treat a non-pregnant woman
- The mother is the number one priority and all care should be focused and directed to improve maternal outcomes.
- Anti-platelet therapy
- Clopidogrel is safe in pregnancy.
- However, there is no data to support the use of ticagrelor or prasugrel in pregnancy
- Anti-thrombotic therapy
- Both unfractionated heparin and low molecular weight heparin are safe in pregnancy. In particular, there is no harm to the fetus as it does not cross the blood placenta barrier.
- Warfarin is known to be teratogenic given its ability to cross the placenta.
- There is currently no evidence regarding direct oral anticoagulants (DOACs) in pregnancy
- Radiation dose in the lab
- Placing abdominal lead shielding on pregnant women does not provide any additional benefit to the foetus as it has no effect in reducing the internal scattering of X-rays as they transit through the pregnant patient.
- Percutaneous coronary intervention typically produces 50-100x less radiation than is required to cause harm to a foetus.
- Reducing the fluoroscopy frame rate to 7.5 frames per second can be a useful tool in minimising the radiation exposure
- Epidural anaesthesia can only be given 24 hours after withdrawal of dual anti-platelet therapy to prevent the risk of epidural haematoma.
- Bush N, Nelson-Piercy C, Spark P, et al. Myocardial infarction in pregnancy and postpartum in the UK. Eur J Prev Cardiol. 2013;20(1):12-20. doi:10.1177/1741826711432117