Guidelines for pregnant patients presenting with STEMI or unstable acute coronary syndromes requiring interventional procedure at LTHT

• Pharmacology
• Radiation
• Procedure
• Inform
• Considerations

Patients who are pregnant presenting with ST elevation myocardial infarction (STEMI) should undergo urgent Primary Percutaneous Coronary Intervention (PPCI) (Class I). Those with Non-STEMI (NSTEMI) and high-risk criteria should undergo invasive management with coronary angiography +/- intervention (Class Iia).¹ High rates of mortality 7-11%, with foetal mortality predominately related to maternal death.^2,4

If proceed:

Pregnancy tests are available in Team Leaders office.
In the event of urgent presentation please consider.

Back to top

Pharmacology

• Aspirin safe (300mg/75mg) in pregnancy and breastfeeding
• Clopidogrel (600mg/300mg/75mg) appears safe in pregnancy. Limited breastfeeding data, probably safe. Shortest duration preferred
• Heparin (unfractionated/low-molecular weight) safe does not cross placenta
• Glycoprotein Iib/IIIa limited data  with tirofiban acceptable choice if needed
  • European Society of Cardiology (ESC) guidelines do not recommend use but are reports of use without complication
  • If used, patient will need caesarean section as risk of foetal intracranial haemorrhage
  • Hold breastfeeding or expressing for duration of infusion

In absence of data bivalirudin, prasugrel and ticagrelor not recommended.¹ Thrombolysis not recommended for STEMI.^1,2

• Others
  • Betablockers safe - metoprolol or bisoprolol but atenolol only if already established on therapy (growth scans from 26-28weeks)
  • Nitrates safe - can cause significant blood pressure drop due to haemodynamic changes
  • Statins unclear - use if benefit felt to outweigh risk
  • For information ACE inhibitors are contra-indicated in pregnancy

Back to top

Radiation

To inform patient PCI uses 50-100x less radiation (3 mSv) than required to harm foetus.²

• Reduce frame rate when able
• Reduce acquisition
• Reduce extreme angulation
• Maximise collimation
• Limit magnification
• No lead covering for patient
• TLD badge for foetus (located in Team Leaders office)
  • To be sent to RRPPF approved dosimetry service in Birmingham for accurate dose calculation
  • Medical Physics informed of all doses related to procedure

Back to top

Procedure

• Radial access preferred
• Position patient in left lateral position (pillow support) if >20 weeks
• Caution with aggressive catheters or injection as high rate of spontaneous coronary artery dissection (SCAD) (22%)⁴
• Stent choice not specified most data with bare metal stent (BMS)
  • ESC says consider drug eluting stent (DES) with short dual antiplatelet therapy
  • American update consider DES 1st/2nd trimester and BMS 3rd trimester
• Balloon angioplasty alone not recommended
• Intra-aortic balloon pump is safe

Back to top

Inform

• Obstetric team via Labour Ward at LGI
  • If <14 weeks gestation no input required, but arrange follow up
  • If >14 weeks gestation inform oncall team with review during normal working hours
  • If >19+6 weeks gestation and any concerns regarding cardiovascular status then immediate Obstetric registrar review and management plan should be discussed with/agreed by Consultant Obstetrician and Interventional Cardiologist

• Consider involving non-interventionalist oncall if case unclear
• Team to be aware during working hours
  • Oncall ward interventionalist
  • Obstetric Hot Week Consultant
  • Consider involving Dr Kate Gatenby / Dr Alex Simms (Acquired Cardiac Diseases in Pregnancy team) (if available)
• All women should be referred to Joint Obstetric/Cardiology Antenatal Clinic for follow up: leedsth-tr.obscardiac@nhs.net

Back to top

Considerations

• Treatment of STEMI or NSTEMI should not be delayed for delivery
• CT coronary angiography not recommended as alternative
• Limit contrast use
  • No studies assessing the amount of free iodine entering foetal circulation or the levels of exposure needed to cause foetal harm. No no reports to date to suggest contrast dye is teratogenic.³

Figure 1: ESC recommendations for the management of coronary artery disease¹