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

Publication: 22/10/2019  
Next review: 07/07/2025  
Clinical Guideline
ID: 6179 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2022  


This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

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

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:


Aspirin 300mg stat



Clopidogrel 600mg stat

after angiographic confirmation that PCI is required



All guidelines recommend PPCI / angiography in STEMI/high risk NSTEMI
Procedural risk beyond routine    
                        4% risk of iatrogenic dissection4
Radiation risk minimal - all measures taken to limit
Contrast risk none documented



As per usual weight based dosing


Radial approach



Left lateral position

>20 weeks gestation


ThermoLuminescent Dosimeter (TLD)

Front and back at foetal level



Obstetrics / Labour Ward

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

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  • 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

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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

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  • 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

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  • 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:

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  • 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


Record: 6179
Clinical condition:

STEMI or unstable acute coronary syndromes

Target patient group: Pregnant patients
Target professional group(s): Secondary Care Doctors
Adapted from:

Evidence base


  1. Regitz-Zagrosek et al. ESC Guidelines for the management of cardiovascular diseases during pregnancy. European Heart Journal 2018; 39: 3165–3241
  2. Ismail et al. ST-elevation acute myocardial infarction in pregnancy: 2016 Update. Clinical Cardiology. 2017;40:399–406
  3. Beckett et al. Safe Use of Contrast Media: What the Radiologist Needs to Know. RadioGraphics 2015; 35:1738–1750
  4. Elkayam et al. Pregnancy-Associated Acute Myocardial Infarction A Review of Contemporary Experience in 150 Cases Between 2006 and 2011. Circulation. 2014;129:1695-1702

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

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