From the Guidelines
Maternal myocardial ischemia on electrocardiogram (EKG) does not automatically warrant a cesarean section, though it may be necessary depending on the clinical situation, as indicated by the most recent guidelines from the American College of Cardiology/American Heart Association 1. The decision should be based on several factors, including:
- Maternal cardiac stability
- Fetal status
- Gestational age
- Severity of the ischemia If the mother is hemodynamically stable with mild ischemic changes, vaginal delivery may still be possible with careful monitoring and management of cardiac stress, as suggested by the European Society of Cardiology guidelines 1. However, if there is evidence of acute myocardial infarction, severe ischemia, hemodynamic instability, or fetal distress, an emergency cesarean section would be indicated. Management should include:
- Cardiology consultation
- Continuous cardiac monitoring
- Oxygen therapy
- Possibly antiplatelet therapy (aspirin 81mg daily) or other cardiac medications as appropriate Pain management is crucial as labor pain increases cardiac workload; epidural anesthesia is often preferred as it reduces cardiac stress, as recommended by the European Society of Cardiology guidelines 1. The underlying reason for this approach is that myocardial ischemia indicates inadequate oxygen supply to the heart, and the additional cardiovascular demands of labor and delivery may worsen cardiac function and potentially lead to heart failure or arrhythmias. The mode of delivery should ultimately be determined through a multidisciplinary approach involving obstetrics, cardiology, and anesthesiology to balance maternal cardiac risk against the risks of cesarean delivery, as emphasized by the American College of Cardiology/American Heart Association guidelines 1. Key considerations include:
- Prepregnancy counseling to assess individualized risk
- Clear documentation of maternal cardiac risks and expected outcomes
- Contingency plans for anticipated complications
- Multidisciplinary management involving ACHD, maternal-fetal medicine, and anesthesiology
- Individualized approach to anticoagulation and other cardiac medications during pregnancy.
From the Research
Maternal Myocardial Ischemia and Cesarean Section
- Maternal myocardial ischemia on electrocardiogram (EKG) is a serious condition that can occur during pregnancy, with a reported incidence of acute myocardial infarction (MI) ranging from 1.5-10/100,000 deliveries 2.
- The management of ischemic heart disease (IHD) in pregnancy is crucial, and cardiologists can successfully manage IHD in pregnancy with obstetric partners 2.
- In cases of maternal myocardial ischemia, a cesarean section (C-section) may be considered, especially if the patient is at high risk for complications or if the condition is severe 3, 4.
- However, the decision to perform a C-section should be based on obstetric considerations and a multidisciplinary approach 3.
- Studies have shown that C-sections can increase the risk of cardiovascular complications, including thromboembolism and stroke, especially in women with pre-existing cardiovascular conditions 5.
- In one study, the risk of severe cardiovascular complications was significantly higher in women who underwent C-section compared to those who had vaginal deliveries (OR 2.23, CI 1.98 to 2.51) 5.
- Another study found that myocardial ischemia can occur in normal patients undergoing elective C-section, with an incidence of 7.69% 6.
Considerations for Cesarean Section
- The benefits of C-section in cases of maternal myocardial ischemia include reducing the risk of complications and improving outcomes for both the mother and the baby 4.
- However, C-sections also carry risks, including increased risk of cardiovascular complications, and should be carefully considered on a case-by-case basis 5.
- The decision to perform a C-section should take into account the individual patient's risk factors, medical history, and obstetric considerations 3, 4.