What is the management approach for chest pain during pregnancy?

Management of Chest Pain in Pregnancy

Chest pain in pregnancy requires immediate systematic evaluation for life-threatening cardiovascular emergencies—particularly acute coronary syndrome, pulmonary embolism, and aortic dissection—with diagnostic imaging and interventions that should NOT be withheld due to pregnancy status, as maternal mortality far outweighs fetal radiation risks. 1

Initial Assessment and Risk Stratification

Immediate Life-Threatening Conditions to Rule Out

• Acute Coronary Syndrome (ACS): Obtain ECG and cardiac biomarkers (troponin) immediately, as pregnancy-associated MI occurs in 1.5-10 per 100,000 deliveries with 5-10% maternal mortality 1, 2
• Pulmonary Embolism (PE): Leading cause of pregnancy-related mortality in developed countries, accounting for 20% of maternal deaths 1
• Aortic dissection: Must be considered in differential diagnosis 3
• Spontaneous coronary artery dissection: Most common cause of pregnancy-associated ACS, occurring predominantly peripartum (median 13 days postpartum) due to progesterone-induced collagen changes in vessel walls 1, 4

Key Risk Factors to Document

• Traditional cardiovascular risk factors: smoking, hypertension, hyperlipidemia, diabetes, advanced maternal age, positive family history 1
• Pregnancy-specific risks: (pre)eclampsia, thrombophilia, postpartum infection, severe postpartum hemorrhage, multiparity 1
• Iatrogenic risk: ergometrine administration for postpartum bleeding can cause coronary vasospasm 1

Diagnostic Approach

For Suspected Acute Coronary Syndrome

If ST-elevation MI is identified, immediately refer to a skilled interventional cardiology center for diagnostic coronary angiography and primary PCI—this is the preferred approach over thrombolysis because it directly visualizes coronary artery dissection and significantly improves survival. 1, 4

• Coronary angiography should be performed despite fetal radiation concerns, as maternal mortality risk (5-10%) far exceeds fetal radiation risk, especially outside the first trimester 1
• For non-ST elevation ACS with intermediate or high-risk criteria, an invasive approach to assess coronary anatomy is indicated 1
• For stable non-ST elevation ACS without risk criteria, watchful waiting and medical therapy is appropriate, but any clinical deterioration mandates invasive strategy 1

For Suspected Pulmonary Embolism

• Begin with lower-extremity duplex ultrasonography if signs/symptoms of DVT are present—positive DVT confirms need for anticoagulation without additional radiation exposure 1
• If DVT ultrasound is negative or not indicated, proceed with either CT pulmonary angiography (CTPA) or ventilation-perfusion (V/Q) scintigraphy 1
• The American Thoracic Society/Society of Thoracic Radiology recommends V/Q scintigraphy over CTPA primarily due to maternal (not fetal) radiation dose concerns, though this remains debated 1
• Critical caveat: Radiography should NOT be withheld from pregnant patients—fetal radiation doses from properly performed diagnostic tests present no measurably increased risk of prenatal death, malformation, or developmental impairment 1, 5

Treatment Strategies

Acute Coronary Syndrome Management

If PCI with stenting is required, use bare metal stents ONLY—drug-eluting stents should be avoided due to unknown safety profile and requirement for prolonged dual antiplatelet therapy. 1, 4

Medical Therapy

• β-blockers and low-dose aspirin (75-100 mg daily): Considered relatively safe and should be initiated 1, 4
• Clopidogrel: Use ONLY when strictly necessary (e.g., after stenting) and for the shortest duration possible due to limited safety data 1, 4
• Absolutely contraindicated: ACE inhibitors, angiotensin receptor blockers (ARBs), and renin inhibitors 1, 4
• Thrombolysis: Reserved only for life-threatening ACS when PCI access is unavailable, as recombinant tissue plasminogen activator may cause subplacental bleeding despite not crossing the placenta 1

Surgical Considerations

• Emergency coronary artery bypass grafting should be considered for left main or severe proximal two-vessel dissection unsuitable for PCI, though mortality rates are potentially high 1, 4
• For recurrent coronary dissections, preterm delivery can be considered according to fetal viability 1

Cardiac Arrest in Pregnancy

If the patient presents in cardiac arrest with uterus at or above the umbilicus:

• Perform standard chest compressions (rate ≥100/min, depth ≥2 inches) with patient supine on firm backboard 1
• Continuous manual left uterine displacement (LUD) is mandatory to relieve aortocaval compression—do NOT use lateral tilt >30° as it reduces chest compression effectiveness 1
• Provide early bag-mask ventilation with 100% oxygen at ≥15 L/min, as hypoxemia develops more rapidly in pregnancy 1
• Use compression-ventilation ratio of 30:2 1
• If no return of spontaneous circulation by 4 minutes of resuscitation, prepare for immediate perimortem cesarean delivery at the site of arrest—do NOT transport the patient 1
• Defibrillation protocol is identical to non-pregnant patients (120-200 J biphasic), with anterolateral pad placement and lateral pad positioned under breast tissue 1

Airway Management Considerations

• Airway management is more difficult in pregnancy due to obesity, sleep apnea, and airway edema 1
• Limit intubation attempts to maximum 2 per technique before moving to supraglottic airway 1
• Use smaller endotracheal tube (6.0-7.0 mm inner diameter) due to glottic edema 1
• Two-handed bag-mask ventilation is more effective than single-handed technique 1

Common Pitfalls to Avoid

• Do not withhold diagnostic imaging due to pregnancy—delayed diagnosis poses far greater risk to mother and fetus than radiation exposure 1, 5
• Do not use ergometrine for postpartum bleeding in patients with chest pain, as it causes coronary vasospasm 1
• Do not use drug-eluting stents if stenting is required 1, 4
• Do not transport a pregnant patient in cardiac arrest for cesarean delivery—perform at site of arrest 1
• Do not use lateral tilt >30° during resuscitation—use manual left uterine displacement instead 1