Chest pain in pregnancy

Chest pain Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Chest pain from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Chest Pain in Pregnancy
Diagnosis
Diagnostic Study of Choice
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
X-ray
Echocardiography and Ultrasound
CT scan
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Interventions
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Chest pain in pregnancy On the Web
Most recent articles
cited articles
Review articles
CME Programs
Powerpoint slides
Images
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Chest pain in pregnancy
CDC on Chest pain in pregnancy
Chest pain in pregnancy in the news
Blogs on Chest pain in pregnancy
to Hospitals Treating Chest pain in pregnancy
Risk calculators and risk factors for Chest pain in pregnancy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Causes

Life-threatening Causes

Life-threatening causes of chest pain among pregnant women include the following:

• Acute MI

• Atherosclerotic plaque rupture: Common in antepartum period
• Coronary dissection: Common in peripartum or postpartum period

• Aortic dissection and other aortic syndromes
• Pulmonary embolism
• Amniotic fluid embolism
• Tension pneumothorax

Other Causes

Other causes of chest pain of pregnancy include the following:

• Asthma exacerbation
• Pneumonia
• Pneumothorax
• TB reactivation
• Gastroesophageal reflux disease
• Vasospasm
• Myocarditis
• Pericarditis
• Endocarditis
• Trauma
• Sarcoidosis
• Severe kyphoscoliosis
• Chest expansion (usually physiological change)
• Breast tenderness (usually physiological change)

Acute MI in Pregnancy

• Incidence: 1 per 35,000 deliveries
• Maternal mortality rate: 5% to 18%, fetal mortality rate: 9%
• Common in third trimester until 1-2 months post-delivery

• Antepartum: Atherosclotic plaque rupture is the most common cause
• Perpartum or postpartum: Coronary artery dissection (LAD > RCA > LC > LM)

Risk Factors

• It is unknown if pregnancy itself is a risk factor in development of acute MI
• The most important risk factors in the development of AMI in pregnancy are generally similar to those in the general population. Risk factors include:

• Age > 35 years
• Diabetes mellitus
• Hypertension
• Smoking
• Connective tissue diseases (e.g. Ehler Danlos syndrome)
• Vasculitis (e.g. Takayasu arteritis)
• Thrombophilia (e.g. antiphospholipid syndrome)
• Acute post-partum stress:

• Severe post-partum hemorrhage
• Post-partum infection

Pathophysiology

• During pregnancy, progesterone release results in structural changes in the vascular intima and media.
• Physiologically, cardiac output and blood volume increase during pregnancy, both of which may increase the risk of cardiovascular events.

Diagnosis

• Diagnosis similar to the general population by: Symptoms, ECG changes, and cardiac biomarkers. To see common normal physiological changes on ECG in pregnancy (may mimic AMI), click here.
• Echocardiography is safe and may be performed to evaluate wall motion abnormalities.
• Fetal monitoring is recommended.

Treatment

• Percutaneous coronary intervention
• If spontaneous coronary artery dissection occurs, a more thorough investigation for connective tissue diseases and vasculitis is wawrranted.

Coronary Spasm

Pathophysiology

• It is thought that there an increased concentrations of RAAS hormones in pregnancy, as well as increased vascular reactivity to angiotensin II and norepinephrine.