Chest pain in pregnancy

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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 troponin.
• CK-MB concentrations may markedly increase during labor and post-delivery due to non-cardiac causes, namely placental and uterine leaks.

• To view common normal physiological changes on ECG in pregnancy (may mimic AMI), click here.
• To view normal physiological changes in biomarker concentrations during labor and delivery: for troponin, click here | for CK-MB, 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.