Chest pain in pregnancy: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Chest pain}} | {{Chest pain}} | ||
{{CMG}} | {{CMG}} ; {{AE}}{{Nuha}} | ||
==Overview== | ==Overview== | ||
Causes of chest pain in [[pregnancy]] are similar to those in the general population. Acute life-threatening causes include [[ST elevation myocardial infarction in pregnancy|myocardial infarction]], [[aortic dissection]], [[tension pneumothorax]], as well as [[thromboembolic]] diseases that are more common in pregnancy, such as [[pulmonary embolism]] and [[amniotic fluid embolism]]. Occasionally, chest pain in pregnant women is caused by physiological changes in pregnancy, namely chest expansion and breast tenderness. | |||
==Causes== | ==Causes== | ||
===Life-threatening Causes=== | ===Life-threatening Causes<ref name="Sahni2012">{{cite journal|last1=Sahni|first1=Gagan|title=Chest Pain Syndromes in Pregnancy|journal=Cardiology Clinics|volume=30|issue=3|year=2012|pages=343–367|issn=07338651|doi=10.1016/j.ccl.2012.04.008}}</ref>=== | ||
Life-threatening causes of chest pain among pregnant women include the following: | Life-threatening causes of chest pain among pregnant women include the following: | ||
*Acute MI | *[[ST elevation myocardial infarction in pregnancy| Acute MI]]: pregnancy has been shown to increase the risk of myocardial infarction(MI) 3 to 4-fold | ||
:*[[Atherosclerosis|Atherosclerotic plaque rupture]]: Common in antepartum period | **The causes range from [[coronary dissection]] , vasospasm, and acute [[plaque]] rupture. | ||
* [[AMI]] can occur during any stage of [[pregnancy]] but is most common in the third [[trimester]] and in the 6-week period after [[delivery]], occurring mostly in [[multigravidas]], most patients being older than 30 years. | |||
**Risk Factors associated with [[AMI]] in [[pregnancy]] are : | |||
*[[Maternal age]] greater than 35 years | |||
*[[Hypertension]] | |||
* [[Diabetes mellitus]].<ref name="pmid18617065">{{cite journal| author=Roth A, Elkayam U| title=Acute myocardial infarction associated with pregnancy. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 3 | pages= 171-80 | pmid=18617065 | doi=10.1016/j.jacc.2008.03.049 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18617065 }}</ref> | |||
**[[Atherosclerosis|Atherosclerotic plaque rupture]]: Common in [[antepartum]] period | |||
**[[Coronary dissection]]: Common in peripartum or postpartum period | |||
**Diagnosis of [[AMI]] in [[pregnant]] women include the constellation of [[symptoms]], [[electrocardiograph]], and [[cardiac]] markers.<ref name="pmid1734798">{{cite journal| author=McLintic AJ, Pringle SD, Lilley S, Houston AB, Thorburn J| title=Electrocardiographic changes during cesarean section under regional anesthesia. | journal=Anesth Analg | year= 1992 | volume= 74 | issue= 1 | pages= 51-6 | pmid=1734798 | doi=10.1213/00000539-199201000-00009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1734798 }}</ref> | |||
***The diagnostic approach is influenced by fetal safety and normal changes during pregnancy. | |||
***Electrocardiograms (ECGs) done during normal pregnancy frequently show a left or right axis deviation, a small Q in lead III, nonspecific T-wave inversions, or an increased R/S ratio in leadsV1 and V2, which can make the ECG diagnosis of ischemia in acute coronary syndromes more challenging. | |||
*[[Aortic dissection]] and other aortic syndromes | *[[Aortic dissection]] and other aortic syndromes | ||
**During pregnancy there is an increase in maternal blood volume, stroke volume, and cardiac output.<ref name="Sahni2012">{{cite journal|last1=Sahni|first1=Gagan|title=Chest Pain Syndromes in Pregnancy|journal=Cardiology Clinics|volume=30|issue=3|year=2012|pages=343–367|issn=07338651|doi=10.1016/j.ccl.2012.04.008}}</ref><ref name="pmid4225694">{{cite journal| author=Manalo-Estrella P, Barker AE| title=Histopathologic findings in human aortic media associated with pregnancy. | journal=Arch Pathol | year= 1967 | volume= 83 | issue= 4 | pages= 336-41 | pmid=4225694 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4225694 }} </ref> | |||
**The effect of maternal hormones on remodeling the tunica media and intima of the arterial wall cause increased shear forces on the aortic wall, which begin in the first and second trimesters but are most notable in the third trimester and peripartum. | |||
**Pre-existing risk factors such as premature atherosclerosis and arterial hypertension, hereditary connective tissue disease such as MFS and Ehlers-Danlos syndrome, previous aortic surgery, bicuspid aortic valve disease, aortitis, surgical manipulation, cardiac catheterization, and cocaine exposure are the most common risk factors in aortic dissection occurring in women younger than 45 years.<ref name="Sahni2012">{{cite journal|last1=Sahni|first1=Gagan|title=Chest Pain Syndromes in Pregnancy|journal=Cardiology Clinics|volume=30|issue=3|year=2012|pages=343–367|issn=07338651|doi=10.1016/j.ccl.2012.04.008}}</ref><ref name="pmid4225694">{{cite journal| author=Manalo-Estrella P, Barker AE| title=Histopathologic findings in human aortic media associated with pregnancy. | journal=Arch Pathol | year= 1967 | volume= 83 | issue= 4 | pages= 336-41 | pmid=4225694 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4225694 }} </ref> | |||
*[[Pulmonary embolism]] | *[[Pulmonary embolism]] | ||
*[[Amniotic fluid embolism]] | *[[Amniotic fluid embolism]] | ||
| Line 15: | Line 30: | ||
===Other Causes=== | ===Other Causes=== | ||
Other causes of chest pain of pregnancy include the following: | Other causes of chest pain of [[pregnancy]] include the following: | ||
*[[Asthma|Asthma exacerbation]] | *[[Asthma|Asthma exacerbation]] | ||
*[[Pneumonia]] | *[[Pneumonia]] | ||
| Line 27: | Line 42: | ||
*[[Trauma]] | *[[Trauma]] | ||
*[[Sarcoidosis]] | *[[Sarcoidosis]] | ||
*[[Kyphoscoliosis|Severe kyphoscoliosis]] | *[[Kyphoscoliosis|Severe kyphoscoliosis]] | ||
*[[Chest expansion]] (usually physiological change) | *[[Chest expansion]] (usually physiological change) | ||
*[[Mastalgia|Breast tenderness]] (usually physiological change) | *[[Mastalgia|Breast tenderness]] (usually physiological change) | ||
== | == Cardiac Testing Considerations for Women Who Are [[Pregnant]], [[Postpartum]], or of [[Child-Bearing]]== | ||
* | * Imaging using [[ionizing radiation]] during [[pregnancy]] or [[postpartum]] while [[breastfeeding]] should generally be avoided. | ||
* | * When imaging is necessary to guide management, the risks and benefits of [[invasive angiography]], [[SPECT]], [[PET]], or [[CCTA]] should be discussed with the [[patient]]. | ||
* If the test is necessary, the lowest effective dose of [[ionizing radiation]] should be used, and considering for tests with no [[radiation]] exposure such as [[echocardiography]], [[CMR imaging]]. | |||
* | * [[Radiation risk]] to the [[fetus]] is very small. | ||
* | * [[Iodinated]] contrast enters the [[fetal circulation]] through the [[placenta]] and should be used with caution in a [[pregnant]] [[woman]]. | ||
* The use of [[gadolinium ]] contrast with [[CMR]] should be avoided and used only when necessary to guide [[clinical]] management and is expected to improve [[fetal]] or [[maternal]] outcome. | |||
* If [[contrast]] is necessary for a [[postpartum]] woman, [[breastfeeding]] may continue because <1% of [[iodinated]] contrast is excreted into the [[breast milk]]. | |||
* | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
[[Category:Up-To-Date]] | |||
Latest revision as of 12:46, 4 January 2022
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Nuha Al-Howthi, MD[2]
Overview
Causes of chest pain in pregnancy are similar to those in the general population. Acute life-threatening causes include myocardial infarction, aortic dissection, tension pneumothorax, as well as thromboembolic diseases that are more common in pregnancy, such as pulmonary embolism and amniotic fluid embolism. Occasionally, chest pain in pregnant women is caused by physiological changes in pregnancy, namely chest expansion and breast tenderness.
Causes
Life-threatening Causes[1]
Life-threatening causes of chest pain among pregnant women include the following:
- Acute MI: pregnancy has been shown to increase the risk of myocardial infarction(MI) 3 to 4-fold
- The causes range from coronary dissection , vasospasm, and acute plaque rupture.
- AMI can occur during any stage of pregnancy but is most common in the third trimester and in the 6-week period after delivery, occurring mostly in multigravidas, most patients being older than 30 years.
- Maternal age greater than 35 years
- Hypertension
- Diabetes mellitus.[2]
- Atherosclerotic plaque rupture: Common in antepartum period
- Coronary dissection: Common in peripartum or postpartum period
- Diagnosis of AMI in pregnant women include the constellation of symptoms, electrocardiograph, and cardiac markers.[3]
- The diagnostic approach is influenced by fetal safety and normal changes during pregnancy.
- Electrocardiograms (ECGs) done during normal pregnancy frequently show a left or right axis deviation, a small Q in lead III, nonspecific T-wave inversions, or an increased R/S ratio in leadsV1 and V2, which can make the ECG diagnosis of ischemia in acute coronary syndromes more challenging.
- Diagnosis of AMI in pregnant women include the constellation of symptoms, electrocardiograph, and cardiac markers.[3]
- Aortic dissection and other aortic syndromes
- During pregnancy there is an increase in maternal blood volume, stroke volume, and cardiac output.[1][4]
- The effect of maternal hormones on remodeling the tunica media and intima of the arterial wall cause increased shear forces on the aortic wall, which begin in the first and second trimesters but are most notable in the third trimester and peripartum.
- Pre-existing risk factors such as premature atherosclerosis and arterial hypertension, hereditary connective tissue disease such as MFS and Ehlers-Danlos syndrome, previous aortic surgery, bicuspid aortic valve disease, aortitis, surgical manipulation, cardiac catheterization, and cocaine exposure are the most common risk factors in aortic dissection occurring in women younger than 45 years.[1][4]
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)
Cardiac Testing Considerations for Women Who Are Pregnant, Postpartum, or of Child-Bearing
- Imaging using ionizing radiation during pregnancy or postpartum while breastfeeding should generally be avoided.
- When imaging is necessary to guide management, the risks and benefits of invasive angiography, SPECT, PET, or CCTA should be discussed with the patient.
- If the test is necessary, the lowest effective dose of ionizing radiation should be used, and considering for tests with no radiation exposure such as echocardiography, CMR imaging.
- Radiation risk to the fetus is very small.
- Iodinated contrast enters the fetal circulation through the placenta and should be used with caution in a pregnant woman.
- The use of gadolinium contrast with CMR should be avoided and used only when necessary to guide clinical management and is expected to improve fetal or maternal outcome.
- If contrast is necessary for a postpartum woman, breastfeeding may continue because <1% of iodinated contrast is excreted into the breast milk.
References
- ↑ 1.0 1.1 1.2 Sahni, Gagan (2012). "Chest Pain Syndromes in Pregnancy". Cardiology Clinics. 30 (3): 343–367. doi:10.1016/j.ccl.2012.04.008. ISSN 0733-8651.
- ↑ Roth A, Elkayam U (2008). "Acute myocardial infarction associated with pregnancy". J Am Coll Cardiol. 52 (3): 171–80. doi:10.1016/j.jacc.2008.03.049. PMID 18617065.
- ↑ McLintic AJ, Pringle SD, Lilley S, Houston AB, Thorburn J (1992). "Electrocardiographic changes during cesarean section under regional anesthesia". Anesth Analg. 74 (1): 51–6. doi:10.1213/00000539-199201000-00009. PMID 1734798.
- ↑ 4.0 4.1 Manalo-Estrella P, Barker AE (1967). "Histopathologic findings in human aortic media associated with pregnancy". Arch Pathol. 83 (4): 336–41. PMID 4225694.