SHORT CASES IN CARDIOLOGY Postpartum acute MI following routine ergometrine administration treated successfully by primary PTCA

A 28 year old white woman had an unplanned home birth due to a short second stage of labour. A healthy boy was delivered vaginally with a midwife in attendance. Before delivering the placenta the patient was given 1 ml of intramuscular Syntometrine (ergometrine maleate 500 μg, oxytocin 5 units; Novartis, Surrey, UK). The placenta and membranes were delivered completely with minimal blood loss. Fifteen minutes later the patient complained of severe central chest tightness radiating to both arms and associated with profuse sweating, nausea, and breathlessness. She was transferred to a local maternity hospital for further assessment. On admission her ECG showed ST segment elevation across the chest leads with 6 mm of ST elevation in leads V4 and V5 confirming an acute anterior myocardial infarction (MI). She was transferred to the coronary care unit at a nearby district general hospital. Thrombolysis was withheld due to the risk of postpartum haemorrhagic complications and she was immediately transferred to a tertiary referral centre 25 miles away where she underwent emergency cardiac catheterisation. The patient had been well previously with no cardiac symptoms and two entirely uncomplicated pregnancies. However, she was a heavy smoker and hypercholesterolaemia was diagnosed after both parents died from coronary artery disease in their early 40s. Coronary angiography revealed diVuse three vessel coronary artery disease with an acute occlusion in the proximal left anterior descending coronary artery (TIMI grade 0 flow) (fig 1A). The occlusion was dilated with a 3 mm balloon followed by insertion of a 9 mm NIR stent with a good angiographic result (fig 1B). TIMI grade 3 flow was restored to the infarct related artery within half an hour of arrival at the tertiary centre (5.5 hours after the onset of chest pain). A subsequent ECG showed resolution of ST elevation and Q waves in leads V1–4. Creatinine kinase (CK) peaked at 9858 U/l (8% CK-MB isoenzyme). Echocardiography showed anteroseptal hypokinesis but other segments of the left ventricle contracted well. Her recovery was uncomplicated.