A 31-year-old parturient delivered twins at 35 weeks' gestation by
cesarean section with
spinal anesthesia. Following
anesthesia induction,
hypotension and
bradycardia occurred, and were immediately treated with
theodrenaline plus cafedrin (
Akrinor) and
atropine. Blood pressure and heart rate increased to 180/100 mmHg and 140 beats per minute, respectively. Several minutes later, the patient developed a
myocardial infarction (MI) that she survived after
intensive care treatment without sequelae. Although the coronary angiography showed normal coronary vessels, an intravascular ultrasound study demonstrated an
atheroma in the left main coronary artery with ruptured fibrous cap. Laboratory screening for risk factors of
coronary artery disease (CAD) showed hypercholesterinemia, increased
factor VII activity, and hyperfibrogenemia. Angiographically normal coronary vessels are frequently found in pregnant patients who suffered MI. In these patients, coronary
spasms have been discussed as the major mechanism of disease. Our case demonstrates that a significant CAD may be present despite angiographically normal findings. Plaque
rupture was triggered by
hypertension and led to MI as the first symptom of disease. On the basis of these findings, we believe that MI during pregnancy is more often caused by plaque
rupture than may be expected, according to the current literature.