Spontaneous Coronary Artery Dissection in a Pregnant Woman Ronald S. McKechnie, MD, Devang Patel, MD, Daniel T. Eitzman, MD, Sanjay Rajagopalan, MD, and Thippeswamy H. Murthy, MD Division of Cardiology, Department of Internal Medicine, University of Michigan Hospitals, Ann Arbor, Michigan BACKGROUND: Spontaneous coronary dissection is a rare condition occurring more often in women, with a higher frequency during the peripartum period. No specific etiol- ogy has been defined to describe this uncommon, yet often fatal phenomenon. CASE: A young woman presented at 36 weeks of a noncom- plicated pregnancy with recent onset of diaphoresis, dys- pnea, and tingling substernal chest discomfort. Upon eval- uation, she developed cardiovascular collapse and ventricular fibrillation requiring aggressive resuscitative measures, eventually leading to extracorporeal membrane oxygenation. Right coronary artery dissection was ulti- mately diagnosed and treated with intracoronary angio- plasty and stent placement. CONCLUSION: Spontaneous coronary dissection must be considered when evaluating a patient with a similar clini- cal presentation, given its overall mortality of more than 50% at presentation, particularly in the peripartum period. (Obstet Gynecol 2001;98:899 –902. © 2001 by the Ameri- can College of Obstetricians and Gynecologists.) Spontaneous coronary dissection is a rare condition oc- curring more often in women, with a higher frequency during the peripartum or postpartum period. Clinical presentation usually appears with sudden collapse and death or with a severe ischemic syndrome. CASE A young gravid woman presented at 36 weeks of a noncomplicated pregnancy with recent onset of dia- phoresis, dyspnea, and tingling substernal chest discom- fort radiating to both arms. The patient had no risk factors for coronary artery disease, family history of sudden death, or any other systemic illnesses. Upon initial evaluation, she developed a tonic-clonic seizure with subsequent onset of hemodynamic collapse requir- ing emergent cesarean delivery. Immediate cardio- vascular monitoring revealed ventricular fibrillation, and resuscitation efforts were performed including anti- arrhythmic medications, multiple defibrillatory shocks, and catecholamine support without significant improve- ment. Rescue implementation of extracorporeal mem- brane oxygenation (ECMO) was initiated for cardiopul- monary support. Electrocardiogram (Figure 1) and transesophageal echocardiogram revealed evidence of inferoposterior and lateral infarction with diminished overall left ventricular function with an ejection fraction of less than 10%. After hemodynamic stabilization with ECMO, emergent cardiac catheterization revealed prox- imal dissection of the right coronary artery (Figure 2). Angioplasty and six consecutive, intracoronary stents were placed, resulting in normal coronary flow within the right coronary artery (Figure 3). Subsequent removal of ECMO support was achieved 3 days later, and repeat echocardiogram upon hospital discharge revealed an improved left ventricular function at 40 – 45% with per- sistent akinetic inferoposterior segments. Both the pa- tient and child were ultimately discharged alive and well from the hospital approximately 2 weeks later. COMMENT Primary dissection of a coronary artery during preg- nancy or the puerperium is a rare, yet potentially fatal entity in otherwise healthy individuals. Since the first case of pregnancy-related dissection was reported in 1931, recent review of the medical literature suggests a mean age of 33, mean parity of 2.7, and mean time span to event of 20 days postpartum in 31 additional pa- tients. 1,2 Given its overall mortality of more than 50% at presentation, this diagnosis must be considered when evaluating a patient with a similar clinical presentation, especially given the good prognosis (85%) in those pa- tients surviving the acute event. 3 Early coronary angiog- raphy should be performed to aid in the choice of imme- diate medical or surgical intervention. Coronary dissection involves the left anterior de- scending artery in approximately 80% of cases and the right coronary artery in most others. 4 However, the etiology of spontaneous coronary dissection in gravid patients remains unclear. Furthermore, no coronary risk factors or connective tissue disorders have been identi- fied as independent risk factors for dissection. Theories regarding the etiology include a pregnancy- induced degeneration of collagen in conjunction with the Address reprint requests to: Thippeswamy H. Murthy, MD, Section of Cardiology, Washington Hospital Center, 110 Irving Street NW, Room 1094, Washington, DC 20010-2975; E-mail: thippeswamy. murthy@medstar.net. 899 VOL. 98, NO. 5, PART 2, NOVEMBER 2001 0029-7844/01/$20.00 © 2001 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc. PII S0029-7844(01)01563-0