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Topic. Myocardial infarction 1.

Lead in.
Myocardial infarction will definitely be in the exam database. It is mentioned in
recent maternal mortality reports and there was a TOG article in 2013.
There is a lot of stuff in this answer that I have imported to give me the facts. I
dont expect you to wade through all the tables, extracts of papers etc., though
some will be of interest I will edit it down to the essentials when I get time.
This is a new EMQ please let me know if you find possible errors or bits that
dont make sense.
There are other questions about maternal mortality which we have done or will
do.
You need to remember the mortality rates, which are in the MBRRACE EMQ which
we did on the 28th. May. If you havent done it, you can access the questions via
Dropbox in the materials for the tutorials folder, or the blog, which you can
access via the main MRCOG page on my website.
Just to refresh your memory, the facts in that answer are:
Maternal
morta
lity
Rate
2006 - 2008 11.39
2009 - 2011 10.63
2010 - 2012 10.12
There was a significant fall in the rate from 06-8 to 10-12.
You need to remember the numbers and the fact that there was a significant fall
from 06-08 to 10-12.

Abbreviations.
ACS: acute coronary syndrome
CAD: coronary artery disease
CG167: NICEs Clinical Guideline 167: Myocardial infarction with ST-segment
elevation. 2013.
DTA: dissection of thoracic aorta
ESC: European Society of Cardiologys guideline: Management of
cardiovascular diseases during pregnancy. European Heart Journal
(2011) 32, 314797.
IHD: ischaemic heart disease
LADCA: left, anterior, descending coronary artery.
LDA: low-dose aspirin (75-150 mg/day).
MBRRACE: MBRRACE-UK: Mothers and Babies: Reducing Risk through Audits and
Confidential Enquiries in the UK
MBRRACE14:MBRRACE 1st. Report. Saving Lives, Improving Mothers Care
Lessons learned to inform future maternity care from the UK and
Ireland Confidential Enquiries into Maternal Deaths and Morbidity
2009-012. Published December 2014
MI: myocardial infarction
MMRpt: Maternal Mortality Report 2006-8: Saving Mothers Lives. Reviewing
maternal deaths to make motherhood safer: 2006-2008
NSTEMI: non-ST-segment elevation myocardial infarction
PPCI: primary percutaneous coronary intervention
PTA: percutaneous transluminal angioplasty
STEMI: ST-segment elevation myocardial infarction
UKOSS: UK Obstetric Surveillance System
UKOSSMI: UKOSSs review of MI see suggested reading
Manchester MRCOG Tutorial Group www.drcog-mrcog.info Tom McFarlane
Page 1 of 18.
VH: ventricular hypertrophy
Wuntakal: see suggested reading

Suggested reading.
UKOSS conducted a review from 2005-10. Myocardial infarction in pregnancy
and the puerperium in the UK. Bush et al. Eur J Prev Cardiol. 2013 Feb;20(1):12-
20.
Wuntakal et al. Myocardial infarction and pregnancy. TOG. Volume 15, Issue
4, pages 247255, October 2013.
Cardiac disease will be the major topic dealt with by MBRRACE in 2016.

Background facts.
The latest triennium for which there are detailed figures for cardiac disease was
2006-8. More of this below.
There were 53 deaths from cardiac disease in 2006-8, 51 in 2009-11 and 53 in
2010-12, making it the leading cause of death once again in all three triennia.
50 were from acquired disease, 3 from congenital heart disease in 2006-8; we
dont have this level of detail for the later triennia.
These figures come from Table 9.1. Causes of cardiac deaths 19942008.
MMRpt., the figures for 2009-11 and 2010-12 are from MBRRACE14.
Congen Acquir Acquir Total Rate /
ital ed ed 105
materni
ties
Ischae Other
mic
n (%) n (%) n (%)
1985 10 9 4 23 1.01
87
1988 9 5 4 18 0.76
90
1991 9 8 20 37 1.60
93
1994 10 6 23 39 1.77
96
1997 10 5 20 35 1.65
99
2000 9 8 27 44 2.20
02
2003 4 16 28 48 2.27
05
2006 3 8 42 53 2.31
08
2009- 51 2.14
11
2010- 54 2.25
12

These figures come from Table 9.2. Causes of cardiac deaths 19942008. MMRpt.
Cause of death 1994 1997 2000 2003 2006
6 9 2 5 8
Sudden adult death syndrome 0 0 4 3 10

Manchester MRCOG Tutorial Group www.drcog-mrcog.info Tom McFarlane


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Peripartum cardiomyopathy 4 7 4 0 9
Aortic dissection 7 5 7 9 7
Myocardial infarction 6 5 8 12 6
Ischaemic heart disease 0 0 0 4 5
Other cardiomyopathy 2 3 4 1 4
Myocarditis or myocardial 3 2 3 5 4
fibrosis
Infective endocarditis 0 2 1 2 2
Thrombosed aortic or tricuspid 1 0 0 0 2
valve
R or L VH or HHD 1 2 2 2 1
Mitral stenosis or valve disease 0 0 3 3 0

Congenital
Pulmonary hypertension (PHT) 7 7 4 3 2
Congenital heart disease (not PHT or
thrombosed aortic valve)
32231
Other 5 0 2 0 0
Total 39 35 44 48*** 53
*Twelve Late deaths reported in 200305.
**Two Late deaths reported in 200608.
***Includes one woman for whom information on cause was not available.

Table 1.4. From MMRpt. 2006-08. Numbers and rates of leading causes of maternal deaths; UK: 19852008
Cause of death Numbers Rates per 100 000 maternities
1985 1988 1991 1994 1997 2000 2003 2006 1985 1988 1991 1994 1997 2000 2003 2006
87 90 93 96 99 02 05 08 87 90 93 96 99 02 05 08
Direc
t
Sepsis 9 17 15 16 18 13 18 26 0.40 0.72 0.65 0.73 0.85 0.65 0.85 1.13
PET 27 27 20 20 16 14 18 19 1.19 1.14 0.86 0.91 0.75 0.70 0.85 0.83
Ecla
Th 32 33 35 48 35 30 41 18 1.41 1.40 1.51 2.18 1.65 1.50 1.94 0.79
VTE
AFE 9 11 10 17 8 5 17 13 0.40 0.47 0.43 0.77 0.38 0.25 0.80 0.57
Early* 16 24 17 15 17 15 14 11 0.71 1.02 0.73 0.68 0.80 0.75 0.66 0.48
Ectopi 11 15 9 12 13 11 10 6 0.48 0.64 0.39 0.55 0.61 0.55 0.47 0.26
c
Misc 4 6 3 2 2 1 1 5 0.18 0.25 0.13 0.09 0.09 0.05 0.05 0.22
TOP 1 3 5 1 2 3 2 0 0.04 0.13 0.22 0.05 0.09 0.15 0.09 0.00
Other 0 0 2 0 0 0 1 0 0.00 0.00 0.09 0.00 0.00 0.00 0.05 0.00
Haem 10 22 15 12 7 17 14 9 0.44 0.93 0.65 0.55 0.33 0.85 0.66 0.39
Anaes 6 4 8 1 3 6 6 7 0.26 0.17 0.35 0.05 0.14 0.30 0.28 0.31
Othr 27 17 14 7 7 8 4 4 1.19 0.72 0.60 0.32 0.33 0.40 0.19 0.17
D
GT 6 3 4 5 2 1 3 0 0.26 0.13 0.17 0.23 0.09 0.05 0.14 0.00
traum
a
Fatty 6 5 2 2 4 3 1 3 0.26 0.21 0.09 0.09 0.19 0.15 0.05 0.13
liver
Other 15 9 8 0 1 4 0 1 0.66 0.38 0.35 0.00 0.05 0.20 0.00 0.04
All D 139 145 128 134 106 106 132 107 6.13 6.14 5.53 6.10 4.99 5.31 6.24 4.67
Indire
ct
Cardia 23 18 37 39 35 44 48 53 1.01 0.76 1.60 1.77 1.65 2.20 2.27 2.31
c
Neuro 19 30 25 47 34 40 37 36 0.84 1.27 1.08 2.14 1.60 2.00 1.75 1.57
Psyc 9 15 16 18 13 0.41 0.71 0.80 0.85 0.57
Cance 11 5 10 3 0.52 0.25 0.47 0.13
r
Othr I 43 45 38 39 41 50 50 49 1.90 1.91 1.64 1.77 1.93 2.50 2.37 2.14
All I 84 93 100 134 136 155 163 154 3.70 3.94 4.32 6.10 6.40 7.76 7.71 6.59
Coinl 26 39 46 36 29 36 55 50 1.15 1.65 1.99 1.64 1.37 1.80 2.60 2.18
LateD - 13 10 4 7 4 11 9 - - - - - - - -
Late - 10 23 32 39 45 71 24 - - - - - - - -
Ind

*The Early Pregnancy deaths category includes only those women who died from the following Direct causes: ectopic
pregnancy, miscarriage, termination of pregnancy or other rare Direct conditions before 24 completed weeks of

Manchester MRCOG Tutorial Group www.drcog-mrcog.info Tom McFarlane


Page 3 of 18.
pregnancy not counted elsewhere. Those women who died from other causes before 24 weeks of gestation are counted
in the relevant chapters, e.g. Embolism, Sepsis, Indirect etc.

Table 1.12. Numbers and percentages of cases of Direct and Indirect deaths by cause and degree of substandard care
(SSC); UK: 200608
Cause Numbers of cases Percentages of cases Percentage of
cases with
no SSC
Total
number of cases
Major Minor Total Major Minor Total
Direct
Thrombosis and thromboembolism 6 4 10 33 22 56 44 18
Pre-eclampsia, eclampsia and acute
fatty liver of pregnancy
14 6 20 64 27 91 9 22
Haemorrhage 4 2 6 44 22 67 33 9
Amniotic fluid embolism 2 6 8 15 46 62 38 13
Early pregnancy deaths 6 6 55 55 45 11
Sepsis 12 6 18 46 23 69 31 26
Anaesthesia 3 3 6 43 43 86 14 7
Total Direct 47 28* 75* 44 26 70 30 107*
Indirect
Cardiac disease 13 14 27 25 26 51 49 53
Other Indirect causes 17 11 28 33 21 54 46 52
Indirect neurological causes 11 12 23 31 33 64 36 36
Psychiatric causes 6 1 7 46 8 54 46 13
Total Indirect 47 38 85 31 25 55 45 154
Total Direct and Indirect 94 66 160 36 25 61 39 261
*Includes one case from choriocarcinoma that is classified as Direct.

1985 1988 1991 1994 1997 2000 2003 2006 2009 2010
87 90 93 96 99 02 05 08 -11 -12
Th 32 33 35 48 35 30 41 18 30 26
VTE
Neuro 19 30 25 47 34 40 37 36 30 31
PET 27 27 20 20 16 14 18 19 10 9
Ecla
Haem 10 22 15 12 7 17 14 9 14 11
Cardia 23 18 37 39 35 44 48 53 51 54
c
Sepsis 9 17 15 16 18 13 18 26 15 12
AFE 9 11 10 17 8 5 17 13 7 8
Fatty 6 5 2 2 4 3 1 3 - -
liver
Anaes 6 4 8 1 3 6 6 7 3 4
GT 6 3 4 5 2 1 3 0 - -
traum
a
Psyc 9 15 16 18 13 13 16
Cance 11 5 10 3 4 3
r

Top 5 causes of death, both direct & indirect by triennium.


Rank 1985 1988 1991 1994 1997 2000 2003 2006 2009- 2010-
87 90 93 96 99 02 05 08 11 12
1 Th/VT Th/VT Cardia Th/VT Cardia Cardia Cardia Cardia Cardia Cardia
E 32 E 33 c E c c c c c c
37 48 35 44 48 53 51 54
2 PET E Neuro Th/VT Neuro Th/VT Neuro Th/VT Neuro Neuro Neuro
27 30 E 47 E 40 E 36 30 31
35 35 41
3 Cardia PET E Neuro Cardia Neuro Th/VT Neuro Sepsis Th/VT Th/VT
c 23 27 25 c 34 E 37 26 E E
39 30 30 26
4 Neuro Haem PET/E PET/E Sepss Haemr PET/E PET/E Sepsis Psych
19 r age 20 20 18 age 18 19 15 16
22 17
5 Sepsis Cardio Haem AFE PET/E Psych Psych Th/VT Haemr Sepsis
AFE 9 18 r age 17 16 16 18 E 18 14 12
15

Top 5 causes of death, direct only by triennium.


Manchester MRCOG Tutorial Group www.drcog-mrcog.info Tom McFarlane
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Rank 1985 1988 1991 1994 1997 2000 2003 2006 2009- 2010-
87 90 93 96 99 02 05 08 11 12
1 Th/VT Th/VT Th/VTE Th/VT Th/VT Th/VT Th/VT Sepsis Th/VT Th/VT
E 32 E 33 35 E E E E 26 E E
48 35 30 41 30 26
2 PET E PET E PET/E PET/E Sepsis Haem PET/E PET/E Sepsis Sepsis
27 27 20 20 18 r age 18 19 15 12
17
3 Haem Haem Haemr AFE PET/E PET/E Sepsis Th/VT Haemr Haemr
r r age age 15 17 16 14 18 E 18 14 11
10 22
4 AFE Sepsis Sepsis Sepsis AFE Sepsis AFE AFE PET/E PET/E
9 17 15 16 8 13 17 13 10 9
5 Sepsis AFE AFE Haem Haem Anae Haem Haem AFE AFE
9 11 10 r r 6 r 9 7 8
12 7 14

Coronary artery anatomy.


http://www.hopkinsmedicine.org/healthlibrary/conditions/cardiovascular
_diseases/anatomy_and_function_of_the_coronary_arteries_85,P00196/

Left main coronary artery divides into branches:


the left anterior descending artery, which supplies blood to the front of the left
side of the heart.
the circumflex artery, which supplies blood to the outer side and back of the
heart.
the right coronary artery supplies blood to the right ventricle, the right atrium,
and the SA (sinoatrial) and AV (atrioventricular) nodes
the right coronary artery divides into smaller branches, including the right
posterior descending artery and the acute marginal artery.
Additional smaller branches are:
obtuse marginal (OM),
septal perforator (SP)
and diagonals.
Click on the above link for a pictorial representation.

CNP.
ACSs are rare in women of childbearing age, but as women delay childbirth until
their late 30s and 40s, coronary artery disease and MI are becoming more
frequent in pregnancy.
Maternal deaths from MI are increasing. In the US, there was a threefold increase
in the incidence of MI during pregnancy from 1990 to 2000. There was a fourfold
increase in maternal deaths reported in the UK from 2000-02 to 2003-05. The
maternal death rate from acute MI is 5% to 7%.
Pathogenesis.
Atherosclerosis is the predominant pathogenesis outside pregnancy, and
increasingly, this holds true in pregnancy. However, in pregnancy, coronary
artery dissection and embolus in the absence of atheroma are more frequent and
must be remembered as causes of ACS.
Causes include:
atheroma in ischaemic heart disease
coronary thrombosis without atheroma
coronary artery dissection
coronary artery aneurysm, spasm or embolism
congenital coronary anomalies
cocaine abuse.

Risk factors for IHD include the following.


Manchester MRCOG Tutorial Group www.drcog-mrcog.info Tom McFarlane
Page 5 of 18.
smoking
diabetes
obesity
FH of IHD
hypertension
hypercholesterolaemia
multigravida > 35 years of age

Acute MI/ACS mostly occurs in the 3rd. trimester, peripartum and postpartum.
The anterior wall of the left ventricle and the territory of the LADCA are the
commonest sites involved.
There is often not a preceding history of angina, or symptoms may be atypical
with epigastric pain or nausea, and the presentation may be acute.
Artery dissection has a particular association with the peripartum period. This
includes coronary artery dissection.
Diagnosis.
Diagnosis outside of pregnancy relies on a combination of history, ECG changes
and cardiac enzymes. Troponin I(Tn I) and T are not altered in normal pregnancy
but Tn I is increased in PET, pulmonary embolism, atrial fibrillation and
myocarditis.
Management
Management for ACS is as for the non-pregnant woman with heparin, -blockers
and nitrates.
LDA is safe for use in pregnancy and should be continued or commenced in
pregnancy for 1ry and 2ry prophylaxia. In the acute management of ACS, 150-
300 mg. can be given.
Thrombolytic (IV and intra-coronary) therapy has been used successfully. It
should not be withheld, but there is a significant risk of bleeding.
Coronary angiography is usually appropriate to determine the underlying cause
of the ACS and percutaneous transluminal angioplasty and stenting may be used
if appropriate.
PPCI, if available, is preferable to thrombolysis as the former is associated with
less bleeding and also allows management of spontaneous dissection (and
atheromatous stenosis) with stent deployment. Angioplasty is associated with an
increased risk of coronary dissection in a vulnerable vessel.
Both aspirin and clopidogrel are recommended acutely after the use of (bare
metal and drug-eluting) stends. There is increasing experience with the use of
clopidogrel in pregnancy, which seems to be safe, but it should be discontinued
for delivery as there is an increased bleeding risk. For this reason bare metal
stents are used in preference to drug-eluting stents (which require dual
antiplatelet therapy for longer) in pregnancy.
Statins should be discontinued prior to pregnancy sicne high doses have caused
skeletal malformations in rates, and in human pregnancy, there is an increased
risk of CNS and limb defects. Discontinuation for the relatively short duration of
pregnanc is unlikely to impact on long-term therapy for hyperlipidaemia.
For those with previous MI, poor prognostic features for future pregnancy include
left ventricular dysfunction and the presence of continuing ischaemia.

Dissection of thoracic aorta.


Pregnancy increases the risk of DTA, which is the commonest cause of death in
pregnancy. Even if the diagnosis is made, the mortality rate associated with this
condition is high.

Clinical features.
Manchester MRCOG Tutorial Group www.drcog-mrcog.info Tom McFarlane
Page 6 of 18.
Aortic dissection should be considered in any pregnant woman presenting with
acute severe chest pain, particularly with interscapular radiation, with jaw pain
and int the presence of systolic hypertension and/or differential BPs in each arm.
There may be symptoms or signs from territory supplied by the coronary, carotid,
subclavian, spinal or common iliac arteries or aortic regurgitation. Most cases in
pregnancy are type A dissections, involving the ascending aorta.
Many cases are misdiagnosed initially as pulmonary emboli.

Pathogenesis
Pregnancy predisposes to aortic dissection, possibly due to haemodynamic shear
stress. Other risk factors include the following:
Marfan syndrome
Turner syndrome
Ehlers-Danlos syndrome type IV (vascular)
Coarctation of the aorta
Bicuspid aortic valve

Diagnosis.
Chest x-ray is mandatory and may show mediastinal widening, but a normal
chest radiograph does not exclude the diagnosis.
Diagnosis may be confirmed with transthoracic or transoesophageal echo-
cardiography, computed tomography, or magnetic resonance imaging.

Management.
The management of type A dissection is surgical. This usually means the
following:
Careful and rapid control of the BP
Expeditious delivery by Cs
Cardiac surgery to replace the aortic root.

UKOSS.
Eur J Prev Cardiol. 2013 Feb;20(1):12-20. doi: 10.1177/1741826711432117. Epub 2011 Nov 29.

Myocardial infarction in pregnancy and postpartum in the UK.


Bush N1, Nelson-Piercy C, Spark P, Kurinczuk JJ, Brocklehurst P, Knight M; UKOSS.

Author information

1
National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK.

Abstract

AIM:

Cardiac disease is a leading cause of maternal death in the developed world, responsible for one-fifth
of all maternal deaths in the UK. The aim of this study was to estimate the incidence of myocardial
infarction (MI) in pregnancy and up to one week postpartum in the UK and describe risk factors,
management and outcomes.

METHODS:

Manchester MRCOG Tutorial Group www.drcog-mrcog.info Tom McFarlane


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A prospective population-based study with nested case control analysis used the UK Obstetric
Surveillance System to identify all women in the UK with MI in pregnancy (in the years 2005-2010). A
control group of 1360 women was used for comparison. Multivariable unconditional logistic regression
was conducted to identify potential risk factors for MI in pregnancy and calculate adjusted odds ratios
with 95% confidence intervals.

RESULTS:

Twenty-five cases of MI in pregnancy were reported, giving an estimated incidence of 0.7 per 100,000
maternities (95%CI 0.5-1.1). Maternal age, smoking, hypertension, twin pregnancy and pre-eclampsia
were independently associated with MI in pregnancy. Fifteen (60%) women underwent coronary
angiography; nine (60%) had coronary atherosclerosis, three (21%) had coronary artery dissection,
one (7%) had a coronary thrombus and two (13%) had normal coronary arteries. Nine women had
angioplasty +/- stenting and two were thrombolysed. No women died.

CONCLUSIONS:

Many risk factors are both recognisable and modifiable. Management of MI in pregnancy was highly
variable indicating a clear need for further information regarding the safety and outcomes of different
interventions. The addition of pregnancy status as a compulsory field in cardiac audit databases
would enable routine collection of this information.

OSS

Question 1.
Lead-in
Where did cardiac disease rank in the direct and indirect causes of maternal
death for the years 2010-12 in MBRRACE14?
Option List
A. 1

B. 2

C. 3

D. 4

E. 5

Answer. A. Cardiac disease has been top of the list for nearly 20 years since the
1997-9 maternal mortality report. U The UKOSS survey noted that it causes
about 20% of all deaths.
MBRRACE was published late details are given in the answer to the EMQ on
MBRRACE. As a result, figures were available for 4 years, not the usual 3 for the
previous maternal mortality reports. Data were given for two triennia: 2009-11
and 2010-12. This shows the pattern you will get used to with future reports,
which will have annual data, with the triennia on a rolling programme that is
updated each year.
Cardiac deaths numbered 51 for 2009-11 and 54 for 2010-12.

The rankings were:


2006-08 2006- 2009-11 2009- 2010-12 2010-

Manchester MRCOG Tutorial Group www.drcog-mrcog.info Tom McFarlane


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8 11 12
Cause No Cause No Cause No
Cardiac 53 Cardiac 51 Cardiac 54
Neurological 36 Neurological 30 Neurological 31
Sepsis 26 Thrombosis/ 30 Thrombosis/ 26
VTE VTE
Eclampsia/P 19 Sepsis 15 Psychiatric 16
ET
Thrombosis/ 18 Haemorrhag 14 Sepsis 12
VTE e

Cardiac disease has been in the top 3 for 30 years and has been number 1 for
almost 20 years.
Note that the numbers are increasing: probably due to average maternal age
and obesity.

Top 5 causes of death, both direct & indirect by triennium.


Rank 1985 1988 1991 1994 1997 2000 2003 2006 2009- 2010-
87 90 93 96 99 02 05 08 11 12
1 Th/VT Th/VT Cardia Th/VT Cardia Cardia Cardia Cardia Cardia Cardia
E 32 E 33 c E c c c c c c
37 48 35 44 48 53 51 54
2 PET E Neuro Th/VT Neuro Th/VT Neuro Th/VT Neuro Neuro Neuro
27 30 E 47 E 40 E 36 30 31
35 35 41
3 Cardia PET E Neuro Cardia Neuro Th/VT Neuro Sepsis Th/VT Th/VT
c 23 27 25 c 34 E 37 26 E E
39 30 30 26

Question 2.
Lead-in
What has happened to the incidence of maternal death due to cardiac disease in
the UK since 1985?
Option List

A. it has roughly increased by a factor


of 1.5
B. it has roughly increased by a factor
of 2.3
C. it has roughly increased by a factor
of 3.0
D. it has roughly reduced by a quarter

E. it has roughly reduced by a half

Answer. B
The figures for incidence per 100,000 maternities are in the table below. I have
even added a graph for those who dont like figures.
198 198 199 199 199 200 200 200 200 201
587 890 193 496 799 002 305 608 9-11 0-12
Cardi 1.01 0.76 1.60 1.77 1.65 2.20 2.27 2.31 2.14 2.25
ac

Manchester MRCOG Tutorial Group www.drcog-mrcog.info Tom McFarlane


Page 9 of 18.
MMR: cardiac disease
2.5
2.2 2.27 2.31 2.14 2.25
2
1.77 1.65
1.5 1.6
1 1.01
0.76
0.5
0
85 88 91 94 97 2000 3 6 9 10
MMR

Question 3.
Lead-in
What was the estimated prevalence of MI in the UKOSS survey?
There is no option list what is your figure?
Answer. 0.7 per 100,000 maternities. It found 25 cases from 2005 10.

Question 4.
Lead-in
What risk factors for MI were identified in the UKOSS survey?
Answer. The survey reported the following:
older maternal age,
hypertension,
pre-eclampsia,
smoking,
twin pregnancy.

Question 5.
Lead-in
What underlying pathological conditions were noted in the UKOSS survey?
Answer. The survey found the following:
coronary atherosclerosis: 9 women, 60%,
coronary artery dissection: 3 women, 21%,
coronary thrombosis: 1 woman, 7%,
normal coronary arteries: 2 women, 13%.
Note that only 15 of the 25 women had coronary angiography, so the figures are
tiny.

Question 6.
Lead-in
What risk factors for MI have been mentioned in recent Maternal Mortality
Reports?
There is no option list.
Write your list and you can compare it with the list in the answers.
Answer. This answer and the next come from the TOG article by Wuntakal et al,
which I commend to you.
Age > 35 years
Family history of CAD / IHD
Obesity
Parity > 3
Pre-existing disease:
diabetes
Manchester MRCOG Tutorial Group www.drcog-mrcog.info Tom McFarlane
Page 10 of 18.
hypertension
ischaemic heart disease
Smoking

Question 7.
Lead in
What risk factors for MI have been reported in other publications?
A big question!! Write your list and compare it with mine.
Answer.
Blood transfusion
Eclampsia / PET
Hyperlipidaemia
Migraine
Post-partum infection
Thrombophilia

Question 8.
Lead-in
How are the causes of MI normally categorised and what are the sub-headings in
the main categories.
You know this or could work it out, certainly the main headings and most of the
sub-headings.
Write your list and you can compare it with the answer.
Answer.
The main categories are atherosclerotic and non-atherosclerotic.
Atherosclerosis has a number of contributory factors that you know.
age
FH of CHD / IHD
hypercholesterolaemia
obesity
pre-existing disease:
CHD / IHD
diabetes
hypertension
smoking
The non-atherosclerotic category includes a number of conditions:
coronary artery dissection
coronary artery spasm
coronary artery thrombosis
congenital anomalies of the coronary arteries
cocaine use

Question 9.
Lead-in
What ECG criteria are used to categorise acute myocardial infarction?
Option List

A. presence of arrhythmia

B. presence of QT interval prolongation

C. presence of ST segment depression

D. presence of ST segment elevation


Manchester MRCOG Tutorial Group www.drcog-mrcog.info Tom McFarlane
Page 11 of 18.
E. presence of T wave inversion

Answer. B. The main categories are STEMI and NSTEMI. CG167 says: STEMI
occurs when a coronary
artery becomes blocked by a blood clot, causing the heart muscle supplied by
the artery to die. It belongs to a group of heart conditions known as acute
coronary syndromes Over the past 30 years, in-hospital mortality after acute
coronary syndromes has fallen from around 20% to nearer 5%... Nearly half of
potentially salvageable myocardium is lost within 1 hour of the coronary artery
being occluded and two-thirds are lost within 3 hours.
PPCI is now preferred to fibrinolysis in the non-pregnant. CG167 says: Offer
coronary angiography, with follow-on primary PCI if indicated, as the preferred
coronary reperfusion strategy for people with acute STEMI if:
presentation is within 12 hours of onset of symptoms
PPCI can be delivered within 120 minutes of the time when fibrinolysis could
have been given.
CG167 does not mention the management of STEMI in pregnancy but Wuntakal
et al say: coronary angiography and PPCI is the treatment of choice. It goes on
to say that the ESC
6.3 Recommendations for the management of coronary artery disease
Table 13 Recommendations for the management of coronary artery disease
Recommendations
ECG and troponin levels should be performed in the case of chest pain
in a pregnant woman,
Coronary angioplasty is the preferred reperfusion therapy for STEMI
during pregnancy
Conservative management should be considered for non ST-elevation
ACS without risk criteria,
Invasive management should be considered for non ST-elevation ACS
with risk criteria (including NSTEMI)
6.2 Management
The first step in ST-elevation ACS is to refer the patient immediately to a skilled
intervention centre for a diagnostic angiogram and a primary PCI.
Interventions during pregnancy. Coronary angiography with the possibility of
coronary intervention (PCI) is preferred to thrombolysis as it will also diagnose
coronary artery dissection. The risk of potential damage to the fetus should be
kept in mind, especially in the first trimester. All reported stenting during the
acute phase of ST-elevation myocardial infarction during pregnancy utilized bare
metal stents; the safety of drug-eluting stents in pregnant woman is therefore
still unknown. As
drug-eluting stents also require prolonged dual antiplatelet therapy they should
be avoided. Although recombinant tissue plasminogen activator does not cross
the placenta it may induce bleeding complications (subplacental bleeding);
therefore, thrombolytic therapy should be reserved for life-threatening ACS when
there is no access to PCI.166 In women with non-ST elevation ACS with
intermediate or high risk criteria, an invasive approach to assess coronary
anatomy is indicated,
while in stable conditions with exertional symptoms, watchful waiting and
medical therapy is the treatment of choice.167 In all patients, if there is a
deterioration in clinical status, an invasive strategy is indicated. In the case of
recurrent coronary dissections, pre-term delivery can be considered according to
fetal viability.
Manchester MRCOG Tutorial Group www.drcog-mrcog.info Tom McFarlane
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Data on emergency coronary artery bypass graft surgery during pregnancy are
rare, with a potentially high mortality rate.163,164
Medical therapy. The use of ACE inhibitors, angiotensin receptor blockers (ARBs),
and renin inhibitors is contraindicated during pregnancy (see Section 11). b-
Blockers and low dose acetylsalicylic acid are considered to be relatively safe,
while this is unknown for thienopyridines. Clopidogrel should therefore only be
used during pregnancy when strictly needed (e.g. after stenting) and for the
shortest duration possible. In the absence of safety data regarding glycoprotein
IIb/IIIa inhibitors, bivalirudin, prasugrel, and ticagrelor, the use of these dugs is
not recommended
during pregnancy.
Delivery. In most cases, vaginal delivery will be appropriate. Delivery
is discussed in Section 2.9.

Question 10.
Lead-in
What ECHO criteria are used to categorise acute myocardial infarction?
Option List

A. presence of arrhythmia

B. presence of atrial dilatation

C. presence of ventricular dilatation

D. presence of mitral valve reflux

E. none of the above

Answer. E. Trick question. ECHO is mainly used to exclude other diagnoses such
as aortic dissection.

Question 11.
Lead-in
With regard to coronary artery dissection, which of the following statements are
false?
Statements.
A. only occurs in women with coronary artery disease

B. mainly occurs in the right anterior descending branch of the coronary


artery
C. is most common in the puerperium

D. is particularly associated with the use of ergometrine for management of


the 3rd. stage and its complications
E. is associated with mortality rates 50%, mainly due to late diagnosis or
mis-diagnosis

Option List

1. A + B + C

Manchester MRCOG Tutorial Group www.drcog-mrcog.info Tom McFarlane


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2. A + C + D

3. B + D

4. B + D + E

5. A + B + C + D + E

Answer. 5. It is described in women with no identifiable disease. It mainly occurs


in the left anterior descending branch. It is most common in the third trimester
and puerperium, the times when the stresses on the coronary vessels are at their
highest. Ergot derivatives are risk factors for acute myocardial infarction, but not
for coronary artery dissection. They include ergometrine and, the drug we tend
to forget is an ergot derivative: bromocryptine. We had very few maternal deaths
in my time at Stepping Hill Hospital in Stockport. One was a woman in the early
days of the puerperium who was found dead. The post-mortem did not reveal a
definite cause of death and the only unusual feature was that she had been
taking bromocryptine for suppression of lactation. It stuck in my mind and left
me very wary of using bromocryptine, the concern being that she might have
had an acute coronary event, such as spasm, sufficient to cause a fatal
arrhythmia but not leave much evidence for the pathologist to draw conclusions.
Wuntakal et al cite mortality rates of 30-40%.

Question 12.
Lead-in
Which ECG feature is particularly used to diagnose MI?
Option List
A. presence of arrhythmia

B. presence of QT interval prolongation

C. presence of ST segment depression

D. presence of ST segment elevation

E. presence of T wave inversion

Answer. D.

Question 13.
Lead-in
Which blood markers are best for the diagnosis of MI?
Markers
1. Treponemin A

2. Treponemin B

3. Troponin A

4. Troponin I

5. Troponin T

Manchester MRCOG Tutorial Group www.drcog-mrcog.info Tom McFarlane


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Option List
A 1+2
B 3
C 3+4
D 3+5
E 4+5
F none of the above

Answer. E. The TOG article states that hospitals tend to use one, not both.

Question 14.
Lead-in
Which of the following statements are true about the blood markers that are best
for the diagnosis of MI?
Statements
1. Their levels are normal in normal pregnancy

2. Their levels are increased from about 28 weeks, making pregnancy-


specific ranges mandatory
3. Their levels rise with prolonged labour

4. Their levels rise with Caesarean section

5. Their levels can be elevated in pregnancy-induced hypertension and


PET
6. Their levels can be elevated in pulmonary embolism

Option List
A 1+3
B 1+3+4
C 2+3+4
D 1+3+5
E 1+5+6
F none of the above

Answer. E. Wuntakal et al say: Troponin is never increased in healthy


pregnant women and is not affected by:
anaesthesia,
Caesarean section,
prolonged labour,
or caesarean section,
. other cardiac markers myoglobin, creatinine kinase, creatinine kinase
isoenzyme MB can be increased significantly in labour.

Question 15
Lead-in
How many maternal deaths due to cardiac disease were reported for the years
2010-12 in MBRRACE14?

Option List
Manchester MRCOG Tutorial Group www.drcog-mrcog.info Tom McFarlane
Page 15 of 18.
A. 10

B. 26

C. 38

D. 47

E. 54

Answer. E. 54. MBRRACE was published late this is dealt with in the answer to
the EMQ on MBRRACE. As a result, figures were available for 4 years, not the
usual 3 for the previous maternal mortality reports. Data were given for two
triennia: 2009-11 and 2010-12.
Cardiac deaths numbered 51 for 2009-11 and 54 for 2010-12.

Question 16.
What were the main causes of maternal death from cardiac disease in 2010-12?
List of possible causes.
A. aortic dissection
B. atherosclerosis
C. atrial fibrillation
D. coronary thrombosis
E. myocardial infarction
F. peripartum cardiomyopathy
G. sudden adult death syndrome
H. ventricular fibrillation

Option List

A. A + B + C + D + E + F + G + H

B. A + B + C + D + E + F + G + H

C. A + B + C + D + E + F + G + H

D. A + B + C + D + E + F + G + H

E. A + B + C + D + E + F + G + H

Answer. A. None of the above. Trick question. I have included this to remind you
of one of the major changes that came when MBRRACE took over the maternal
mortality reports from CMACE. CMACE had produced 3-yearly reports that went
into detail about all the main topics. MBRRACE is going to produce annual reports
that give the overall figures. These will be supplemented by detailed reports, but
they will have a 3-year cycle.
MBRRACE14, the 1st. report, looked in detail at the following:
sepsis
haemorrhage

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amniotic fluid embolism
anaesthetic-related causes
neurological
other indirect causes.
The report gave all the relevant numbers and analysis, but only for these topics.
Cardiac disease was not included, so the report just gave the basic figures: the
numbers of cardiac deaths and the split between congenital and acquired. The
2016 report will look in detail at cardiac deaths, so full details will be available
then, including numbers for myocardial infarction.
I suspect that you might be asked about when the various detailed topic reports
will be produced and suggest adding them to your last-minute-revision list.
Year Detailed topics
2015 coincidental deaths
late deaths
malignancy-related deaths
psychiatric deaths
thrombosis & VTE
2016 cardiac deaths
early pregnancy deaths
eclampsia and PET

Question 17.
How many maternal deaths were attributed to myocardial infarction in
MBRRACE14?

Option List

A. 0

B. 5

C. 8

D. 12

E. 36

Answer. A. 0. Trick question. This is the same as question

Question 18.
Lead-in
What are the latest figures for the split between congenital and acquired disease
in deaths due to cardiac disease and what years do they derive from?

Option Lists
List 1 List 2
A 3: F 2006-08
100
B 6: G 2007-09
100
C 13: H 2008-10
100

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D 31: I 2009-11
100
E 50: J 2010-12
100

Answer. B & F: 6 per 100 and 2006-8. As explained above, we did not get a
detailed breakdown of cardiac deaths in MBRRACE14 and wont get them until
2016. Hence the latest figures are from 2006-8, the previous report. There were
53 cardiac deaths, 3 congenital and 50 acquired. This made the calculation easy!

Lead-in
Question 6.
Lead-in
Which causes of death have occupied the number 1 spot in the ranking order of
the causes of direct and indirect maternal deaths in the past 30 years?
List of causes.
1. AFE

2. anaesthesia

3. early pregnancy: ectopic, miscarriage & TOP

4. cardiac disease

5. haemorrhage

6. PET, eclampsia, pregnancy-induced hypertension

7. psychiatric disease including suicide

8. sepsis

9. thromboembolism/ thrombosis

Option List

A. 4 + 5

B. 4 + 9

C. 4 + 5 + 6 + 8

D. 4 + 5 + 6 + 7 + 8

E. all of the above

Answer. B. 4 + 9. Note that this is all causes of death; it would be different if we


were looking separately at direct and indirect causes.

Manchester MRCOG Tutorial Group www.drcog-mrcog.info Tom McFarlane


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