Clinical Practice and Cases in Emergency Medicine

Introduction: Peripartum cardiac arrest is increasing in incidence. While pulmonary embolism (PE) remains an important cause of peripartum morbidity and mortality, other cardiovascular emergencies such as myocardial infarction (MI) are now the leading cause of pregnancy-related death. Emergency physicians (EP) need to be well versed in subtle electrocardiographic (ECG) signs of coronary ischemia to better care for peripartum patients in cardiac arrest.

Case Report: A 38-year-old gravida 2 parity1 female three days post-partum presented in cardiac arrest. After approximately 12 minutes of Advanced Cardiac Life Support including electric defibrillation, the patient experienced sustained return of spontaneous circulation. The physician team was primarily concerned for PE based on an initial ECG demonstrating terminal QRS distortion in V2 but no ST-segment elevation myocardial infarction (STEMI). Computed tomography angiography (CTA) of the chest did not reveal PE. Repeat ECG after CTA demonstrated STEMI criteria, and the patient was emergently taken to the cardiac catheterization laboratory where she was found to have 99% occlusion of the left anterior descending artery.

Conclusion: Emergency physicians should have a high index of suspicion for MI when managing peripartum patients in cardiac arrest. The ECG findings specific for coronary-occlusive acute MI but not included in the classic STEMI criteria increase accuracy and prevent delays in diagnosis; however, the clinical uptake of this paradigm has been slow. Early recognition of terminal QRS distortion can help EPs more rapidly diagnose the etiology of cardiac arrest.