A Rare Cause of an Acute Myocardial Infarction in a Young Pregnant Woman After Misoprostol-Induced Abortion.

Spontaneous coronary artery dissection (SCAD) is an uncommon but increasingly recognized cause of acute coronary syndrome (ACS), myocardial infarction (MI), and sudden cardiac death, particularly in younger individuals without traditional cardiovascular risk factors. Pregnancy-associated SCAD (P-SCAD) is a specific subset of SCAD that accounts for a significant number of MIs in pregnant and postpartum women. Misoprostol is a prostaglandin E1 analogue that is used for medical termination of pregnancy and has been associated with coronary vasospasm in rare cases; however, our case highlights a potential new association between this drug and SCAD.  A 29-year-old African American woman with no significant past medical history presented to the emergency room with seizure-like activity and unresponsiveness witnessed by her sister while they were traveling on a road trip few hours after taking Misoprostol for termination of an ectopic pregnancy. Coronary angiography showed focal 95% stenosis of the proximal left anterior descending (LAD) artery with TIMI 1 flow concerning spontaneous coronary artery dissection versus coronary vasospasm. A decision was made to proceed with percutaneous coronary intervention to the LAD. The procedure was complicated by no reflow and retrograde advancement of dissection/hematoma to the left main coronary artery, requiring further stenting with overlapping stents from the ostial left main coronary artery to the proximal LAD artery. During the procedure, the patient developed multiple cardiac arrests with pulseless electrical activity requiring advanced cardiac life support, pressors, and left ventricular assist device (LVAD) placement for mechanical circulatory support. She subsequently showed marked improvement and was successfully weaned off vasopressors, and the LVAD was removed by day 4 in the ICU. On day 8, the patient was successfully extubated. The follow-up 2D echocardiogram showed improvement in the ejection fraction to 40-45%. The patient was safely discharged and made significant cardiovascular recovery. This is an interesting case discussion highlighting a rare and potential association between a commonly prescribed medication and a serious cardiovascular complication. It has been observed that SCAD occurs with higher frequency during pregnancy, peripartum period, and with the use of exogenous hormones although the exact etiology remains unclear. More research should be done to better understand the potential cardiovascular adverse effects of Misoprostol, especially on patients with underlying SCAD.