Cardiovascular complications following medical termination of pregnancy: An updated review

Table 1 Patients with infective endocarditis following medical termination of pregnancy

No.	Age/details	Time interval	Antibiotic prophylaxis	Microbiological diagnosis	Valves involved	Other complications	Management	Final outcome	Ref.
1	17 yr/clandestine abortion	28 d	No	Neg	TV	None	Mx	Survived	[10]
2	30 yr/post ciprofloxacin and doxycycline	10 d	No	GBS	MV	S Ar, R Ar	Mx, MVR	Survived	[11]
3	31 yr/post-surgical abortion	48 d	No	GBS	TV	STE	Mx, TVR	Survived	[12]
4	37 yr/post-surgical abortion, past history of AVR/MVR for IE	60 d	Yes (ampicillin and gentamycin)	GBS	AV	SE	Mx	Survived	[13]
5	18 yr/elective abortion	Several weeks	No	GBS	TV	SE	Mx	Survived	[14]
6	30 yr/elective abortion	28 d	No	GBS	TV	SE, 1st HB	Mx, TVR	Survived	[15]
7	33 yr/elective abortion	28 d	No	GBS	TV	SE, VRA	Mx, TVR	Survived	[16]
8	24 yr/elective abortion	28 d	No	GBS	TV	SE, RHF	Mx	Survived	[17]
9	15 yr/elective abortion	7 d	Doxycycline	GBS	PV	SE, PAA	Mx, PVR	Survived	[18]
10	15 yr/elective abortion	11 d	Ciprofloxacin + doxycycline	GBS	AV	HF, AR	Mx, AVR	Survived	[19]
11	18 yr/elective abortion	14 d	Doxycycline	GBS	TV	SE	Mx, Emb	Survived	[20]
12	22 yr/elective abortion	7 d	-	GBS	TV	SE, PAA, TR	Mx	Lost to follow-up	[21]
13	Young female	-	-	-	Mu	-	Mx, AVR, TVR	Death	[22]
14	37 yr	11 d	-	GBS	TV	SE, SI	Mx	Survived	[23]
15	25 yr/rheumatic heart disease	14 d	-	MSSA	Mu	SE	Mx	Survived	[24]
16	21 yr	21 d	-	E coli	MV	HF	Mx, MVR	Survived	[25]

GBS: Group B streptococcus; MSSA: Methicillin sensitive staphylococcus aureus; MV: Mitral valve; TV: Tricuspid valve; AV: Aortic valve; PV: Pulmonary valve; Mu: Multiple valves involved; S Ar: Septic arthritis; R Ar: Reactive arthritis; STE: Septic thromboembolism; SE: Septic embolism; 1^st HB: First degree heart block; VRA: Valve ring abscess; RHF: Right heart failure; PAA: Pulmonary artery aneurysm; HF: Heart failure; TR: Tricuspid regurgitation; AR: Aortic regurgitation; SI: Sacroilitis; Mx: Medical management; MVR: Mitral valve replacement; PVR: Pulmonary valve replacement; AVR: Aortic valve replacement; Emb: Embolectomy; TVR: Tricuspid valve replacement.

Table 2 Patients with takotsubo cardiomyopathy following medical termination of pregnancy

No.	Age, gestation	Clinical feature	TTC criteria: EKG and Trop; echo; coronary angiography negative; pheochromocytoma	Possible pathophysiology	Treatment given	Outcome: Mortality and EF repeat	Ref.
1	36 yr, 12 wk gestation	Misc; hypovolemia	ECG: ST and Trop T elevated; eCHO: TTE (35%) EF, hypok LV apex; coronary angiography: Negative	Catecholamine surge: (1) Direct toxicity; (2) Coronary vasoconstriction; and (3) Microvascular spasm	IV furosemide	5th d repeat echo: LV to EF: 60%. F/u: 11 mo, no relapse	[26]
2	22 yr, gestation: NA	Post Sx TOP with evacuation of retained POC; hypovolemia	EKG: Normal and Trop T elevated; 2D echo: DCM; coronary angiography: Negative	Catecholamine release post procedure	Diuretics. Bisoprolol and lisinopril	Echo: Repeat day 2 had EF 56%. Follow-up, full recovery	[27]
3	37 yr, Misc	Chest pain, radiating to the neck	EKG: ST depression, Trop T elevated; 2D echo: EF < 40%; coronary angiography: Negative	NA	NA	F/u echo EF normal. F/u Trop T normal	[28]
4	43 yr, gestation: NA	Chest pain	EKG: Normal and Trop T elevated; echo: LV hypokinesia, apical, diaphragmal, posterio-basal segments; coronary angiography: Negative	Stress factors: (1) H/o fetal death at 18 wk gestation; and (2) Domestic stress	Beta-blockers, ACE inhibitors, aspirin	5 d later, 2D echo EF 72%, normal wall movements. F/u: Developed 4 episodes of TTC, 6 mo, 9 mo, 10 mo, and 19 mo later. With eventual normalization of EF	[29]
5	43 yr, 9 wk gestation	Post Sx TOP. Shock, hypoxia, cardiac arrest requiring CPR	EKG: T wave inv, Trop T elevated; echo: LV EF 33%, LV apex hypo/akinesia; angiography: NA	h/o autoimmune diseases; post-op stress; cervical infiltration of epinephrine	Infusion of levosimendan	Echo: 3 mo later showed return of the LV function to normal	[30]
6	28 yr, 12 wk gestation	Chest pain	EKG: T wave inv, Trop T elevated; echo: EF (30%-35%); hypokinesia mid ventricular and hyperKinesia apical and basal wall; coronary angiography: Negative	Post abortion depression; suicidal ideation	Carvedilol. Lisinopril spironolactone	F/u echo: NA. Hemodynamically stable on follow-up	[31]
7	32 yr, 10 + 1 wk gestation; Misc	Abdominal pain, vaginal bleeding. Later underwent POC evacuation	EKG: Intermittent VT and QRS broadening. Trop T: NA; TTE: EF: 32%, global LV hypokinesia and akinesia of inferior and inferioseptal wall; coronary angiogra gestation phy: Negative	Septic miscarriage with blood C/S: Group C Streptococcus; amphetamine usage	IV antibiotics	Full recovery in 6 wk. 2D echo: Normal on repeat	[32]

Misc: Miscarriage; POC: Product of conception; Sx TOP: Surgical termination of pregnancy; CPR: Cardiopulmonary resuscitation; ST: Sinus tachycardia; DCM: Dilated cardiomyopathy; VT: Ventricular tachycardia; Post-op: Post-operation; EF: Ejection fraction; LV: Left ventricle; TTC: Takotsubo cardiomyopathy; TTE: Transthoracic echocardiography; NA: Not available; EKG: Electrocardiogram; C/S: Culture and susceptibility; F/u: Follow-up.

Table 3 Patients with spontaneous coronary artery dissection following medical termination of pregnancy

No.	Age	C/F and EKG	Labs and imaging	Angiography	Management and prognosis	Ref.
1	36 yr	Chest pain 2 wk post abortion. ECG: STE in V2-V4, STD in inferior leads	Cardiac biomarkers: Normal. Echo: Normal	Angiography: Type C dissection in LAD	Management: PCI with stenting to LAD. Survived, no similar episodes at follow-up after 8 mo	[33]
2	41 yr	2 wk post still birth, became unresponsive, cardiac arrest post CPR, ROSC. ECG: STE in leads 2, 3, avF	Cardiac biomarkers: Normal. Echo: Decreased LV contractility, EF: 30%	Angiography: Type 2 SCAD involving distal RCA	Management: Medical management. Survived post cardiac arrest, anoxic brain injury	[34]
3	33 yr	Chest pain 10 d post abortion. EKG: STE in inferior leads	Cardiac biomarkers: Increased	Angiography: Dissection involving RCA	Management: PCI. Survived	[35]
4	N/A	2 cases had SCAD a/w stillbirth and miscarriage	N/A	N/A	N/A	[36]

C/F: Clinical features; EKG: Electrocardiogram; N/A: Not applicable; STE: Sinus tachycardia elevation; STD: Sinus tachycardia depression; CPR: Cardiopulmonary resuscitation; ROSC: Return of spontaneous circulation; SCAD: Spontaneous coronary artery dissection; LV: Left ventricle; EF: Ejection fraction; LAD: Left anterior descending artery; RCA: Right coronary artery; PCI: Percutaneous coronary intervention.

Table 4 Patients with arrhythmia following medical termination of pregnancy

No.	Age	Clinical details	Arrythmia observed	Possible mechanism for arrythmia	Treatment given	Outcome	Ref.
1	NA, 2nd trimester	Induced by PGF2a	Bradycardia	Drug induced hypokalemia	NA	NA	[37]
2	32 yr, 20th wk gestation	Induced by PGF2a	Bradycardia and hypotension	PG acting on ventricular receptor	IV RL, 0.5 mg atropine no response	F/u 1 mo EKG and echo normal	[38]
3	37 yr, 10 wk gestation	In miscarriage	Bradyarrythmia	POC through cervix trigger vagal stimulation	POC removed	EKG normal on F/u	[39]
4	42 yr, 12 wk gestation	Miscarriage, with lower abdominal pain	Bradyarrythmia with hypotension. USG TVS: POC in UC	POC through cervix, triggering vagus	POC removed	BP and HR improved	[40]
5	Age: NA, 2nd trimester	Induced by PGF2α and IV oxytocin	Bradycardia, hypothermia and hypotension	Rupture of the cervix	NA	NA	[41]

PGF2a: Prostaglandin F2 alpha; NA: Not available; USG: Ultrasound; TVS: Transvaginal ultrasound; POC: Product of conception; UC: Uterine cavity; RL: Ringer lactate; F/u: Follow-up; EKG: Electrocardiogram; BP: Blood pressure; HR: Heart rate.