ischemic heart disease is rare during pregnancy , occurring in approximately one in 10,000 live births . the risk of myocardial infarction ( mi ) in pregnancy is reported from one per 37,500 to 6.2 per 100,000 deliveries.13 the diagnosis is by clinical findings , electrocardiogram ( ecg ) , and measurement of the serum level of the cardiac specific contractile protein , troponin 1.4 , 5 the most common forms of angina are stable and unstable angina , which are usually due to atherosclerosis . but coronary spasm , coronary dissection , and thrombus have been reported as other causes.6 , 7 prinzmetal s angina ( variant angina ) is rare and it accounts for only 2 out of every 100 cases of angina . we report a pregnant woman who presented with signs and symptoms of acute mi and whose ecg findings and troponin 1 level were compatible with mi , leading to the final diagnosis of prinzmetal s angina . a 35-year - old woman , gravid 3 ( with a history of two cesarean section operations ) , developed acute mi at the 30 week of gestation . she was a non - smoker and had no history of drug abuse or systemic disease . she referred to the emergency ward due to a sudden , severe pain in the neck and between the two scapulas that had started during sleep at 5 am , with cold sweat and nausea . her blood pressure was 200/150 mm hg ; she had a history of increased blood pressure of two weeks duration . the patient also had tachycardia , rales in the bases of the lungs , signs of anteroseptal mi in the ecg ( figure 1 ) , and increased troponin 1 blood level . we performed a cesarean section operation because of severe preeclampsia , repeat cesarean section , and transverse lie . four days after delivery , the patient s blood pressure was 140/80 mmhg and coronary angiography showed total occlusion of the second obtuse marginal artery ( om2 ) in addition to diffuse spasm of the left circumflex coronary artery ( lcx ) ( figure 2 ) . at the seventh day after delivery in the ward , the patient had chest pain and st - segment elevation in the inferior leads ( figure 3 ) as well as signs of pulmonary edema . the ecg changes reversed after intravenous trinitroglycerin ( figure 4 ) . based on the ecg , the diagnosis was inferior wall ischemia . we performed angiography for a second time and surprisingly the lcx and om2 coronary arteries were normal and there was narrowing in the rca ( figure 5 ) . we conclude that this discrepancy between the first and second ecgs and angiographic findings were due to prinzmetal s angina . a few days later , the patient was discharged ( blood pressure = 130/80 mmhg ) on diltiazem , atorvastatin , captopril , nitrocontin , furosemide , and clopidogrel while the ecg showed previous anteroseptal mi ( figure 6 ) . an ecg three months after discharge showed the same findings too ( figure 7 ) . mi in pregnancy is rare but can produce significant maternal and neonatal morbidity . prompt diagnosis and immediate therapy are necessary to lower the high likelihood of the mortality of mother and fetus . the highest incidence of mi seems to occur in the third trimester and in multigravidas older than 33 years old . acute mi in pregnancy is commonly located in the anterior wall , and acute maternal death rate is reported to be 1930%.13 , 8 complications of pregnancy that are significantly associated with acute mi are preeclampsia , postpartum hemorrhage , postpartum infection , and fluid and electrolyte imbalance.1 , 9 shock from postpartum hemorrhage,10 ergonovine,11 and prostaglandin e1 ( pge1)12 is reported as a risk factors for mi in pregnancy . our patient was a 35-year - old , obese , multiparous , pregnant woman with preeclampsia , and her symptoms of mi appeared at rest in the early hours of morning . prinzmetal s angina usually occurs at rest and happens between the midnight and early morning . people with prinzmetal s angina are often younger than those with the other forms of angina . the gold standard for diagnosis is coronary angiography with injection of provocative agents ( like ergonovine ) into the coronary arteries . . also administration of intracoronary nitroglycerin in cases of vasospasm can cause marked diffuse vasodilatation.13 treatment with calcium - channel blockers or nitrates eliminates spasm in most of these patients . in our patient , the discrepancy between the first and second angiographic findings was the confirmatory evidence that she had prinzmetal s angina . this conclusion was derived from the fact that the first angiographic examination showed that the lad coronary artery was normal despite the definite occurrence of an mi in its territory , thus suggesting transient spasm . furthermore , a subsequent bout of inferior wall ischemia with confirmation of transient spasm by angiography was another piece of confirmatory evidence . last but not least , asymptomatic rca spasm , detected in the last angiography , was another clue to the propensity of the coronary arteries to vasospasm , which is the sine qua non of prinzmetal s angina .
acute myocardial infarction ( mi ) during pregnancy is rare and mi due to prinzmetal s angina is much rarer . 
 we present a 35-year - old , obese , multigravida , and pre - eclamptic woman , who developed acute anterior wall mi at the 30th week of gestation . on coronary angiography , 
 the second obtuse marginal branch was totally occluded and the right coronary artery ( rca ) was normal . 
 three days later , she had chest pain and st elevation in the inferior leads . on second angiography , there was narrowing in the rca , while the obtuse marginal branch was patent . 
 we presume that this discrepancy between the first and second electrocardiograms and angiographic findings was due to prinzmetal s angina .