LETTERS TO EDITOR
Year : 2019 | Volume
| Issue : 3 | Page : 274-276
Cesarean delivery in congenital heart block and need of temporary pacing: A case report
Sumit Soni, Amarjyoti Hazarika
Department of Anaesthesiology and Intensive Care, PGIMER, Chandigarh, India
Dr. Amarjyoti Hazarika
Department of Anaesthesiology and Intensive Care, PGIMER, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
|Date of Web Publication||26-Jun-2019|
|How to cite this article:|
Soni S, Hazarika A. Cesarean delivery in congenital heart block and need of temporary pacing: A case report. Saudi J Anaesth 2019;13:274-6
|How to cite this URL:|
Soni S, Hazarika A. Cesarean delivery in congenital heart block and need of temporary pacing: A case report. Saudi J Anaesth [serial online] 2019 [cited 2019 Dec 7];13:274-6. Available from: http://www.saudija.org/text.asp?2019/13/3/274/260802
The management of pregnant women with complete heart block (CHB) presenting during pregnancy and without pacing remains debatable. To bear up against any hemodynamic variations in peripartum period, temporary pacemakers have been advocated by some authors. However, because of scarcity of literature, the necessity of temporary pacemaker has not been assessed objectively. Herein, we discuss the successful management of a pregnant woman with congenital CHB for emergency cesarean delivery under spinal anesthesia (SA) without temporary pacing.
A 24-year-old primigravid of 39 weeks and 5 days referred to our hospital with oligohydramnios and increased BP. On examination, her heart rate (HR) was 48 BPM, and blood pressure was 140/96 mmHg. In electrocardiogram (ECG), sinus bradycardia with narrow QRS complexes was seen, suggestive of CHB. There was no history of syncope, presyncope, or palpitations, and she was not on any medications that explained her current vitals. On echocardiography, all the parameters were found to be within normal limits. During labor pains, her HR varied between 45 and75 BPM. Initial plan was to augment labor with injection oxytocin without temporary pacing. In the meantime, non reassuring CTG was detected with variable and early decelerations. Plan was changed to perform emergency cesarean section under SA with temporary pacemaker kept available if bradycardia or syncope occurred. Transcutaneous pacing pads were also applied. SA was given with injection bupivacaine 0.5% heavy 1.8 ml in L3-L4 space. Surgery was started after achieving a sensory block level up to T6 on pinprick. ECG, pulse oxymetry, and invasive BP were monitored. A vigorous baby was delivered with Apgar score of 9/10 at 1 min and 10/10 at 5 min and was handed over to the attending pediatrician. Intraoperatively, HR remained above 50 BPM and surgery got completed uneventfully. Postoperatively, continuous monitoring was done, and she was discharged on seventh postoperative day uneventfully.
CHB detected for the first time during pregnancy is rare. CHB may be congenital or acquired. Prognosis in patients with acquired heart block is generally worse, whereas isolated congenital CHB is relatively benign with narrow QRS complexes on ECG. In isolated congenital CHB, the block to conduction is at the level of AV node, and the ventricular conduction remains intact, therefore, QRS complexes in ECG are narrow. The rate is relatively high and can vary from 40–80 BPM. Rate may increase with exercise, atropine, or sympathomimetics, whereas in acquired CHB, the AV junction or bundle branches are usually involved. QRS complexes in ECG are wide, and the rate is lower and is not increased by exercise or atropine. Our case was detected with congenital CHB. In most studies of pregnancy with CHB, patients were asymptomatic excepting one, which reported 29% incidence of syncope and 38% of palpitations. CHB has been associated with IUGR (14%), preterm delivery (11%), and oligohydramnios (7%) but has not been linked to any other pregnancy related complication so far. The data regarding the incidence of cesarean section among those with CHB is limited. In the study of 21 symptomatic patients by Mandal et al., 3 patients required cesarean section for obstetric indications. In another case series of 4 patients, 2 patients underwent cesarean section. In asymptomatic cases, without significant underlying heart disease feto-maternal outcome is favorable. Permanent pacemaker is indicated if the patient becomes symptomatic.
Although pacing in symptomatic patients has been demonstrated clearly, in asymptomatic patients guidelines are not clear because of scarcity of data. Our patient was asymptomatic, and HR was responsive to labor pains, so we planned cesarean delivery without temporary pacemaker though we were well prepared with temporary pacemaker available in case any complication occurred.
As regard to the most appropriate anesthetic technique for cesarean delivery in pregnant patients with CHB, there are no specific recommendations.
Most authors recommend use of graded epidural or low dose spinal with epidural to avoid the sudden onset sympatholysis that can occur with SA, which can potentially worsen the hemodynamic condition because those with CHB may not compensate with an increase in HR.,, However, despite these theories, in our case, the surgery proceeded uneventfully under low dose subarachnoid block with invasive hemodynamic monitoring and a back up temporary pacemaker in hand.
Post-partum period monitoring is also important in these patients. After delivery, some of the cardiovascular changes that occur during pregnancy, such as hemodilution, increased blood volume, and peripheral vascular resistance, revert to pre-pregnancy levels. These altered hemodynamic variables can worsen the symptoms and may require permanent pacing. Our patient was discharged on seventh post-operative day uneventfully and is under regular follow-up.
In conclusion, the approach to manage a parturient with CHB presenting for cesarean section should be multidisciplinary with close invasive monitoring, hemodynamic support, and regional anesthetic techniques. In such cases, we would recommend a multi-disciplinary team approach including an interventional cardiologist. All the necessary chronotropic (atropine and isoproterenol), inotropic, and pressor agents should be kept at hand while keeping drugs such as beta-blockers (used in hypertensive disorders of pregnancy) away from the working area. If general anesthesia is planned, agents such as ketamine and etomidate may be preferred, and succinylcholine must be used cautiously as it can cause bradycardia. To avoid polypharmacy, regional anesthesia would be preferable. It is hoped that our experience will assist others in the management of such patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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