The Journal of Obstetrics and Gynecology of India (November–December 2016) 66(S2):S623–S625 DOI 10.1007/s13224-016-0905-z
CASE REPORT
Pregnancy with Complete Heart Block Kalpana Baghel1 • Zehra Mohsin1 • Swati Singh1 • Sandeep Kumar1 • Maaz Ozair1
Received: 29 December 2015 / Accepted: 12 April 2016 / Published online: 9 May 2016 Ó Federation of Obstetric & Gynecological Societies of India 2016
About the Author Kalpana Baghel is working as Assistant Professor in Obstetrics and Gynaecology at Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh. Her areas of interest are operative obstetrics, gynecological endoscopy and oncology.
Keywords Complete heart block Temporary pacemaker Permanent pacemaker
Dr. Kalpana Baghel M.S., D.N.B. (Obstetrics and Gynecology), Assistant Professor; Dr. Zehra Mohsin M.D. (Obstetrics and Gynecology), Associate Professor; Dr. Swati Singh M.D. (Medicine), Senior Resident, Cardiology Centre; Dr. Sandeep Kumar M.D. (Medicine), Senior Resident, Cardiology Centre; Dr. Maaz Ozair M.D. (Medicine), Senior Resident, Rajeev Gandhi Centre for Diabetes and Endocrinology, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, India. & Kalpana Baghel [email protected] 1
Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, India
123
Introduction Complete heart block is a conduction disorder characterized by a random relationship between the atrial and the ventricular activation where the atrial impulses are not conducted to the ventricle. The incidence of complete heart block (CHB) is estimated to be 1 in 15,000 to 20,000 live births [1]. It may be congenital or acquired. The acquired variety is rare during pregnancy as this type is mostly seen after 50 years of age [1]. However, the congenital variety is seen during pregnancy but that is also very rare and only few cases have been reported in the literature. Whenever encountered in a pregnant women, CHB presents a challenge for the obstetrician and calls for a multidisciplinary approach involving the cardiologist and anesthesiologist.
Baghel et al.
The Journal of Obstetrics and Gynecology of India (November–December 2016) 66(S2):S623–S625
Case Report A 24-year-old primigravida reported to the labor room with complaint of amenorrhea 9 months and labor pains since 5 h. She was 41 weeks 3 days of gestation by LMP. There were no antenatal visits, and the antenatal period was uneventful with no episode of syncopal attack or breathlessness during antenatal period. There was a significant past history of syncopal attacks during childhood and two episodes 3 years back also. On examination, she was conscious oriented with pulse rate of 40 beats/min and blood pressure of 130/88 mmHg. Her respiratory rate was 22 per minute, and chest was bilaterally clear. On CVS examination, S1 and S2 were normal with a pansystolic murmur heard at the area of apex radiating to the axilla. On per abdomen examination fundal height corresponded to 36 weeks with cephalic presentation. The fetal heart rate was regular, and she was having regular uterine contractions of moderate intensity every 3 min. On vaginal examination, os was closed with a firm cervix of around 3 cm. Pelvic examination revealed convergent sidewalls, borderline interischial diameter and TDO 3 knuckles. Her routine investigations revealed no abnormality. Biophysical profile revealed a 2.95-kg baby with 10/10 manning score. The diagnosis of complete heart block was confirmed by 12-lead ECG. The decision for cesarean section was taken in view of cephalopelvic disproportion. A multidisciplinary approach was taken, and temporary pacemaker paced at 60 beats/min was implanted through the transfemoral route. Cesarean section was done under general anesthesia. A healthy female baby of 3 kg with normal heart rate and normal Apgar score was delivered. Postoperative period was uneventful. On further workup for the cause of heart block ECHO revealed no abnormality. Antinuclear antibodies (ANA) were also negative. Permanent pacing was done on 5th postoperative day using single-chamber pacemaker in VVI mode paced at 60 beats/ min. Patient was discharged in good health on 10th postoperative day. Follow-up for next 3 months was uneventful, and she is still under regular follow-up (Fig. 1).
Discussion The incidence of CHB is around 1:15,000 to 1:20,000. CHB is usually asymptomatic without any specific problems during pregnancy. There are only few studies on pregnancy with CHB. In most of these studies, the pregnant women were asymptomatic during pregnancy except for Mandal et al. [2–4] who reported 21 pregnant women with complete heart block and found all of them to be symptomatic syncope and palpitation seen in 29 and 38 % women, respectively. CHB does not cause any specific
624
Fig. 1 X-ray with permanent pacemaker in situ
pregnancy-related problems except for few cases of IUGR and preterm delivery [2, 4]. The patient reported here also did not have any symptoms during the antenatal period, and no pregnancy-related complication was seen. No other complication like oligohydramnios or IUGR was seen in our case; however, Mandal et al. [2] reported complications like IUGR (14 %), oligohydramnios (7 %), preterm labor (11 %) in the 21 patients studied. Suri et al. [4] also reported IUGR in two out of the four cases studied with absent and reversed diastolic flow leading to a preterm delivery by cesarean section. There are different opinions regarding the need for pacemaker during pregnancy. Modi et al. [5] favored managing asymptomatic patients without pacemaker with emergency arrangements for pacing available. Hidaka et al. [6] suggested that pacemaker is not routinely required during labor in patients with AV block. Khardke et al. [7] recommended that temporary pacing should be done in patients with atropine-resistant bradycardia, first- and second-degree AV block and atrial fibrillation with low ventricular rate. Similarly, there is no definite recommendation regarding permanent pacing; however, some authors have suggested it to be done early in pregnancy as syncopal attacks could be life threatening and pacing may significantly reduce morbidity and mortality [8]. In the present case, temporary pacing was done by transfemoral route before cesarean and permanent pacing was done on
123
The Journal of Obstetrics and Gynecology of India (November–December 2016) 66(S2):S623–S625
postcesarean day 5 considering the history of syncopal attacks and to reduce the risk of development of mitral regurgitation later on. Suri et al. [3] also used temporary pacing support only in two out of the four cases at the time of labor and did permanent pacing postpartum in 3 of them as they presented with syncope. Similarly, Mandal et al. [2] reported delivery with pacemaker (either temporary or permanent) in 16 out of 21 cases and 5 required pacing postpartum. Although in this case cesarean section was done for cephalopelvic disproportion, the preferred mode in most other studies was vaginal. In the study done by Mandal et al., 86 % women had vaginal delivery and only 14 % underwent cesarean section for obstetrical indications. In their series of four patients with CHB, Suri et al. reported spontaneous vaginal delivery in two patients, while cesarean was done in other two cases, one for breech presentation and the other for reversed end-diastolic flow with oligohydramnios. Due to the sudden onset high sympathetic blockade spinal anesthesia often results in bradycardia which may be devastating for the patients with CHB. For this reason, use of incremental epidural or lowdose combined spinal and epidural has been recommended by most of the authors for any instrumental delivery or cesarean section [2, 4, 5]. The baby delivered in this case was a 3.0-kg baby with normal Apgar score. In most other studies also, no neonatal heart block has been seen [2–4]. Comment 1: Emergency resuscitative measures may be needed any time. To tackle such type of emergency, a complete team with a interventional cardiologist, anesthesiologist and gynecologist must be available all the time. Such patients should always be managed at well-equipped centers with intensive care facilities. Comment 2: Interventional cardiologist should be available. As the patients are at risk of mortality due to unpredictable syncope, emergency resuscitative measures should always be at hand with a interventional cardiologist present all the time as bradycardia unresponsive to drugs will need immediate pacing. This is particularly important at the time of labor when the cardiac demands are more and the patient is more prone to develop syncopal attacks due to slowing of heart rate associated with Valsalva maneuver [4]. Comment 3: Drugs indicated should be ready, and drugs contraindicated should be kept away. While managing such patients, particular attention should be given as to what drugs can aggravate the heart block and should be kept away from the patient. Drugs like labetalol (for preeclampsia) and nifedipine (for preterm labor) which are commonly used otherwise are contraindicated and should be kept away. If general anesthesia is planned in such patients, then drugs with least depressing effect on the heart should be preferred like ketamine for induction of
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anesthesia. Agents like fentanyl and suxamethonium have been reported to cause bradycardia and asystole so should be avoided. Drugs needed to increase the heart rate during sudden fall in rate or syncopal attack like atropine and isoproterenol should be kept at hand [9].
Conclusion Every syncope should be taken seriously. ECG is a very cheap, reliable and easily available tool to diagnose such a grave condition as CHB. This condition could be completely asymptomatic during pregnancy and diagnosed only at the time of labor when patient comes in contact with the health facilities for the first time. Once diagnosed, it needs a multidisciplinary approach for management involving obstetrician, anesthesiologist and cardiologist. At last, the importance of putting your hand on the patient’s pulse can never be undermined. Compliance with Ethical Standards Conflict of interest Kalpana Baghel, Zehra Mohsin, Swati Singh, Sandeep Singh, Maaz Ozair declare that they have no conflict of interest. Ethical Standards The case has been reported after taking informed consent from the patient. All study was in accordance with the ethical standards of the Institutional Ethical Committee of Jawaharlal Nehru Medical College, AMU, Aligarh.
References 1. Perloff JK. The clinical recognition of congenital heart disease. 6th ed. Philadelphia: Elsevier; 2003. 2. Mandal S, Mandal D, Sarkar A, et al. Complete Heart Block and Pregnancy Outcome: An Analysis from Eastern India. SOJ Gynaecol Obstet Womens Health. 2015;1(1):5. 3. Bangal V, Shinde K, Borawake S, et al. Cesarean section in a case of third degree heart block with severe hypertension. J MGIMS. 2012;17(i):52–4. 4. Suri V, Keepanasseri A, Aggarwal N, et al. Maternal complete heart block in pregnancy: Analysis of four cases and review management. J Obstet Gynaecol Res. 2009;35(3):434–7. 5. Modi MP, Butala B, Shah VR. Anaesthetic management of an unusual case of complete heart block for LSCS. Indian J Anaesth. 2006;50(1):43–4. 6. Hidaka N, Chiba Y, Kurita T, et al. Is Intrapartum temporary pacing required for women with complete atrioventricular block? An analysis of seven cases. BJOG. 2006;113(5):605–7. 7. Kharde VV, Patil VV, Vk Dhulkhand, et al. A parturient with complete heart block for cesarean section. J Anaeth Clin Pharmacol. 2010;26:401–2. 8. Michaelsson M, Jonzon A, Riesenfeld T. Isolated congenital complete atrioventricular block in adult life: a prospective study. Circulation. 1995;92(3):442–3. 9. Budzikowski AS. Third degree atrioventricular block medications. http://emedicine.medscape.com/article/162007-medication#4.
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CASE REPORT
Pregnancy with Complete Heart Block Kalpana Baghel1 • Zehra Mohsin1 • Swati Singh1 • Sandeep Kumar1 • Maaz Ozair1
Received: 29 December 2015 / Accepted: 12 April 2016 / Published online: 9 May 2016 Ó Federation of Obstetric & Gynecological Societies of India 2016
About the Author Kalpana Baghel is working as Assistant Professor in Obstetrics and Gynaecology at Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh. Her areas of interest are operative obstetrics, gynecological endoscopy and oncology.
Keywords Complete heart block Temporary pacemaker Permanent pacemaker
Dr. Kalpana Baghel M.S., D.N.B. (Obstetrics and Gynecology), Assistant Professor; Dr. Zehra Mohsin M.D. (Obstetrics and Gynecology), Associate Professor; Dr. Swati Singh M.D. (Medicine), Senior Resident, Cardiology Centre; Dr. Sandeep Kumar M.D. (Medicine), Senior Resident, Cardiology Centre; Dr. Maaz Ozair M.D. (Medicine), Senior Resident, Rajeev Gandhi Centre for Diabetes and Endocrinology, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, India. & Kalpana Baghel [email protected] 1
Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, India
123
Introduction Complete heart block is a conduction disorder characterized by a random relationship between the atrial and the ventricular activation where the atrial impulses are not conducted to the ventricle. The incidence of complete heart block (CHB) is estimated to be 1 in 15,000 to 20,000 live births [1]. It may be congenital or acquired. The acquired variety is rare during pregnancy as this type is mostly seen after 50 years of age [1]. However, the congenital variety is seen during pregnancy but that is also very rare and only few cases have been reported in the literature. Whenever encountered in a pregnant women, CHB presents a challenge for the obstetrician and calls for a multidisciplinary approach involving the cardiologist and anesthesiologist.
Baghel et al.
The Journal of Obstetrics and Gynecology of India (November–December 2016) 66(S2):S623–S625
Case Report A 24-year-old primigravida reported to the labor room with complaint of amenorrhea 9 months and labor pains since 5 h. She was 41 weeks 3 days of gestation by LMP. There were no antenatal visits, and the antenatal period was uneventful with no episode of syncopal attack or breathlessness during antenatal period. There was a significant past history of syncopal attacks during childhood and two episodes 3 years back also. On examination, she was conscious oriented with pulse rate of 40 beats/min and blood pressure of 130/88 mmHg. Her respiratory rate was 22 per minute, and chest was bilaterally clear. On CVS examination, S1 and S2 were normal with a pansystolic murmur heard at the area of apex radiating to the axilla. On per abdomen examination fundal height corresponded to 36 weeks with cephalic presentation. The fetal heart rate was regular, and she was having regular uterine contractions of moderate intensity every 3 min. On vaginal examination, os was closed with a firm cervix of around 3 cm. Pelvic examination revealed convergent sidewalls, borderline interischial diameter and TDO 3 knuckles. Her routine investigations revealed no abnormality. Biophysical profile revealed a 2.95-kg baby with 10/10 manning score. The diagnosis of complete heart block was confirmed by 12-lead ECG. The decision for cesarean section was taken in view of cephalopelvic disproportion. A multidisciplinary approach was taken, and temporary pacemaker paced at 60 beats/min was implanted through the transfemoral route. Cesarean section was done under general anesthesia. A healthy female baby of 3 kg with normal heart rate and normal Apgar score was delivered. Postoperative period was uneventful. On further workup for the cause of heart block ECHO revealed no abnormality. Antinuclear antibodies (ANA) were also negative. Permanent pacing was done on 5th postoperative day using single-chamber pacemaker in VVI mode paced at 60 beats/ min. Patient was discharged in good health on 10th postoperative day. Follow-up for next 3 months was uneventful, and she is still under regular follow-up (Fig. 1).
Discussion The incidence of CHB is around 1:15,000 to 1:20,000. CHB is usually asymptomatic without any specific problems during pregnancy. There are only few studies on pregnancy with CHB. In most of these studies, the pregnant women were asymptomatic during pregnancy except for Mandal et al. [2–4] who reported 21 pregnant women with complete heart block and found all of them to be symptomatic syncope and palpitation seen in 29 and 38 % women, respectively. CHB does not cause any specific
624
Fig. 1 X-ray with permanent pacemaker in situ
pregnancy-related problems except for few cases of IUGR and preterm delivery [2, 4]. The patient reported here also did not have any symptoms during the antenatal period, and no pregnancy-related complication was seen. No other complication like oligohydramnios or IUGR was seen in our case; however, Mandal et al. [2] reported complications like IUGR (14 %), oligohydramnios (7 %), preterm labor (11 %) in the 21 patients studied. Suri et al. [4] also reported IUGR in two out of the four cases studied with absent and reversed diastolic flow leading to a preterm delivery by cesarean section. There are different opinions regarding the need for pacemaker during pregnancy. Modi et al. [5] favored managing asymptomatic patients without pacemaker with emergency arrangements for pacing available. Hidaka et al. [6] suggested that pacemaker is not routinely required during labor in patients with AV block. Khardke et al. [7] recommended that temporary pacing should be done in patients with atropine-resistant bradycardia, first- and second-degree AV block and atrial fibrillation with low ventricular rate. Similarly, there is no definite recommendation regarding permanent pacing; however, some authors have suggested it to be done early in pregnancy as syncopal attacks could be life threatening and pacing may significantly reduce morbidity and mortality [8]. In the present case, temporary pacing was done by transfemoral route before cesarean and permanent pacing was done on
123
The Journal of Obstetrics and Gynecology of India (November–December 2016) 66(S2):S623–S625
postcesarean day 5 considering the history of syncopal attacks and to reduce the risk of development of mitral regurgitation later on. Suri et al. [3] also used temporary pacing support only in two out of the four cases at the time of labor and did permanent pacing postpartum in 3 of them as they presented with syncope. Similarly, Mandal et al. [2] reported delivery with pacemaker (either temporary or permanent) in 16 out of 21 cases and 5 required pacing postpartum. Although in this case cesarean section was done for cephalopelvic disproportion, the preferred mode in most other studies was vaginal. In the study done by Mandal et al., 86 % women had vaginal delivery and only 14 % underwent cesarean section for obstetrical indications. In their series of four patients with CHB, Suri et al. reported spontaneous vaginal delivery in two patients, while cesarean was done in other two cases, one for breech presentation and the other for reversed end-diastolic flow with oligohydramnios. Due to the sudden onset high sympathetic blockade spinal anesthesia often results in bradycardia which may be devastating for the patients with CHB. For this reason, use of incremental epidural or lowdose combined spinal and epidural has been recommended by most of the authors for any instrumental delivery or cesarean section [2, 4, 5]. The baby delivered in this case was a 3.0-kg baby with normal Apgar score. In most other studies also, no neonatal heart block has been seen [2–4]. Comment 1: Emergency resuscitative measures may be needed any time. To tackle such type of emergency, a complete team with a interventional cardiologist, anesthesiologist and gynecologist must be available all the time. Such patients should always be managed at well-equipped centers with intensive care facilities. Comment 2: Interventional cardiologist should be available. As the patients are at risk of mortality due to unpredictable syncope, emergency resuscitative measures should always be at hand with a interventional cardiologist present all the time as bradycardia unresponsive to drugs will need immediate pacing. This is particularly important at the time of labor when the cardiac demands are more and the patient is more prone to develop syncopal attacks due to slowing of heart rate associated with Valsalva maneuver [4]. Comment 3: Drugs indicated should be ready, and drugs contraindicated should be kept away. While managing such patients, particular attention should be given as to what drugs can aggravate the heart block and should be kept away from the patient. Drugs like labetalol (for preeclampsia) and nifedipine (for preterm labor) which are commonly used otherwise are contraindicated and should be kept away. If general anesthesia is planned in such patients, then drugs with least depressing effect on the heart should be preferred like ketamine for induction of
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Pregnancy with Complete Heart Block
anesthesia. Agents like fentanyl and suxamethonium have been reported to cause bradycardia and asystole so should be avoided. Drugs needed to increase the heart rate during sudden fall in rate or syncopal attack like atropine and isoproterenol should be kept at hand [9].
Conclusion Every syncope should be taken seriously. ECG is a very cheap, reliable and easily available tool to diagnose such a grave condition as CHB. This condition could be completely asymptomatic during pregnancy and diagnosed only at the time of labor when patient comes in contact with the health facilities for the first time. Once diagnosed, it needs a multidisciplinary approach for management involving obstetrician, anesthesiologist and cardiologist. At last, the importance of putting your hand on the patient’s pulse can never be undermined. Compliance with Ethical Standards Conflict of interest Kalpana Baghel, Zehra Mohsin, Swati Singh, Sandeep Singh, Maaz Ozair declare that they have no conflict of interest. Ethical Standards The case has been reported after taking informed consent from the patient. All study was in accordance with the ethical standards of the Institutional Ethical Committee of Jawaharlal Nehru Medical College, AMU, Aligarh.
References 1. Perloff JK. The clinical recognition of congenital heart disease. 6th ed. Philadelphia: Elsevier; 2003. 2. Mandal S, Mandal D, Sarkar A, et al. Complete Heart Block and Pregnancy Outcome: An Analysis from Eastern India. SOJ Gynaecol Obstet Womens Health. 2015;1(1):5. 3. Bangal V, Shinde K, Borawake S, et al. Cesarean section in a case of third degree heart block with severe hypertension. J MGIMS. 2012;17(i):52–4. 4. Suri V, Keepanasseri A, Aggarwal N, et al. Maternal complete heart block in pregnancy: Analysis of four cases and review management. J Obstet Gynaecol Res. 2009;35(3):434–7. 5. Modi MP, Butala B, Shah VR. Anaesthetic management of an unusual case of complete heart block for LSCS. Indian J Anaesth. 2006;50(1):43–4. 6. Hidaka N, Chiba Y, Kurita T, et al. Is Intrapartum temporary pacing required for women with complete atrioventricular block? An analysis of seven cases. BJOG. 2006;113(5):605–7. 7. Kharde VV, Patil VV, Vk Dhulkhand, et al. A parturient with complete heart block for cesarean section. J Anaeth Clin Pharmacol. 2010;26:401–2. 8. Michaelsson M, Jonzon A, Riesenfeld T. Isolated congenital complete atrioventricular block in adult life: a prospective study. Circulation. 1995;92(3):442–3. 9. Budzikowski AS. Third degree atrioventricular block medications. http://emedicine.medscape.com/article/162007-medication#4.
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