Bradyarrhythmias in pregnancy: a case report and review of management

Anesthetic Considerations for Cesarean Delivery in a Patient With Third-Degree Heart Block: A Case Report

Congenital third-degree complete heart block (CHB) detected during pregnancy is a rare condition. This report discusses a pregnant patient with an incidental finding of CHB and its implications for maternal and fetal outcomes. A 21-year-old female patient, gravida 2 para 0 (G2P0010), first registered at five weeks, two days gestation, with an incidental finding of third-degree heart block. Her baseline heart rate of 40-50 beats per minute, with no prior cardiac diagnosis. She had a history of miscarriage at six weeks' gestation. During the current pregnancy, she experienced two episodes of dizziness upon standing, each resolving within a minute without signs of hemodynamic instability. A 12-lead EKG and 24-hour Holter monitoring confirmed CHB, and echocardiography ruled out secondary causes. Cardiology and electrophysiology recommended temporary transcutaneous pacing and bedside atropine in case of instability. CHB in pregnancy is often congenital and characterized by independent ventricular activity due to atrial stimulus blockage. While typically asymptomatic, symptoms such as dizziness, hypotension, syncope, severe bradycardia, and cardiac arrest can occur. Pregnancy and labor stress, including the Valsalva maneuver, can exacerbate bradyarrhythmia, leading to adverse outcomes. Inadequate fetal perfusion and oxygenation can result in fetal bradycardia and hypoxia. Management requires a multidisciplinary approach, with echocardiograms, Holter monitoring, and, in some cases, cardiac MRI to rule out structural heart disease. Asymptomatic patients with good functional capacity may avoid permanent pacemakers, though temporary pacing is considered on a case-by-case basis. Neuraxial anesthesia is preferred for cesarean delivery in both symptomatic and asymptomatic CHB patients due to its minimal impact on myocardial function. General anesthesia should be avoided when possible. If necessary, anesthetic agents with minimal cardiac depression, such as ketamine, etomidate, rocuronium, and isoflurane, are recommended. Assisted early deliveries, such as vacuum or forceps, can help reduce the risk of Valsalva-induced bradycardia. Asymptomatic CHB cases without significant heart disease typically have favorable outcomes. However, careful cardiovascular monitoring and individualized care plans are essential to mitigate potential complications. Postpartum cardiology follow-up is necessary to assess the development of new symptoms and determine the need for a permanent pacemaker. This case highlights the importance of early diagnosis, adequate monitoring, early elective delivery, and multidisciplinary management in CHB during pregnancy. Neuraxial anesthesia and strategic labor management are key to ensuring positive maternal and fetal outcomes. Further research is needed to develop standardized guidelines for this rare condition.

Post-partum maternal bradycardia: A case series and literature review

Background

Unlike tachyarrhythmias, which are common in pregnancy, there is a paucity of data regarding maternal bradycardias. Our objective was to describe the characteristics, associated conditions, and prognosis of women who develop bradycardia post-partum.

Method

We conducted a retrospective chart review of patients referred to the Obstetrical Medicine service at British Columbia Women's Hospital from January 2012 to May 2020 for post-partum maternal bradycardia.

Results

Twenty-four patients with post-partum bradycardia were included (age 34.2  ±  4.8 years; heart rate 40.4  ±  8.1 beats per minute; blood pressure 131/72 mm Hg). Sinus bradycardia (79.2%) was the most common rhythm. Dyspnea (29.4%) and chest pain (23.5%) were common symptoms. Mean time to resolution of bradycardia was 3.6  ±  3.8 days. Associated conditions potentially explaining the bradycardia were preeclampsia (54.1%), underlying (16.7%), medications (8.3%), and neuraxial anesthesia (8.3%).

Conclusions

Maternal bradycardia is an uncommon condition complicating the post-partum period, that is generally self-limiting, with the majority only require clinical observation.

Management of Complete Heart Block in a Pregnant Woman with Systemic Lupus Erythematosus-Associated Complications: Treatment Considerations and Pitfalls

We present a case of a pregnant woman with systemic lupus erythematosus (SLE) who was diagnosed with asymptomatic complete heart block (CHB) during pregnancy. To evaluate possible risks and benefits of pacemaker (PM) implantation, a multidisciplinary counselling board was held. Its recommendation was to perform PM implantation to prevent intra-uterine growth restriction from insufficient cardiac output using a fluoroscopic protective shield. The procedure was performed without complications and established permanent pacing on onwards ECG examinations. The patient subsequently gave birth to a healthy newborn. After a retrospective clinical case evaluation and review of relevant literature, a presumptive association between CHB and the primary diagnosis was proposed. Above that, pregnant women with SLE who develop hypertension are commonly treated with methyldopa, which may cause conduction abnormalities. Clinical recommendations for young female patients expecting pregnancy are lacking in this area. Careful diagnostic and treatment approaches should be used in the management of possible SLE-related complications in women of child-bearing age, focusing on preventable events.

Diagnosis and management of arrhythmias in pregnancy

Arrhythmias are the most common cardiac complications occurring in pregnancy. Although the majority of palpitations in pregnancy may be explained by atrial or ventricular premature complexes, the full spectrum of arrhythmias can occur. In this article, we establish a systematic approach to the evaluation and management of arrhythmias in pregnancy. Haemodynamically unstable arrhythmias warrant urgent cardioversion. For mild cases of benign arrhythmia, treatment is usually not needed. Symptomatic but haemodynamically stable arrhythmic patients should first undergo a thorough evaluation to establish the type of arrhythmia and the presence or absence of structural heart disease. This will ultimately determine the necessity for treatment given the potential risks of anti-arrhythmic pharmacotherapy in pregnancy. We will discuss the main catalogue of anti-arrhythmic medications, which have some established evidence of safety in pregnancy. Based on our appraisal, we provide a treatment algorithm for the tachyarrhythmic pregnant patient.

Atrioventricular Block in Pregnancy: 15.8 Seconds of Asystole

Atrioventricular (AV) block in pregnancy is infrequently encountered and there is little management guidance available. We present a case of a 24-year-old G3P1011 at 24 weeks' gestation who presented to the obstetrics and gynecology clinic complaining of palpitations, fatigue, and dyspnea on exertion. Cardiology workup including an electrocardiogram (ECG) and Holter monitor detected second-degree type II (Mobitz) AV block with the longest asystole event lasting 15.8 seconds. 

A St. Jude's dual-chamber pacemaker (Abbott Laboratories, Abbott Park, IL) was implanted immediately. Standard radiation precautions were taken with additional shielding for the fetus. The patient experienced significant improvement in her symptoms. The patient went into labor at 37 3/7 weeks. Due to non-reassuring fetal heart tones, a cesarean section was performed, and a healthy baby girl was born. 

The management of heart block in pregnancy can be divided into involving those who are symptomatic and those who are asymptomatic. Symptoms of heart block can include palpitations, fatigue, dyspnea, and/or syncope; the presence of these symptoms warrants the placement of a pacemaker, preferably during pre-pregnancy or during the first two trimesters, as high-grade heart block is associated with significant mortality. Those who are in their last trimester or postpartum should consider the use of a temporary pacemaker as heart block could be due to pregnancy-related cardiovascular changes. 

For women with heart block, labor and delivery could result in worsening of bradycardia due to uterine contractions displacing blood into the central circulation. Most women with heart block do well in labor and delivery and having a pacemaker is not necessarily an indication for a cesarean section.

Congenital complete heart block in the setting of severe pre-eclampsia requiring urgent cesarean section

Congenital complete heart block is a rare phenomenon that may be discovered during pregnancy in patients who were previously asymptomatic. Peripartum management of these patients mandates a multidisciplinary approach with careful planning regarding indications for pacing, appropriate anesthetic technique, and contingency planning. Approaches to anesthetic management for congenital complete heart block have been described, but management in association with severe pre-eclampsia has not been reported. We describe the anesthetic management of a parturient with complete heart block who presented with severe pre-eclampsia requiring urgent cesarean section.

Cesarean section under spinal anesthesia in acquired complete atrioventricular block without a pacemaker: A case report

Pregnancy with complete atrioventricular block is rare, and its perioperative management is controversial. We successfully managed cesarean section in a pregnancy with acquired complete atrioventricular block under spinal anesthesia without a pacemaker. Asymptomatic pregnant women with acquired complete atrioventricular block can tolerate cesarean section under spinal anesthesia without a pacemaker.

Anaesthetic management of pregnant patients with cardiac implantable electronic devices: case reports and review

Heart disease is a leading cause of maternal mortality and morbidity. Pregnant women with structural, conduction or degenerative cardiac disease who require rhythm control or who are at high risk of sudden cardiac death may carry a cardiac implantable electronic device or may occasionally require the insertion of one during their pregnancy. These women are now encountered more frequently in clinical practice, and it is essential that a multidisciplinary approach, beginning from the early antenatal phase, be adopted in their counselling and management. Contemporary cardiac rhythm control devices are a constantly evolving technology with increasingly sophisticated features; anaesthetists should therefore have an adequate understanding of the principles of their operation and the special considerations for their use, in order to enable their safe management in the peripartum period. Of particular importance is the potential adverse effect of electromagnetic interference, which may cause device malfunction or damage, and the precautions required to reduce this risk. The ultimate goal in the management of this patient subgroup is to minimise the disruption to cardiovascular physiology that may occur near the time of labour and delivery and to control the factors that impact on device integrity and function. We present the ante- and peripartum management of two pregnant women with an implantable cardioverter-defibrillator, followed by a review and update of the anaesthetic management of parturients with cardiac implantable electronic devices.

Heart Disease and Pregnancy

Cardiac disease remains a major cause of morbidity and mortality in pregnant and post-partum women, although progress has been made, with specialist joint obstetric-cardiology clinics providing an integrated, safe and personalised service to these women. As a result, fewer non-specialist cardiologists are managing women in pregnancy with cardiovascular disease. The aim of this review is to provide a brief overview of current knowledge and practice in the field, with an emphasis on the major physiological changes which occur during pregnancy, focussing on progress through the trimesters, clinical assessment in pregnancy, management of delivery (concentrating on managed vaginal delivery), drug treatment, key conditions and risk assessment. The latter factor is particularly important in terms of being able to identify high-risk women earlier and to counsel them appropriately. Pregnant women with cardiovascular conditions can, with appropriate knowledge and counselling, be managed safely in specialist multidisciplinary services, but there is a need for cardiologists to understand the key changes and risks involved in pregnancy, delivery and the post-partum period.

Complete heart block in pregnancy: case report, analysis, and review of anesthetic management

Maternal complete heart block can pose significant challenges for the anesthesiologist in the antepartum, peripartum, and postpartum periods. Some patients may present for the first time in the puerperium with dizziness, weakness, syncope, or congestive heart failure as a result of the additional hemodynamic burden that accompanies pregnancy. Although there is an increase in permanent pacemaker placement in young symptomatic patients before pregnancy, prophylactic placement of pacemakers in asymptomatic parturients is not always indicated. The need for temporary or permanent pacemakers in asymptomatic women should be assessed on a case-by-case basis; many of these patients may be safely managed during labor and delivery without pacing. The parturient with complete heart block must be followed vigilantly during pregnancy and post delivery, as the need for pacemaker insertion can also arise in the postpartum period. We present a case of third-degree heart block in a 26-year-old parturient.

Peri-operative management of hysterostomy in a parturient with complete heart block, placenta accreta and intrauterine death

BACKGROUND

Complete heart block in pregnancy has serious implications particularly during the period of delivery. This is more so if the delivery is an operative one as the presence of heart block may produce haemodynamic instability in the intra operative period. We report a unique case of a pregnant mother with complete heart block undergoing hysterostomy, complicated by placenta accreta and intrauterine death.

CASE PRESENTATION

A 37 year old Malaysian Chinese parturient was admitted at 25 weeks gestation following a scan which suggested intrauterine death and placenta accreta. She was diagnosed to have congenital complete heart block after her first delivery eight years previously but a pacemaker was never inserted. These medical conditions make her extremely likely to experience massive bleeding and haemodynamic instability. Among the measures taken to optimise her pre-operatively were the insertion of a temporary intravenous pacemaker and embolization of the uterine arteries to minimize peri-operative blood loss. She successfully underwent surgery under general anesthesia, which was relatively uneventful and was discharged well on the fourth post-operative day.

CONCLUSION

Congenital heart block in pregnancies in the presence of potential massive bleeding is best managed by a team, with meticulous pre-operative optimization. Suggested strategies would include insertion of a temporary pacemaker and embolization of the uterine arteries to reduce the risk of the patient getting into life threatening situations.