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Joglar JA, Kapa S, Saarel EV, Dubin AM, Gorenek B, Hameed AB, Lara de Melo S, Leal MA, Mondésert B, Pacheco LD, Robinson MR, Sarkozy A, Silversides CK, Spears D, Srinivas SK, Strasburger JF, Tedrow UB, Wright JM, Zelop CM, Zentner D. 2023 HRS expert consensus statement on the management of arrhythmias during pregnancy. Heart Rhythm 2023; 20:e175-e264. [PMID: 37211147 DOI: 10.1016/j.hrthm.2023.05.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 05/23/2023]
Abstract
This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.
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Affiliation(s)
- José A Joglar
- The University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Elizabeth V Saarel
- St. Luke's Health System, Boise, Idaho, and Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | | | | | | | | | | | | | - Luis D Pacheco
- The University of Texas Medical Branch at Galveston, Galveston, Texas
| | | | - Andrea Sarkozy
- University Hospital of Antwerp, University of Antwerp, Antwerp, Belgium
| | | | - Danna Spears
- University Health Network, Toronto, Ontario, Canada
| | - Sindhu K Srinivas
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | - Carolyn M Zelop
- The Valley Health System, Ridgewood, New Jersey; New York University Grossman School of Medicine, New York, New York
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2
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Christensen AP, Singh V, England AJ, Khiani R, Herrey AS. Management and complications of complete heart block in pregnancy. Obstet Med 2023; 16:120-122. [PMID: 37441659 PMCID: PMC10334037 DOI: 10.1177/1753495x211033489] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 06/07/2021] [Indexed: 04/13/2024] Open
Abstract
Although rare, increasing numbers of women with pacemakers are becoming pregnant. We describe the complications of a woman with arrhythmia and a pacemaker for complete heart block experienced before, during, between and after her pregnancies. We illustrate the benefits of multidisciplinary care, good communication and regular assessment in a stable, but complex woman.
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Affiliation(s)
- AP Christensen
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - V Singh
- Department of Obstetrics & Gynaecology, Royal Free Hospital NHS Foundation Trust, London, UK
| | - AJ England
- Department of Anaesthesia, Royal Free Hospital NHS Foundation Trust, London, UK
| | - R Khiani
- Department of Cardiology, Royal Free Hospital NHS Foundation Trust, London, UK
| | - AS Herrey
- Department of Cardiology, Royal Free Hospital NHS Foundation Trust, London, UK
- Department of Cardiology, Bartshealth NHS Trust, London, UK
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3
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Management of Complete Heart Block in a Pregnant Woman with Systemic Lupus Erythematosus-Associated Complications: Treatment Considerations and Pitfalls. Medicina (B Aires) 2022; 59:medicina59010088. [PMID: 36676711 PMCID: PMC9864118 DOI: 10.3390/medicina59010088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 12/15/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023] Open
Abstract
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.
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Wang K, Xin J, Huang G, Wang X, Yu H. Pregnancy maternal fetal outcomes among pregnancies complicated with atrioventricular block. BMC Pregnancy Childbirth 2022; 22:307. [PMID: 35399072 PMCID: PMC8994888 DOI: 10.1186/s12884-022-04650-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 04/04/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Atrioventricular block (AVB) during pregnancy is rare. Case study for pregnancy with AVB have been reported but a consensus guideline for peripartum management has not been established. This study aimed to investigate cardiac and obstetric complications and outcomes in our pregnant women with AVB and share our management experience.
Methods
This was a retrospective study. We reviewed a total of 74 pregnant women with AVB who delivered at our tertiary care center in the past 10 years. The patients were categorized into four groups according to the degree of block. The data were analyzed and compared among the four groups of patients.
Results
Regarding the cardiac complications, the cardiac function level showed significant difference among patient groups. The higher NYHA class were observed in patients with higher degree AVB. Pacemaker was placed before delivery in 32/33 patients with III° AVB, 8/25 patients with II° AVB, and 0/16 patient with I° AVB. Other types of arrhythmias except AVB were present in all groups of patients but more frequently observed in type I patients with II° AVB. No other heart abnormalities were observed among the patient groups. Obstetric complications were found in 21 women (28.4%), including premature labor, premature rupture of membranes (PROM), gestational diabetes mellitus (GDM), preeclampsia, etc. The incidence rate of fetal cardiac abnormalities was 6.58%. But no statistical difference was detected among four groups of patients for fetal and maternal complications and fetal cardiac abnormalities (P>0.05). Caesarean section was performed more in patients with high-degree AVB than in patients with low-degree AVB. No maternal or neonatal death in our cases.
Conclusions
Most women with AVB could achieve successful pregnancy and delivery. Patients with II° AVB type II and III° AVB should be monitored vigilantly during pregnancy and post-partum. Temporary pacing before delivery appeared to be beneficial for women with III°AVB, and accurate diagnosis and care by a multidisciplinary team was recommended.
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Irianti S, Tjandraprawira KD, Sumawan H, Karwiky G. Total atrioventricular block in pregnancy -Case report. Ann Med Surg (Lond) 2022; 75:103441. [PMID: 35386776 PMCID: PMC8977913 DOI: 10.1016/j.amsu.2022.103441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/25/2022] [Accepted: 02/28/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction and importance Bradycardia in pregnancy due to total atrioventricular block (TAVB) is a rare occurrence, often asymptomatic and may arise from a congenital disorder. Pacemaker is often required. Cases are few and management is not yet standardised. Case presentation A 24-year-old G2P0A1 of 9 months gestation presented with labor pains. She had had history of bradycardia diagnosed since a year prior but had not undergone tests nor received treatments. Her heart rate was 55-60 x/minute, her cardiotocography was reassuring and electrocardiogram revealed a TAVB with ventricular escape rhythm. As she had not had a pacemaker, an urgent cardiologist consultation was arranged during which a temporary pacemaker was installed. She underwent a caesarean section with general anaesthesia after which she had an uneventful recovery.A 38-year-old G2P1A0 of 2 months of gestation presented with slow heart rhythm and a history of asthma to the outpatient clinic. She also had not undergone tests nor received medication. At presentation, her heart rate was 48 x/minute and her ECG revealed a TAVB with junctional escape rhythm. She had a pacemaker installed at 8 months of gestation and subsequently underwent an elective caesarean section at 37 weeks under regional anaesthesia. She had an uneventful recovery afterwards. Clinical discussion TAVB in pregnancy requires a concerted effort involving obstetricians, cardiologists, and intensivists. Pacemaker implantation is recommended. Whilst vaginal delivery remains first-choice, caesarean section is indicated under obstetric indications. Conclusion Screening, early recognition, risk stratification and thorough planning are required to successfully manage TAVB in pregnancy.
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Affiliation(s)
- Setyorini Irianti
- Department of Obstetrics and Gynecology, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Kevin Dominique Tjandraprawira
- Department of Obstetrics and Gynecology, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Herman Sumawan
- Department of Obstetrics and Gynecology, Universitas Jendral Soedirman, Prof. Margono Soekarjo General Hospital, Purwokerto, Indonesia
| | - Giky Karwiky
- Department of Cardiology, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
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6
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Abstract
Pregnancy with complete heart block is rare, its management is not streamlined and requires a multidisciplinary team approach involving the obstetrician, cardiologist, anaesthesiologist and neonatologist. High index of suspicion in a woman with slow heart rate and electrocardiographic examination will ensure the diagnosis of this condition. Such patient can be managed conservatively or may require temporary or permanent pacemaker implantation. We present a 26-year-old primigravida with complete heart block at term pregnancy. She was asymptomatic throughout her pregnancy with pulse rate between 50 and 60 beats per minute. Vaginal delivery was planned under continuous ECG monitoring. Isoprenaline drip and temporary pacemaker were kept stand-by. However, for obstetric reasons caesarean section was performed successfully under spinal anaesthesia without a pacemaker. Method of anaesthesia was planned to keep the haemodynamics stable and drugs causing bradycardia were avoided.
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Affiliation(s)
- Sasmita Swain
- Obstetrics and Gynaecology, SCB Medical College & Hospital, Cuttack, Odisha, India
| | | | - Sandhyarani Behera
- Obstetrics and Gynaecology, SCB Medical College & Hospital, Cuttack, Odisha, India
| | - Swayamsiddha Mohanty
- Obstetrics and Gynaecology, SCB Medical College & Hospital, Cuttack, Odisha, India
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Hogan AM, Christmas T, Missfelder-Lobos H, Wilson A, Belham M. The anesthetist as cardiologist: a case of heart block identified in the peripartum period. Int J Obstet Anesth 2020; 44:101-105. [PMID: 32931999 DOI: 10.1016/j.ijoa.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/29/2020] [Accepted: 08/16/2020] [Indexed: 11/30/2022]
Abstract
We describe a case of undiagnosed heart block which was detected during the postpartum surgical repair of a vaginal tear, and the subsequent investigations that confirmed diagnosis of atrio-ventricular heart block.
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Affiliation(s)
- A M Hogan
- Department of Anaesthetics, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK; Cognitive Neuroscience & Psychiatry, UCL Great Ormond Street Institute of Child Health, London, UK.
| | - T Christmas
- Department of Anaesthetics, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - H Missfelder-Lobos
- Department of Obstetrics & Gynaecology, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - A Wilson
- Department of Obstetrics & Gynaecology, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - M Belham
- Department of Cardiology, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
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8
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Das A, Basnet P, Shrestha R, Hada A, Bhandari B. Pregnancy with Complete Heart Block-An Emergency Cesarean Section with Temporary Pacemaker: A Case Report. JNMA J Nepal Med Assoc 2020; 58:597-599. [PMID: 32968295 PMCID: PMC7580374 DOI: 10.31729/jnma.5172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Management of a pregnant woman with complete heart block 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. Herein, we report a case of successful management of a 24 year old, pregnant woman with CHB who had an uneventful emergency caesarean delivery under spinal anesthesia after temporary pacing. She was an unbooked patient detected with CHB first time during active stage of labour. She delivered a healthy male baby and was discharged from the hospital in a stable and satisfactory condition on seventh postoperative day.
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Affiliation(s)
- Anamika Das
- Department of Obstetrics and Gynecology, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Pritha Basnet
- Department of Obstetrics and Gynecology, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Ramesh Shrestha
- Department of Obstetrics and Gynecology, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Abha Hada
- Department of Obstetrics and Gynecology, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Bidhur Bhandari
- Department of Obstetrics and Gynecology, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
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Crea P, Dattilo G, Giordano A, Luzza F, Oreto G. How to 'safely' manage delivery of a pregnant woman with congenital atrioventricular block? J Cardiovasc Med (Hagerstown) 2019; 21:460-462. [PMID: 31789715 DOI: 10.2459/jcm.0000000000000913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Pasquale Crea
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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10
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Nakashima A, Miyoshi T, Aoki-Kamiya C, Nishio M, Horiuchi C, Tsuritani M, Iwanaga N, Katsuragi S, Neki R, Ikeda T, Yoshimatsu J. Predicting postpartum cardiac events in pregnant women with complete atrioventricular block. J Cardiol 2019; 74:347-352. [PMID: 31060956 DOI: 10.1016/j.jjcc.2019.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 03/12/2019] [Accepted: 04/01/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Women with complete atrioventricular block (CAVB) can tolerate hemodynamic changes during pregnancy; however, the incidence of cardiac events in women with CAVB may increase after delivery. The aim of this study was to investigate predictive factors for postpartum cardiac events in pregnant women with CAVB. METHODS AND RESULTS Pregnant women with CAVB who received perinatal management at a tertiary cardiac center from 1981 to 2015 were retrospectively reviewed. Univariate and multivariate logistic analyses of postpartum cardiac events were performed. Postpartum cardiac event was defined as cardiopulmonary arrest, cardiac failure, or the need for permanent pacemaker implantation (p-PMI) within 3 months after delivery. A total of 63 pregnancies in 36 women with CAVB were included in this study; 25 had undergone p-PMI before pregnancy. Regardless of p-PMI status, women with CAVB had no further increases in heart rate during the second and third trimesters. No heart failure was found during pregnancy and delivery. Postpartum cardiac events occurred in 9 pregnancies (14.3%) in 8 women with CAVB; 3 had cardiac failure and p-PMI, 3 had cardiac failure, 2 required p-PMI, and 1 had cardiopulmonary arrest. Multivariate analysis showed that perinatal ventricular pause (odds ratio 11.60, 95% confidence interval 1.90-82.18, p<0.01) and family history of CAVB (odds ratio 10.59, 95% confidence interval 1.36-90.56, p=0.03) were associated with postpartum cardiac events. CONCLUSIONS All cardiac events occurred during the postpartum period among women with CAVB, and ventricular pause during the perinatal period and a family history of CAVB were predictors of postpartum cardiac events. Close follow-up should be considered during the postpartum period for women with high-risk CAVB.
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Affiliation(s)
- Ayaka Nakashima
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takekazu Miyoshi
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Obstetrics and Gynecology, Mie University, Tsu, Japan.
| | - Chizuko Aoki-Kamiya
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Miho Nishio
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Chinami Horiuchi
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Obstetrics and Gynecology, Mie University, Tsu, Japan
| | - Mitsuhiro Tsuritani
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Naoko Iwanaga
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Shinji Katsuragi
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Reiko Neki
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University, Tsu, Japan
| | - Jun Yoshimatsu
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan
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11
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Mohapatra V, Panda A, Behera S, Behera JC. Complete Heart Block in Pregnancy: A Report of Emergency Caesarean Section in a Parturient without Pacemaker. J Clin Diagn Res 2016; 10:QD01-QD02. [PMID: 27891405 DOI: 10.7860/jcdr/2016/20173.8606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 07/05/2016] [Indexed: 11/24/2022]
Abstract
Management of women with Complete Heart Block (CHB) presenting without pacing, during pregnancy and labour is debatable. Temporary pacemakers have been routinely inserted for labour and birth probably to withstand any haemodynamic variations. However, due to lack of large scale prospective studies, the necessity of this procedure has not been objectively assessed. Also, the most appropriate anaesthetic technique for caesarean section in women with CHB is yet to be clarified. We report herein the case of a pregnant woman with CHB who had uneventful emergency caesarean delivery under spinal anaesthesia without temporary pacing. She was an unbooked case detected with congenital CHB first time during active labour; echocardiography showed no structural cardiac disease and her heart rate increased with atropine. We suggest further research so that guidelines could be established to prevent unnecessary morbidity and expense of temporary pacemaker insertion. Newly diagnosed cases of asymptomatic CHB in late pregnancy should be worked up for chronotropic responsiveness using atropine and responsive cases may be managed without pacemaker.
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Affiliation(s)
- Vandana Mohapatra
- Senior Resident, Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences (AIIMS) , Bhubaneswar, Odisha, India
| | - Aparajita Panda
- Assistant Professor, Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS) , Bhubaneswar, Odisha, India
| | - Satyanarayan Behera
- Senior Resident, Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences (AIIMS) , Bhubaneswar, Odisha, India
| | - Jagadish Chandra Behera
- Senior Resident, Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences (AIIMS) , Bhubaneswar, Odisha, India
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12
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Baghel K, Mohsin Z, Singh S, Kumar S, Ozair M. Pregnancy with Complete Heart Block. J Obstet Gynaecol India 2016; 66:623-625. [PMID: 27803526 DOI: 10.1007/s13224-016-0905-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 04/12/2016] [Indexed: 11/24/2022] Open
Affiliation(s)
- Kalpana Baghel
- Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, India
| | - Zehra Mohsin
- Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, India
| | - Swati Singh
- Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, India
| | - Sandeep Kumar
- Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, India
| | - Maaz Ozair
- Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, India
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13
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Sundararaman L, Hochman Cohn J, Ranasinghe JS. Complete heart block in pregnancy: case report, analysis, and review of anesthetic management. J Clin Anesth 2016; 33:58-61. [PMID: 27555134 DOI: 10.1016/j.jclinane.2016.01.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 02/27/2015] [Accepted: 01/20/2016] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Lalitha Sundararaman
- Department of Anesthesiology, University of Miami Miller School of Medicine, C-300, 1611 NW 12 Ave, Miami, FL 33136 USA
| | - Jennifer Hochman Cohn
- Department of Anesthesiology, University of Miami Miller School of Medicine, C-300, 1611 NW 12 Ave, Miami, FL 33136 USA.
| | - J Sudharma Ranasinghe
- Department of Anesthesiology, University of Miami Miller School of Medicine, C-300, 1611 NW 12 Ave, Miami, FL 33136 USA
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Dubbs SB, Tewelde SZ. Cardiovascular Catastrophes in the Obstetric Population. Emerg Med Clin North Am 2015; 33:483-500. [DOI: 10.1016/j.emc.2015.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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15
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Keepanasseril A, Maurya DK, Suriya YJ, Selvaraj R. Complete atrioventricular block in pregnancy: report of seven pregnancies in a patient without pacemaker. BMJ Case Rep 2015; 2015:bcr-2014-208618. [PMID: 25754166 DOI: 10.1136/bcr-2014-208618] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Obstetric management of a woman with a permanent pacemaker in situ is well reported in the literature; but those who present without pacing are still debatable. The necessity for setting the optimal timing or rate of temporary artificial pacing, specifically for labour, has not been objectively assessed. Temporary pacing in most cases reported in the literature might be to withstand the variations in haemodynamic status during delivery and labour. We report a case of a patient with complete heart block without any pacing who had seven pregnancies without any significant changes in haemodynamic status during labour and delivery. Managing a pregnancy without pacing might be an appropriate alternative for women without any underlying cardiac disorder, as it will not lead to significant changes in the haemodynamic system.
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Affiliation(s)
- Anish Keepanasseril
- Department of Obstetrics & Gynecology, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India
| | - Dilip Kumar Maurya
- Department of Obstetrics & Gynecology, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India
| | - Yavana J Suriya
- Department of Obstetrics & Gynecology, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India
| | - Raja Selvaraj
- Department of Cardiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
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16
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Sengupta A, Slater TA, Sainsbury PA. The investigation and management of broad complex tachycardia and ventricular standstill presenting in pregnancy: A case report. Obstet Med 2014; 7:131-4. [PMID: 27512440 DOI: 10.1177/1753495x14539679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A 23 year old pregnant lady at 35 weeks gestation presented to accident and emergency with worsening dyspnoea, palpitations and dizziness. Twelve lead electrocardiogram, routine bloods and echocardiography were normal. Ambulatory monitoring previously had shown an episode of monomorphic broad complex tachycardia (BCT) and a short episode of ventricular standstill. She was admitted for cardiac monitoring until delivery. Several episodes of ventricular standstill and self-terminating BCT were recorded, which were not associated with symptoms. The patient's symptoms either corresponded with sinus rhythm or supraventricular tachycardia. She underwent elective caesarean section at 37 weeks with no complications. The patient's symptoms reduced considerably post delivery, and she was discharged three days later. Unfortunately she then had a presyncopal episode whilst holding her baby. Due to concern regarding the safety of her baby she had a permanent pacemaker implanted to allow safe beta-blockade. She remains asymptomatic six months later.
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Affiliation(s)
- Anshuman Sengupta
- Department of Cardiovascular and Diabetes Research, LIGHT Laboratories, University of Leeds, Leeds, United Kingdom
| | - Tom A Slater
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds, United Kingdom
| | - Paul A Sainsbury
- Department of Cardiology, Bradford Royal Infirmary, Bradford, United Kingdom
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Rai V, Shariffuddin II, Chan YK, Muniandy RK, Wong KK, Singh S. Peri-operative management of hysterostomy in a parturient with complete heart block, placenta accreta and intrauterine death. BMC Anesthesiol 2014; 14:49. [PMID: 25002831 PMCID: PMC4083103 DOI: 10.1186/1471-2253-14-49] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 06/25/2014] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Vineya Rai
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Ina I Shariffuddin
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Yoo K Chan
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Rajesh K Muniandy
- Department of Medicine Based, School of Medicine, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
| | - Kang K Wong
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Sukcharanjit Singh
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
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Abstract
A 22-year-old second gravida presented to the antenatal clinic at 28 weeks of gestation with frequent fainting attacks (2-3 episodes/day), palpitations and dyspnea (New York Heart Association Functional Classification II). Her pulse rate was 40 b.p.m. A 12-lead electrocardiogram and 24-h Holter revealed complete heart block. A transvenous permanent pacemaker (ventricular demand rate-responsive), paced at a rate of 60 pulses/min, was successfully implanted. A multidisciplinary approach was taken and the patient delivered a healthy baby boy of 2.8 kg at 38 weeks. She remained asymptomatic and was discharged in good condition. Management varies from expectant management to temporary pacemaker insertion to permanent pacing during pregnancy. In a young patient with sinus bradycardia, the primary criterion for a pacemaker is the concurrent observation of a symptom (e.g., syncope) with bradycardia (e.g., heart rate 35-40 b.p.m. or asystole for 3 s). Symptomatic pregnant women should always be counseled for a permanent pacemaker.
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Affiliation(s)
- Niharika Dhiman
- Obstetrics and Gynaecology Department, Safdarjung Hospital, New Delhi, India. ;
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19
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Isoproterenol infusion for treatment of refractory symptomatic bradycardia in parturients with congenital complete heart block. Int J Obstet Anesth 2011; 20:361-3; author reply 363. [DOI: 10.1016/j.ijoa.2011.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Revised: 05/10/2011] [Accepted: 05/23/2011] [Indexed: 11/16/2022]
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HIDAKA NOBUHIRO, CHIBA YOSHIHIDE, FUKUSHIMA KOTARO, WAKE NORIO. Pregnant Women with Complete Atrioventricular Block: Perinatal Risks and Review of Management. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2011; 34:1161-76. [DOI: 10.1111/j.1540-8159.2011.03177.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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21
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Abstract
Physiologic changes in maternal haemodynamics, hormones and autonomic properties contribute to arrhythmias in pregnancy. While arrhythmias most commonly occur in pregnant women with structural heart disease or those with a history of cardiac arrhythmias, they can also occur de novo in women with no documented cardiac disease.
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22
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Thaman R, Curtis S, Faganello G, Szantho GV, Turner MS, Trinder J, Sellers S, Stuart GA. Cardiac outcome of pregnancy in women with a pacemaker and women with untreated atrioventricular conduction block. Europace 2011; 13:859-63. [DOI: 10.1093/europace/eur018] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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23
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Azarisman S, Fahmi L, Huda AN, Azam Y. Emergent Caesarean section in parturient with congenital complete atrioventricular block. JRSM SHORT REPORTS 2010; 1:50. [PMID: 21234113 PMCID: PMC2994351 DOI: 10.1258/shorts.2010.010033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Shah Azarisman
- Department of Internal Medicine, International Islamic University Malaysia , Kuantan , Malaysia
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24
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Cordina R, McGuire MA. Maternal cardiac arrhythmias during pregnancy and lactation. Obstet Med 2010; 3:8-16. [PMID: 27582834 PMCID: PMC4989762 DOI: 10.1258/om.2009.090021] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2009] [Indexed: 11/18/2022] Open
Abstract
Arrhythmias occurring during pregnancy can cause significant symptoms and even death in mother and fetus. The management of these arrhythmias is complicated by the need to avoid harm to the fetus and neonate. It is useful to classify patients with arrhythmias into those with and without structural heart disease. Those with a primary electrical problem, but an otherwise normal heart, often tolerate rapid heart rates without compromise whereas patients with problems such as rheumatic heart disease, congenital heart disease or cardiomyopathy may quickly decompensate during an arrhythmia.
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Affiliation(s)
- Rachael Cordina
- Department of Cardiology, Royal Prince Alfred Hospital
- Department of Medicine, University of Sydney, Sydney, Australia
| | - Mark A McGuire
- Department of Cardiology, Royal Prince Alfred Hospital
- Department of Medicine, University of Sydney, Sydney, Australia
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25
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Suri V, Keepanasseril A, Aggarwal N, Vijayvergiya R, Chopra S, Rohilla M. Maternal complete heart block in pregnancy: Analysis of four cases and review of management. J Obstet Gynaecol Res 2009; 35:434-7. [DOI: 10.1111/j.1447-0756.2008.00961.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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26
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Tietge W, Daniëls M. A case of an acquired high-degree AV block in a pregnant woman. Neth Heart J 2008; 16:419-21. [PMID: 19127320 PMCID: PMC2612111 DOI: 10.1007/bf03086190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Acquired heart block during pregnancy is rare. We describe the case of a 29-year-old pregnant female with fatigue due to an unexplained high-degree AV conduction disorder. She was treated with a dual chamber pacing system. Further pregnancy and delivery were without complications. The sparse literature on this topic is reviewed. (Neth Heart J 2008;16:419-21.).
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Affiliation(s)
- W Tietge
- Department of Cardiology, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
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27
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Adamson DL, Nelson-Piercy C. Managing palpitations and arrhythmias during pregnancy. Postgrad Med J 2008; 93:1630-6. [PMID: 18003696 DOI: 10.1136/hrt.2006.098822] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Dawn L Adamson
- Department of Cardiology, Hammersmith Hospital NHS Trust, London, UK
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