Maternal complete heart block in pregnancy: Analysis of four cases and review of management

Pregnancy and complete atrioventricular block: a case report

Bradycardia in pregnancy due to complete atrioventricular block (CAVB) is a rare but serious occurrence that can be life-threatening to the mother and fetus. Patients with CAVB may be asymptomatic, but symptomatic cases require urgent and definitive management.

Case presentation

The case of a 20-year-old primigravida with previously undiagnosed CAVB who attended the obstetric emergency service in labor is presented. The route of delivery was vaginal without complications. The decision was made to implant a permanent dual-chamber pacemaker on the third day of the puerperium, and the patient did no present cardiovascular symptoms during outpatient follow-up.

Clinical discussion

CAVB is a rare but serious condition in pregnancy that can be congenital or acquired. While some cases are relatively benign, others can lead to decompensation and fetal complications. There is no consensus on the best delivery route, but vaginal delivery is generally safe unless contraindicated for obstetric reasons. Pacemaker implantation may be necessary in some cases and can be performed safely during pregnancy.

Conclusion

This case highlights the importance of cardiac evaluation in pregnant patients, especially those with a history of syncope. It also highlights the need for adequate and urgent management in symptomatic cases of CAVB in pregnancy and adequate evaluation to decide when to implant the pacemaker as a definitive measure.

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.

Management of pregnant patients with pulmonary arterial hypertension

Pregnant individuals with pulmonary arterial hypertension (PAH) have significantly high risks of maternal and perinatal mortality. Profound changes in plasma volume, cardiac output and systemic vascular resistance can all increase the strain being placed on the right ventricle, leading to heart failure and cardiovascular collapse. Given the complex network of opposing physiological changes, strict contraception and reduction of hemodynamic fluctuations during pregnancy are important methods of minimizing the risk of maternal mortality and improving the outcomes following pregnancy. In this review, we discuss the recent research progress into pre-conception management and the various therapeutic strategies for pregnant individuals with PAH.

Pregnancy maternal fetal outcomes among pregnancies complicated with atrioventricular block

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.

Total atrioventricular block in pregnancy -Case report

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.

An Incidental Finding of Congenital Complete Heart Block Presenting in Active Labor: A Multidisciplinary Approach

Congenital complete heart block is a rare occurrence. In some cases, it remains asymptomatic until adulthood or in the case of women until pregnancy. It is usually secondary to placental transfer of maternal antibodies and is associated with high mortality and morbidity. We present a case of a parturient who presented in active labor with premature rupture of membranes and decreased fetal movements. We found that the patient had a complete heart block with mild effort intolerance on evaluation. Markers for metabolic and ischemic causes were negative, and we made a provisional diagnosis of congenital complete heart block. The patient underwent a lower section cesarian section under spinal anesthesia with temporary pacemaker backup. Postoperatively, the patient underwent permanent pacemaker implantation. This case report underlines the importance of standard American Society of Anesthesiologists (ASA) monitoring, including a 12-lead electrocardiogram (ECG), which could prove decisive and life-saving in dire circumstances.

Pregnancy with complete heart block

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.

Reversible Complete Heart Block in a Pregnant Woman Related to Sertraline Treatment

Complete heart block (CHB) is a serious condition, usually affecting older patients. We report a case of CHB in a 31-year-old pregnant woman treated with sertraline in whom atrioventricular (AV) conduction normalized after discontinuation of sertraline. Results of subsequent genetic investigations for inherited cardiomyopathy and ion-channel disease and a pharmacogenetic study of sertraline pharmacokinetics were negative. Reversible CHB in this younger pregnant patient was temporally related to sertraline. This case underlines the importance of identifying reversible causes when a young patient presents with AV block with unknown trajectory and prognosis, as well as regular recording of electrocardiograms in pregnant patients on psychotropic medications.

[Cardiac arrhythmias in pregnancy : Epidemiology, clinical characteristics, and treatment options]

Symptomatic arrhythmias rarely occur during pregnancy and are predominantly benign. However, the increasing average age of women who are pregnant, especially in Western European countries, has contributed to a significant increase in arrhythmias in pregnant women in recent years. Previous or existing heart diseases can increase the occurrence of arrhythmias. In most cases pregnancy is safe and without consequences for the child and/or mother. Further cardiological work-up (including ECG and echocardiography, and possibly cardiac MRI) should always be performed. The indication for treatment should be made in close cooperation between obstetricians and cardiologists considering symptoms, hemodynamics and prognosis. In the absence of larger studies on efficacy and side effects of antiarrhythmic drugs, these should be administered very cautiously, under strict indication and whenever possible by avoiding the first trimester. Cardiologists with special expertise in arrhythmias should always be consulted, especially in the case of complex and relevant rhythm disturbances.

Rhythmusstörungen in der Schwangerschaft

Symptomatische Rhythmusstörungen treten während einer Schwangerschaft selten auf und sind überwiegend gutartig. Sie stellen dennoch eine besondere klinische Herausforderung dar, wobei sich diagnostische und therapeutische Möglichkeiten in Zusammenhang mit gleichzeitig älterem Durchschnittsalter bei Schwangerschaften in den vergangenen Jahren deutlich verbessert haben. In der Regel ist eine Schwangerschaft trotz Auftreten von Rhythmusstörungen sicher und ohne Folgen für das Kind. Vorbekannte oder vorhandene Herzerkrankungen können das Auftreten von Rhythmusstörungen begünstigen. Es sollte immer eine weiterführende kardiologische Diagnostik (u. a. EKG und Echokardiografie) erfolgen. Die Indikation zur Therapie sollte in enger Absprache zwischen Geburtsmediziner und Kardiologen/Rhythmologen erfolgen und dabei Symptomatik, Hämodynamik und Prognose berücksichtigen. Bei fehlenden größeren Studien zu Wirksamkeit und Nebenwirkungen von Antiarrhythmika sollten diese nur sehr zurückhaltend, unter strenger Indikation und am ehesten unter Umgehung des 1. Trimenons verabreicht werden. Insbesondere bei komplexen und prognostisch relevanten Rhythmusstörungen sollten immer Kardiologen mit besonderer rhythmologischer Erfahrung hinzugezogen werden.

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.

Pregnancy with Complete Heart Block-An Emergency Cesarean Section with Temporary Pacemaker: A Case Report

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.

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.

Consensus Document of the Italian Association of Hospital Cardiologists (ANMCO), Italian Society of Pediatric Cardiology (SICP), and Italian Society of Gynaecologists and Obstetrics (SIGO): pregnancy and congenital heart diseases

The success of cardiac surgery over the past 50 years has increased numbers and median age of survivors with congenital heart disease (CHD). Adults now represent two-thirds of patients with CHD; in the USA alone the number is estimated to exceed 1 million. In this population, many affected women reach reproductive age and wish to have children. While in many CHD patients pregnancy can be accomplished successfully, some special situations with complex anatomy, iatrogenic or residual pathology are associated with an increased risk of severe maternal and fetal complications. Pre-conception counselling allows women to come to truly informed choices. Risk stratification tools can also help high-risk women to eventually renounce to pregnancy and to adopt safe contraception options. Once pregnant, women identified as intermediate or high risk should receive multidisciplinary care involving a cardiologist, an obstetrician and an anesthesiologist with specific expertise in managing this peculiar medical challenge. This document is intended to provide cardiologists working in hospitals where an Obstetrics and Gynecology Department is available with a streamlined and practical tool, useful for them to select the best management strategies to deal with a woman affected by CHD who desires to plan pregnancy or is already pregnant.

Complete Heart Block in Pregnancy: A Report of Emergency Caesarean Section in a Parturient without Pacemaker

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.

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.

Complete atrioventricular block in pregnancy: report of seven pregnancies in a patient without pacemaker

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.

The investigation and management of broad complex tachycardia and ventricular standstill presenting in pregnancy: A case report

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.

CARDIAC ARRHYTHMIAS DURING PREGNANCY: A CLINICAL APPROACH

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.