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

Abstract

A 26-year-old, gravida 2 abortion 1, unbooked case, presented to the labour ward at 36+5 weeks gestational age in active labour. Two years back, she had an induced abortion at 6 weeks of gestation by medical methods. During her present pregnancy, she had irregular antenatal check ups at a local hospital with no followup in the third trimester. She had no known history of any medical illnesses, drug intake or addiction. On examination, her pulse rate was 42/minute, while blood pressure was 110/80 mmHg. Cardiorespiratory system examination was unremarkable. Obstetric examination revealed term size uterus with fetus in longitudinal lie and cephalic presentation. There were regular uterine contractions, fetal heart rate was 140 beats/minute. On per vaginal examination, cervix was fully effaced, os was 4 centimetres dilated, vertex station was at -2 and membranes were intact.Cardiologist's opinion was sought in view of persistent bradycardia. Electrocardiogram (ECG) was done which showed sinus bradycardia with narrow QRS complexes suggestive of congenital Complete Heart Block (CHB) [Table/ Fig-1]. Echocardiography was normal. Routine blood investigations were within normal limit. Pulse rate settled to 70-76/minute with intravenous injection atropine. Plan was to proceed with temporary pacing if heart rate did not increase after injection atropine or any deterioration in haemodynamic status occurred.Labour was augmented with injection oxytocin. In the meantime, thick meconium stained liquor was detected on artificial rupture of membranes and cardiotocograph showed non-reassuring fetal heart rate pattern. The woman was taken up for caesarean section under emergent conditions without temporary pacing. However, injection isoprenaline and temporary pacemaker was kept on standby. She was preloaded with 750 mililitres of Ringer's lactate solution prior to spinal anaesthesia. Two mililitres of hyperbaric 0.5% Bupivacaine was injected into subarachnoid space at L3-L4 level with the woman in left lateral position. A sensory level upto T8 was achieved. A late preterm vigorous male baby with birth weight of 2400 grams (appropriate for date) was delivered. The average estimated total blood loss was approximately 600 mililitres. Monitoring included continuous ECG, pulse oximeter and both invasive and noninvasive blood pressure. During surgery, heart rate dipped to 50/minute once; it responded to atropine [Table/ Fig-2]. Intraoperative haemodynamics remained stable and surgery proceeded uneventfully.Postoperatively, continuous monitoring was done with pulse oximeter and invasive blood pressure. The woman's heart rate remained steady at 54-64 beats/minute. Analgesia was achieved with injection diclofenac 75mg intravenous 8 th hourly. Postpartum period was uneventful; she was discharged on the seventh postoperative day. The neonate did not have any rhythm disturbance. She was doing well on follow up at 6 weeks. She was prescribed progesterone only pill (desogestrel 75μg) for 3 months and advised to continue follow-up in cardiology. M...

Complete heart block in pregnancy

“…[2] Evaluation of chronotropic competence can also be achieved with atropine and is a key step to determine whether a pacemaker will be necessary. [3] Atropine was avoided in this patient due to uncertainty of its effect upon the fetus, and a similar evaluation of chronotropic competency was established with moderate exercise.…”

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

“…Temporary PMs have been routinely inserted for those pregnancies without a PM. However, its necessity has not yet been discussed enough . Previous reports have described the indication of temporary PMs in patients undergoing C‐section with congenital CAVB.…”

“…Previous reports have described the indication of temporary PMs in patients undergoing C‐section with congenital CAVB. Some of them suggested that implantation of a PM prior to C‐section is unnecessary in an asymptomatic pregnant with congenital CAVB . However, case reports describing C‐section in pregnancy with acquired CAVB without insertion of a temporary PM are limited .…”

“…Therefore, it is necessary to consider the indication of spinal anesthesia in pregnancies with acquired CAVB. Kumar et al reported successful management of C‐sections in asymptomatic congenital CAVB under spinal anesthesia with PM placement, and Mohapatra et al reported successful management of emergent C‐section in asymptomatic congenital CAVB using spinal anesthesia without a PM . Sundararaman et al also reported successful management of vacuum‐assisted delivery in asymptomatic congenital CAVB under combined spinal‐epidural anesthesia .…”

“…However, its necessity has not yet been discussed enough. 3 Previous reports have described the indication of temporary PMs in patients undergoing Csection with congenital CAVB. Some of them suggested that implantation of a PM prior to C-section is unnecessary in an asymptomatic pregnant with congenital CAVB.…”