Management of Cardiac Pacemakers in a Pregnant Patient

Abstract

Introduction: Despite the increasing use of permanent cardiac pacemakers in a younger patient population, there are little data related to pregnancy. We present our experience in managing a pregnant patient with a pre-existing pacemaker and review the existing literature to establish management guidelines. Case: A 27-year-old G1 P0 presented for prenatal care in the first trimester of pregnancy. She had a past medical history of bradycardia, hypotension and syncope that required dual chamber cardiac pacemaker placement 6 years earlier, and one episode of left upper extremity venous thrombosis related to replacement of the pacemaker wire 4 years earlier. In the early second trimester, the patient began experiencing light-headedness and breathlessness with exertion. The rate settings of the pacemaker were increased with resolution of the patient's symptoms. The patient underwent primary cesarean section at 39 weeks gestation with delivery of a healthy term infant. Preoperative anesthesia consultation was obtained. The postoperative course was uneventful. Pre-pregnancy pacemaker settings were re-established after the postpartum period. Discussion: The current literature on managing pregnant patients with pre-existing pacemakers is quite limited. Such patients require a multidisciplinary approach to care. Normal physiologic changes in pregnancy may necessitate rate adjustments. Other than routine thromboprophylaxis, no other anticoagulation is needed. Route of delivery is generally based on obstetric indications. During surgery consider using bipolar electrocautery in place of unipolar electrocautery, to reduce electromagnetic interference. Also, the placement of the grounding pad should be as far away from the pacemaker as possible. It should be anticipated that the patient will return to her baseline cardiac status postpartum and therefore pacemaker settings can be adjusted accordingly.

Pregnancy with Cardiac Pacemaker: A Multidisciplinary Approach to Rare Case Management

“…This may cause pregnant woman to require pacemaker support or can change how a patient with an implanted pacemaker is managed. 4 During pregnancy, there is significant increase in cardiac output (30-40%) and a reduction in the systemic vascular resistance of the mother. Initially, this is caused by a raise in the stroke volume, but later on, tachycardia may be the cause.…”

“…In the case of permanent pacemakers, transvenous lead placement is done through axillary, cephalic, or through subclavian veins. 4 Our patient had a single-chamber permanent pacemaker controlling the heartbeat pacing by connecting the lead to right ventricle. Single-chamber pacemakers have the benefits of lower rate of thromboembolism, less chances of atrial fibrillation, and lower mortality as compared with dual chamber pacemakers.…”

“…And some of the genetic conditions have specific markers which can be detected by chorionic venous sampling or amniocentesis. 4 During pregnancy, a multidisciplinary approach for the management of these patients should be done. Prior consultation with a cardiologist is advised because it can be challenging to mention the difference between typical pregnancy symptoms and moderate cardiac dysfunction, which may call for a change in pacemaker programming of the patient.…”

“…The treatment giving obstetrician has to be aware about all this while managing a pregnant female with pacemaker in situ. 4 Congenital heart disease may raise the chance of fetomaternal adverse outcomes in pregnant woman; this risk is independent of whether the woman was clinically stable at the time of conception. Therefore, the management of cardiac diseases in pregnancy is very crucial and may turn into nightmare for an obstetrician if not taken care properly.…”