Management of complete heart block during pregnancy

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.

Total atrioventricular block in pregnancy –Case report

“…The controversy arises from the requirement for generator replacement, exposure to teratogenic fluoroscopic materials prior to pacemaker implantation and complications associated with the implantation itself. Thus, it was initially thought that pacemakers for asymptomatic patients is made case-per-case [ 6 ].…”

“…It is recommended to implant permanent pacemakers before pregnancy. Even if they presented late, then pacemakers would still be recommended [ 6 , 10 ]. If a permanent pacemaker cannot be installed during pregnancy, a temporary pacemaker then replaced by a permanent one postpartum would be recommended [ 6 , 10 ].…”

Atrioventricular Block in Pregnancy: 15.8 Seconds of Asystole

“…Those who are asymptomatic and are hemodynamically stable during pregnancy, labor, and postpartum may not require a permanent pacemaker. However, the EP cardiologist should be on standby in case the need for temporary pacing presents itself [ 5 , 6 , 7 ].…”

“…All emergent cases that present late in pregnancy or during labor should be counseled for a temporary pacer followed by a permanent pacer in the postpartum period. Thamen et al described a small study of 26 pregnancies in which resolution of AV block occurred postpartum for some pregnancies, implying that pregnancy-related hemodynamic shifts may affect the conduction system [ 7 , 8 ]. Therefore, re-assessment of symptoms should be performed prior to permanent pacer implantation [ 7 ].…”

“…This could lead to reflex bradycardia, further worsening AV nodal blockade in heart disease patients [ 11 ]. However, overall, those with a pacemaker who underwent vaginal delivery tolerated labor stress well, and having a pacemaker is not necessarily an indication for a cesarean section [ 7 ].…”