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LETTER TO EDITOR
Year : 2019  |  Volume : 20  |  Issue : 2  |  Page : 112-113
 

Complete heart block in pregnancy: Concerns for anesthesia


1 Department of Anaesthesiology and Critical Care, Pt. B. D. Sharma PGIMS, Rohtak, Haryana, India
2 Department of Anaesthesiology, Narayana Superspeciality Hospital, Gurugram, Haryana, India

Date of Web Publication28-Aug-2019

Correspondence Address:
Dr. Jyoti Sharma
Department of Anaesthesiology and Critical Care, Pt. B. D. Sharma PGIMS, Rohtak, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_27_19

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How to cite this article:
Sharma J, Gupta A. Complete heart block in pregnancy: Concerns for anesthesia. Indian Anaesth Forum 2019;20:112-3

How to cite this URL:
Sharma J, Gupta A. Complete heart block in pregnancy: Concerns for anesthesia. Indian Anaesth Forum [serial online] 2019 [cited 2019 Sep 22];20:112-3. Available from: http://www.theiaforum.org/text.asp?2019/20/2/112/265646




Sir,

Complete heart block (CHB) is rare in general population. Its incidence is about 1:15000–1:20000 live births, and it is mostly congenital.[1] Moreover, progression of heart block from 1st degree to CHB within antenatal period is even less known. During antenatal visit, electrocardiogram (ECG) and other cardiac investigations are done only in symptomatic patients.

We present the case of a patient who had a history of cardiac arrhythmias during her first lower segment caesarean section (LSCS) and consequently was investigated thoroughly during her second pregnancy. Initially, when she contacted the hospital, along with all other investigations, ECG was done which revealed 1st-degree heart block, and consequently, a cardiac opinion was taken for the same reason. On follow-up at 26 weeks, changes in heart block pattern were observed. Two-dimensional echocardiography revealed normal cardiac structure. The cardiologist advised 24-h Holter monitoring to detect further conduction abnormality. Holter finding confirmed 1st-degree heart block with 2.5 h of bradycardia; the lowest heart rate (HR) recorded was 38/min whereas the average HR was 78/min. There were sinus pauses, ventricular premature contractions (VPCs), couplets, and intermittent episodes of 2nd-degree heart block [Figure 1].
Figure 1: Electrocardiogram at 26 weeks

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Keeping in view the asymptomatic nature (i.e., no episodes of palpitation and syncope), uneventful progression of pregnancy with normal fetal growth, and the absence of structural cardiac abnormality, the option of pacemaker insertion was deferred to a later stage for the fear of radiation exposure to the developing fetus.[2],[3] However, the patient was advised to be cautious and report any event as early as possible.

The patient was readmitted for elective LSCS at term, and we were surprised to find CHB pattern along with escape rhythm. The progression to CHB within a span of 2½ months was very alarming [Figure 2]. She was not on any rate reducing drugs or calcium channel blockers.
Figure 2: Electrocardiogram at term

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In view of variable cardiac conduction blockade,[4] preventive temporary pacemaker was inserted before elective LSCS and was programmed with HR of 80/min, with sensitivity of 1.5 mA.

Preloading was done with half liter of Ringer lactate solution. Subarachnoid block was given to the patient with 2.2 ml of 0.5% bupivacaine heavy in the left lateral position. Necessary precaution was taken not to dislodge the pacing wires. HR in the intraoperative period was fixed at 80/min with the help of pacemaker. Postspinal hypotension was responsive to fluid administration, and the case proceeded uneventfully with continuous pacing. The patient was monitored for 48 h in intensive care unit and was discharged from the hospital with future advice for permanent pacemaker insertion.

The case highlights the unusual progression of heart block during pregnancy. Such unpredictability requires repeated cardiac evaluation and temporary or permanent pacing (if indicated), before initiating any anesthesia for elective surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Perloff JK. The Clinical Recognition of Congenital Heart Disease. 6th ed.. Philadelphia: Elsevier; 2003.  Back to cited text no. 1
    
2.
Modi PM, Butala B, Shah RV. Anaesthetic management of an unusual case of complete heart block for LSCS. Indian J Anaesth 2006;50:43-4.  Back to cited text no. 2
    
3.
Hidaka N, Chiba Y, Kurita T, Satoh S, Nakano H. Is intrapartum temporary pacing required for women with complete atrioventricular block? An analysis of seven cases. BJOG 2006;113:605-7.  Back to cited text no. 3
    
4.
Kharde VV, Patil VV, Dhulkhand VK, Divekar DS. A parturient with complete heart block for cesarean section. J Anaeth Clin Pharmacol 2010;26:401-2.  Back to cited text no. 4
    


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