Cesarean section in a case of third degree heart block with severe

52

Case Report

* Professor and Head, ** Post Graduate Students, Department of Obstetrics and Gynecology, Rural Medical College, Loni. 413736. Ahmednagar. E-mail : [email protected]

CESAREAN SECTION IN A CASE OF

THIRD DEGREE HEART BLOCK WITH SEVERE HYPERTENSION

V BANGAL*, K SHINDE**, S BORAWAKE**, R SINGH**

ABSTRACT

Occurrence of pregnancy in a woman suffering from third degree heart block is a high

risk situation. It may put life of the woman and her unborn baby into danger. A case is reported

here, who was unbooked, presented at 32 weeks of gestation with third degree heart block with

severe hypertension and features of severe intrauterine growth restriction. After control of blood

pressure with medication and after temporary cardiac pacing, emergency cesarean section was

performed under general anesthesia. Maternal and fetal outcome were good. She was discharged

with the advice regarding permanent cardiac pacing, regular follow up and contraception. Joint

efforts by Obstetrician, Pediatrician, Physician, Interventional cardiologist and Anesthesiologist

resulted in the optimum outcome.

Introduction

Pregnancy complicated with complete

heart block is rare and usually required termination

of pregnancy in the past. Improvement in medical

technology in the form of cardiac pacing has

allowed taking these women to term. Overall

maternal and neonatal outcome is not affected 1, 2in asymptomatic cases . A good team approach

in the management, results in optimum

outcome.

Case report

A 26 year old, gravida two, para one,

abortion one, unbooked case was admitted with

32 weeks of pregnancy with complete heart block

and severe hypertension with intra uterine growth

restriction. On examination, she was conscious,

oriented, with pulse rate of 40 beats per minute

and blood pressure of 150/100 mm of Hg. There

was bilateral pedal edema and puffiness over the

face. Per abdominal examination revealed 30

weeks size uterus with fetus in longitudinal lie

with cephalic presentation. Liquor was less in

amount. Fetal heart was 130 beats per minute,

regular. Per vaginal examination showed

unfavorable cervix. Her investigations revealed

trace of albumin in urine, normal platelet count

and normal prothrombin time. Her liver and

kidney function tests were normal. Obstetric

ultrasound revealed 31.3weeks live baby with

amniotic fluid index of 8cms and normal

biophysical profile. Color Doppler study revealed

diastolic notch in uterine artery. ECG confirmed

the diagnosis of complete heart block.

Echocardiography showed evidence of only

trivial tricuspid regurgitation. She was given bed rest

and was put on antihypertensive drugs.

(Tab. Alpha methyl dopa, 250mg three times a

day). Her blood pressure increased to 190/110

J MGIMS, March 2012, Vol 17, No (i), 52 - 54

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V Bangal & et al

Figure 1 : Chest radiogram showing permanentpacemaker in situ

mm Hg after three days of admission.

Cardiologist's opinion was sought for high blood

pressure and complete heart block. She was put

on two additional antihypertensive agents and

doses were adjusted. Maternal and fetal monitoring

was continued. She went in spontaneous labour.

In view of severe growth restriction, hypertension,

oligohydramnios and unfavorable cervix, decision

of cesarean section under general anesthesia was

taken. Anesthesiologist requested for cardiologist

consultation for cardiac pacing during anesthesia

and surgery. In view of the persistent bradycardia

below 45 beats per minute, decision of temporary

pacing was taken. Temporary transvenous cardiac

pacing was done by interventional cardiologist

in intensive care unit by inserting a bipolar pacing

electrode via subclavian vein up to apex of right

ventricle, under ultra sonographic guidance (Fig

1). The heart rate was artificially adjusted to 60

beats per minute. It was decided to pace the heart

only when heart rate drops down below 50 beats

per minute. Cesarean section was carried out

under general anesthesia. She delivered a female

preterm baby with birth weight of 1.3 kg with

good Apgar score. There was no intra operative

complication. She developed bradycardia twice

on first postoperative day, which was managed

by cardiac pacing. Subsequently her heart rate

remained steady at the rate of 50-60 beats per

minute. She was asymptomatic in postoperative

period. Prophylactic antibiotics were continued

for 7 days. Temporary pacemaker was removed

on third postoperative day. Overall postoperative

period was uneventful. She was discharged with

baby on eleventh postoperative day, with a advice

for permanent pacemaker at higher center,

regular follow up visits and contraception.

Discussion

Complete heart block is rare during

pregnancy. Majority of cases remain asymptomatic

and do not need any active intervention during 3pregnancy or delivery .Permanent cardiac pacing

is advocated in symptomatic cases during first

and second trimester. Women may become

symptomatic during labour due to further slowing

of heart rate due to Valsalva maneuver during 4second stage . Temporary pacing helps to prevent

5cardiac complications during cesarean section .

While the distinction between acquired and

congenital heart block may be difficult, our case

fulfilled the criteria for the diagnosis of congenital 6heart block as described by Wood (1965) . Joint

consultation between Obstetrician, Cardiologist,

Anesthesiologist and Pediatrician resulted in

optimum outcome.

References

1. Kumkum A, Gupta S, Gurucharan A. An unusual

case of complete heart block with triplet pregnancy.

Indian Heart Journal. 2003; 55:641-642.

2. Mehta S, Goswami D, Tempe A. Successful

pregnancy outcome in a patient with complete

heart block. Journal of postgraduate medicine. 2003;

49:98.

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Cesarean section in a case of third degree heart block with severe hypertension.

3. Dalvi B, Chaudhary A, Kulkarni HL. Therapeutic

guidelines for congenital complete heart block

presenting in pregnancy. Obstet Gynecol

1992;79:802-4.

4. Sharma JB, Malhotra M, Pandit P. Successful

pregnancy outcome with cardiac pacemaker after

complete heart block. Int J Gynecol Obstet 2000;68:145-6.

5. Cevik B ,Colakoglu S, Ilham C. Anesthetic

management of cesarean delivery in pregnant

women with a temporary pacemaker. Anest Analg

2006;103:500-501

6. Wood, P.H. Diseases of the heart and circulation nd2 ed,.Eyre and Spottiswoode, London, 1956; 324.

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Cesarean section in a case of third degree heart block with severe