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Letters to the Editor: Letters & Announcements

Anesthetic Management of Cesarean Delivery in Pregnant Women with a Temporary Pacemaker

Çevik, Banu MD; Çolakoglu, S MD; Ilham, C MD; Örskiran, A MD

Author Information
doi: 10.1213/01.ANE.0000227203.80338.B4
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To the Editor:

Parturients with heart disease are a challenge for anesthesiologists (1). A 19-yr-old primigravida at 38 wk of gestation was scheduled for elective Cesarean delivery. She had no history of cardiac disease before pregnancy. At 28 wk she presented with syncope. Complete heart block was diagnosed by Holter monitoring. However, pacemaker implantation was not indicated as her symptoms resolved spontaneously. She remained asymptomatic until 38 wk of gestation and was admitted for elective cesarean delivery.

On preanesthetic evaluation, her electrocardiogram showed complete heart block with junctional escape rhythm (Fig. 1). Chest examination was normal. Her arterial blood pressure was 140/90 mm Hg. There was generalized edema. She had a single fetus in cephalic presentation, uterine height corresponded to 36 wk of gestation, and fetal heart rate was 140 bpm. On the day before the scheduled surgery, a temporary pacemaker was placed, with heart rate set at 70 bpm (Fig. 2). A permanent pacemaker was advised after 48 h.

F1-62
Figure 1.:
Rhythm of the patient’s heart before pacing.
F2-62
Figure 2.:
Rhythm of the patient’s heart after implantation of temporary pacemaker.

The patient underwent cesarean delivery under general anesthesia, monitored by noninvasive arterial blood pressure, electrocardiogram, and pulse oximetry. The procedure, delivery, and initial recovery were unremarkable. In the third postoperative hour, the temporary pacemaker failed, and the patient was transferred to coronary care unit for permanent pacemaker implantation. She was followed over the next 48 h, and was discharged home after 3 days.

Benign arrhythmias are common during pregnancy. Most of these arrhythmias are atrial in origin and have no adverse hemodynamic sequelae. However, in some cases arrhythmias are the first manifestation of underlying organic heart disease (2). Heart block is one such arrhythmia and is an unusual complication of pregnancy. Typically complete heart block is asymptomatic, so prophylactic placement of a permanent pacemaker is not usually indicated (3). The indications for permanent pacemaker implantation have changed considerably in the last two decades. The latest guidelines of the American Heart Association and the American Collage of Cardiology suggest that asymptomatic heart block does not require permanent pacemaker implantation (4).

Experts do not agree upon the criteria for temporary pacemaker placement (5). Unexpected interruption of the pacing can cause serious consequences (6). Temporary pacing is most commonly used to treat symptomatic bradycardia for short periods. Toprak et al. (7) described two episodes of severe bradycardia in the same patient during general anesthesia, the second of which they managed with a temporary pacemaker. Nakamura and colleagues recommended temporary pacemakers for asymptomatic patients with sick-sinus syndrome who were resistant to atropine. Furthermore, they suggested combining drug treatment with temporary pacing to treat vasovagal syncope (8). For symptomatic patients in the first and second trimesters, permanent pacemaker implantation is the therapy of choice. If the patient is at or near term, temporary pacing right before induction of labor can prevent the complications of prolonged temporary pacing. Because altered hemodynamics can contribute to the patient’s symptoms during pregnancy, the patient should be reassessed in the postpartum period before permanent pacemaker implantation is contemplated (9). Criteria for temporary pacing include atropine-resistant bradycardia, first- and second-degree atrioventricular block, and atrial fibrillation with low ventricular rate (10).

Pacing was not indicated in our patient because she was initially asymptomatic. We instituted temporary pacing before general anesthesia to avoid brady arrhythmias during cesarean delivery and instituted permanent pacing when she became symptomatic postoperatively.

Banu Çevik, MD

S. Çolakoglu, MD

C. Ilham, MD

A. Örskiran, MD

Department of Anesthesiology and Reanimation

Dr. Lütfi Kirdar Kartal Training and Research Hospital

Istanbul, Turkey

[email protected]

References

1. Zangrillo A, Landoni G, Pappalardo F, et al. Different anesthesiological management in two high risk pregnant women with heart failure undergoing emergency cesarean section. Minerva Anestesiol 2005;71:227–36.
2. Camann WR, Thornhill ML. Cardiovascular disease. In: Obstetric anesthesia: principles and practice, 2nd ed. Chestnut DH, ed. St. Louis: Mosby, 1999:776–809.
3. Mehta S, Goswami D, Tempe A. Successful pregnancy outcome in a patient with complete heart block. J Postgrad Med 2003;49:98.
4. Gregoratos G, Cheitlin MD, Conill A, et al. ACC/AHA guidelines for implantation of cardiac pacemakers and antiarrhytmia devices: a report of the American College of Cardiology/American Heart Association Task force on Practice Guidelines (Committee on Pacemaker Implantation). Am Coll Cardiol 1998;31:1175–209.
5. Fuantes Rodriguez R, Sebastianes Marfil MC, Mato Ponce M, et al. Preoperative prophylactic pacemakers: apropos of their indication in a disputed case. Rev Esp Anestesiol Reanim 2001;48:38–41.
6. Parekh SD, Alston TA. Temporary pacemaker who wouldn’t quit. Anesthesiology 2004;101:810.
7. Toprak V, Yentur A, Sakarya M. Anaesthetic management of severe bradycardia during general anaesthesia using temporary cardiac pacing. Br J Anaesth 2002;89:655–7.
8. Nakamura S, Nishiyama T, Hanaoka K. General anesthesia for a patient with asymptomatic sick sinus syndrome [in Japanese]. Masui 2005;54:912–3.
9. Avasthi K, Gupta S, Avasthi G. An unusual case of complete heart block with triplet pregnancy. Indian Heart J 2003;55:641–2.
10. Csontos CS, Bogar L, Melczer L. Temporary pacemakers for non-cardiac surgery. Eur J Anaesthesiol 2003;20:575–88.
© 2006 International Anesthesia Research Society