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Journal of Postgraduate Medicine, Vol. 49, No. 1, Jan-March, 2003, pp. 98 Letter to the Editor Successful Pregnancy Outcome in a Patient with Complete Heart Block Mehta S, Goswami D, Tempe A The Department of Obstetrics and Gynaecology, Lok Nayak Hospital, New Delhi, India. E-mail: drmehta@hotpop.com Code Number: jp03025 Sir, We recently had a patient aged 30 years who was 7 months' pregnant with complaints of labour pains. There was no history of leaking or bleeding per vaginum and she had no symptoms suggestive of heart disease. On examination her pulse rate was 46 / minute and regular, BP was 110/60mm/Hg. Mild pallor was present. There was no cyanosis or oedema, jugular venous pressure was not raised. Examination of cardio-respiratory system revealed no abnormality. On abdominal examination there was a singleton foetus in cephalic presentation; uterine height corresponded to 30 weeks of gestation. There were mild uterine contractions, foetal heart rate was 140 beats/minute. Her haemoglobin was 9g%, urine analysis was normal. ECG showed complete heart block. Echocardiography was normal. Investigations were done to rule out possible underlying causes of heart block - Anti-Nuclear antibody was negative (which ruled out SLE) and serum TSH was 2.8ng/ml (which ruled out thyroid disorders). She was put on temporary pacemaker. Her labour pains subsided without any medication after 6 hours and the pacemaker was removed after 48 hours. Permanent pacemaker was advised but patient could not afford it at that time. Patient came to the antenatal OPD for regular follow-up. She was admitted with labour pains at 39 weeks of gestation. She had no cardiac symptoms. Her pulse rate was 44 beats/ minute and BP was 110/70 mm/Hg. Her general, physical and cardiovascular examination was unremarkable. On abdominal examination uterus was term size, foetal heart rate was 144/minute and she was getting good uterine contractions. Per vaginal examination showed cervix to be dilated upto 4 cms. She was put on temporary pacemaker with heart rate set at 70 beats/minute. Her labour progressed well and she delivered a female baby of weight 2630 grams with Apgar scores of 9 and 10 at one and five minutes respectively. The temporary pacemaker was removed after 48 hours. Her post partum period was uneventful and she breast-fed her baby. She was discharged in a stable condition with advice for follow up in the cardiology department for permanent pacing. Heart block is an unusual complication of pregnancy. By itself complete heart block rarely creates any obstetric problems, so prophylactic placement of a permanent pacemaker is not indicated in all asymptomatic patients.1 IUGR and polycythemia have been associated with complete heart block.2 Labour in these patients may be complicated by syncope and convulsions caused by slowing of the heart rate during the Valsalva manoeuvre exercised at the time of forceful contractions of the second stage of labour which should be shortened by using forceps. Management involves use of cardiac pacemaker,3,4 which should be implanted before pregnancy (or whenever heart block is diagnosed in pregnancy) to maintain cardiac function. For symptomatic patients in the first and second trimester, permanent pacemaker implantation is the therapy of choice. In symptomatic women who present at or near term, temporary pacing followed by induction of labour should be done at the earliest possible time to prevent complications of prolonged temporary pacing. Overall maternal and neonatal outcome is unaffected in such cases. Mehta S, Goswami D, Tempe A The Department of Obstetrics and Gynaecology, Lok Nayak Hospital, New Delhi, India. E-mail: drmehta@hotpop.com References
Copyright 2003 - Journal of Postgraduate Medicine. Online full-text also available at http://www.jpgmonline.com/ |
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