27 Gangguan Irama JTG

Case Report
ABNORMAL HEART RHYTM IN PREGNANCY
ANDALAS UNIVERSITY
By:
dr. Aswin Boy Pratama, SpOG

Trainee of Fetomaternal Subspeciality Education
Program
Mentor:
Prof. Dr. dr. Hj. Yusrawati, SpOG, Subs-KFM
(K)
Dr. Dr. dr. Joserizal Serudji SpOG, Subs-KFM
(K)
FETOMATERNAL SUBSPECIALITY EDUCATION PROGRAM

OBSTETRICS AND GYNECOLOGY
MEDICAL FACULTY OF ANDALAS UNIVERSITY
2024
PROGRAM STUDI SUBSPESISALIS OBSTETRI DAN
GINEKOLOGI PEMINATAN KEDOKTERAN FETOMATERNAL
FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS
RSUP Dr. M. DJAMIL PADANG
LEMBAR PENGESAHAN
Nama : dr. Aswin Boy Pratama, SpOG

Semester : I (Satu)
Telah menyelesaikan kasus Kehamilan

dengan Penyulit Abnormal Heart Rhytm
Padang, April 2024
Pembimbing Peserta Pendidikan Subspesialis Obgyn

Peminatan Kedokteran Fetomaternal
Dr.Dr.dr.Joserizal Serudji SpOG(K) dr. Aswin Boy Pratama,SpOG
MENGETAHUI
KPS SUBSPESIALIS OBGYN

PEMINATAN KEDOKTERAN
FETOMATERNAL FK UNAND
Prof.Dr.dr.Hj.Yusrawati,SpOG(K)
CHAPTER 1
INRODUCTION
Case: Mrs. Syahrani 27 years old 01107860 with G1P0A0H0 15-16 weeks
gestational ages presents to fetomaternal. This patient referral from Secondary
hospital. She had had history of bradycardia diagnosed since a teenager but had
not undergone tests nor received treatments. Now she has diagnosed by
cardiologist with AV block on peace maker.
Bradycardia in pregnancy due to total atrioventricular block (TAVB) is a rare

occurrence, often asymptomatic and may arise from a congenital disorder.
Pacemaker is often required. Cases are few and management is not yet
standardised. TAVB in pregnancy requires a concerted effort involving
obstetricians, cardiologists, and intensivists. Pacemaker implantation is
recommended. Whilst vaginal delivery remains first-choice, caesarean section is
indicated under obstetric indications.
CHAPTER II
LITERATURE REVIEW
2.1 Introduction
Bradycardia in pregnancy due to total atrioventricular block is a rare yet serious
occurrence [1]. In most cases, it is often asymptomatic but symptomatic cases
would require urgent and definitive management [1]. Total atrioventricular block
may be a congenital disorder or stem from an acquired pathology [2]. Lack of
awareness often delays diagnosis with some patients presenting late during labour
[3]. Definitive management requires pacemaker implantation but there has been
controversy in the past regarding its necessity [3].
Unfortunately, due to its rarity, only few cases have been described in the
literature and guidelines on optimal management have been sparse. As a result, no
uniform management recommendations are available and, in some cases,
clinicians have had to explore the best form of management for their patient. In
Indonesia, to the best of the authors’ knowledge, there have been no case reports
so far of bradycardia in pregnancy due to a congenital disorder. This case report
wishes to highlight the rare cases, the challenges we had, the lack of experience
we encountered and the solutions we undertook using the best clinical evidence
available so far.
2.2 Discussion
Bradyarrhythmia among female of reproductive age is rare, even rarer is
bradyarrhythmia in pregnancy [1]. It is estimated that the prevalence of
bradyarrhythmia is in 1/20,000 women of reproductive age [1]. However, this
figure may also be an estimation as the true prevalence remains unknown. In this
case, the bradyarrhtyhmia is caused by TAVB. There are various etiologies to
TAVB in pregnancy [2]. The most common is congenital TAVB, in which
patients are born with a disconnected cardiac electric conduction system with no
communication between the sinoatrial (SA) node and the AV node [2] (1). Other
causes are often acquired including ischemic heart diseases, drug toxicity, nodal
ablation, electrolyte imbalance and post-operative heart blocks due to past cardiac
surgeries [2]. Systemic diseases such as amyloidosis, sarcoidosis and systemic
lupus erythematosus (SLE) may also cause TAVB [2]. The two cases in this
report had congenital TAVB as they had no history toward acquired TAVB.
Fig 1.
Complete atrioventricular block and its ECG waveforms Complete
atrioventricular block and its ECG waveforms [5].
Thus far, the recommendation is to implant pacemakers among those showing

signs and symptoms of heart failure. However, it is among those asymptomatic
that the recommendations are less strong and ambiguous. 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].
With no large-sized studies, clinicians have had to depend on small-scale studies
and occasional case reports suggesting different treatments. Whilst many advocate
for pacemakers, there have been other studies demonstrating its lack of clinical
benefit among asymptomatic patients [7]. Recently, the American Heart
Association (AHA) and the European Society of Cardiology (ESC) have updated
their guidelines and they now recommend a permanent pacemaker implantation
for those having complete heart block with high-risk features in pregnancy,
regardless of symptom presence [8,9]. If permanent pacemaker is not available,
then at least temporary pacemaker is sufficient [8,9].
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]. Still, evaluations are necessary since drastic hemodynamic changes occur
between pregnancy and postpartum [6]. In our case report, both patients
unfortunately had unplanned pregnancies and they had not consulted obstetricians
prior to their pregnancies. Still, the second patient had been diagnosed with
bradyarrhythmia during her antenatal consultations and could have a pacemaker
implanted during pregnancy whilst the other patient had to have the pacemaker
implanted during active labour. Both scenarios were far from ideal.
After the pacemaker was implanted, the next concern was the optimal route of
delivery. The recommendation is to deliver vaginally with operative vaginal
delivery if necessary [3,10]. Caesarean section remains reserved under obstetric
indications [3]. There is an additional concern with routine caesarean section.
Spinal anaesthesia during caesarean section induces hypotension and among
patients with bradycardia, the required compensatory mechanisms to respond to
hypotension may be lacking [3]. General anaesthesia is also associated with
hypotension [3]. Thus, a combination of epidural and spinal anaesthesia may be
better due to the immediate effect of spinal anaesthesia and the top-up dosing
available from epidural anaesthesia [1]. However, both of our cases opted for
caesarean section as the attending consultants were hesitant to opt for vaginal
delivery due to their lack of experience in managing such complex cases.
Fortunately, the caesarean sections went well, and the patients made good
recovery.
There has not been conclusive evidence that TAVB in pregnancy leads to foetal
complications such as preterm birth, intrauterine growth restriction, preeclampsia,
and foetal distress [11]. Notably, Hidaka et al. discovered that there was no
significant difference in the risks towards foetal complications among those with
and without pacemaker installed [11]. However, the study had few subjects due to
case rarity and its conclusion needs to be interpreted carefully.
There are several forms of contraception to be recommended with intrauterine
devices and hormonal implants being the reversible long-term options whilst
sterilisation is irreversible [12,13]. Other hormonal methods such as progesterone
pills and injections may also be indicated if it suits the patient's preferences.
[12,13].
2.3 Next Pregnancy

For future pregnancies, a thorough planning is necessary. In the preconceptional
stage, every pregnancy plan should be dealt with in a multidisciplinary clinic
involving cardiologists, obstetricians, intensivist and specialty nurses [14]. There
needs to be a risk stratification undertaken before any pregnancy is to be
attempted [15]. There are several such stratification scores available, including the
modified WHO (mWHO) scale, Cardiac Diseases in Pregnancy (CARPREG)
and Zwangerschap bij Aangeboren Hartafwijking (ZAHARA) scale [15]. The
ZAHARA scale was specifically devised with congenital cardiac diseases in mind
and according to this scale, a history of prior arrhythmia (bradyarrhtyhmia) places
patients at a risk of 7.5% for future cardiac complications [16].
For patients deciding for pregnancies, there needs to be a continuous risk
stratification process throughout pregnancy [15]. At the antenatal consultations,
USG, foetal echocardiography and maternal ECG are recommended [14]. Foetal
echocardiography should be performed during the 2nd trimester by a qualified
paediatric cardiologist [14].
In the third trimester, between 32 and 34 weeks there should be a clear delivery
plan [14]. Whilst vaginal delivery remains first-line, operative vaginal delivery
and caesarean section should also be discussed [14]. Postpartum, patients will
require further puerperal visits to assess maternal cardiac function until 2–3
months post-delivery [14].
To conclude, there is still little clinical experience with TAVB in pregnancy. The
primary recommendation is to implant pacemakers regardless of symptoms. The
second recommendation is to opt for vaginal delivery unless obstetric indications
preclude it. A multidisciplinary team involving cardiologists, obstetricians,
intensivist and nurses are required to manage such cases.
CHAPTER III
DISCUSSION
Screening, early recognition, risk stratification and thorough planning are required
to successfully manage TAVB in pregnancy. Bradycardia in pregnancy due to
total atrioventricular block (TAVB) is a rare occurrence, often asymptomatic and
may arise from a congenital disorder. Pacemaker is often required. Cases are few
and management is not yet standardised. TAVB in pregnancy requires a concerted
effort involving obstetricians, cardiologists, and intensivists. Pacemaker
implantation is recommended. Whilst vaginal delivery remains first-choice,
caesarean section is indicated under obstetric indications.
References
1. Sundararaman L., Hochman Cohn J., Ranasinghe J.S. Complete heart block in pregnancy: case
report, analysis, and review of anesthetic management. J. Clin. Anesth. 2016;33:58–
61. [PubMed] [Google Scholar]
2. Knabben V., Chhabra L., Slane M. StatPearls Publishing; Treasure Island (FL): 2021. Third-
Degree Atrioventricular Block. StatPearls (Internet) [Google Scholar]
3. Suri V., Keepanasseril A., Aggarwal N., Vijayvergiya R., Chopra S., Rohilla M. Maternal
complete heart block in pregnancy: analysis of four cases and review of management. J.
Obstet. Gynaecol. Res. 2009;35(3):434–437. [PubMed] [Google Scholar]
4. Agha R.A., Franchi T., Sohrabi C., Mathew G., Kerwan A. The SCARE 2020 guideline:
updating consensus surgical CAse REport (SCARE) guidelines. Int. J. Surg. 2020;84:226–
230. [PubMed] [Google Scholar]
5. Malmivuo J., Plonsey R. 1995. Bioelectromagnetism. 19. The Basis of ECG Diagnosis. [Google
Scholar]
6. Dhiman N., Sarda N., Arora R. Management of complete heart block during pregnancy. J.
Obstet. Gynaecol. Res. 2013;39(2):588–591. [PubMed] [Google Scholar]
7. 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(5):605–607. [PubMed] [Google Scholar]
8. Kusumoto F.M., Schoenfeld M.H., Barrett C., Edgerton J.R., Ellenbogen K.A., Gold M.R., et al.
ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia
and cardiac conduction delay: a report of the American college of cardiology/American heart
association task force on clinical practice guidelines and the heart rhythm
society. Circulation. 2018;140(8):e382–e482. 2019. [PubMed] [Google Scholar]
9. Glikson M., Nielsen J.C., Kronborg M.B., Michowitz Y., Auricchio A., Barbash I.M., et al. ESC
Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur. Heart
J. 2021;42(35):3427–3520. 2021. [PubMed] [Google Scholar]
10. Sharma J.B., Malhotra M., Pundir P. Successful pregnancy outcome with cardiac pacemaker
after complete heart block. Int. J. Gynaecol. Obstet. 2000;68(2):145–146. [PubMed] [Google
Scholar]
11. Hidaka N., Chiba Y., Fukushima K., Wake N. Pregnant women with complete atrioventricular
block: perinatal risks and review of management. Pacing Clin.
Electrophysiol. 2011;34(9):1161–1176. [PubMed] [Google Scholar]
12. Swan L. Congenital heart disease in pregnancy. Best Pract. Res. Clin. Obstet.
Gynaecol. 2014;28(4):495–506. [PubMed] [Google Scholar]
13. Thorne S., MacGregor A., Nelson-Piercy C. Risks of contraception and pregnancy in heart
disease. Heart. 2006;92(10):1520–1525. [PMC free article] [PubMed] [Google Scholar]
14. RCOG . Royal College of Obstetricians and Gynaecologists; London: 2011. Cardiac Disease
and Pregnancy - Good Clinical Practice No. 13. [Google Scholar]
15. van Hagen I.M., Roos-Hesselink J.W. Pregnancy in congenital heart disease: risk prediction
and counselling. Heart. 2020;106(23):1853. [PMC free article] [PubMed] [Google Scholar]
16. Manolis A., Manolis T., Metaxa S. Pregnancy and cardiovascular
disease. Rhythmos. 2013;8:45–56. [Google Scholar]

27 Gangguan Irama JTG

Uploaded by

Copyright:

Available Formats

27 Gangguan Irama JTG

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

27 Gangguan Irama JTG

Uploaded by

Copyright:

Available Formats

Case Report

ABNORMAL HEART RHYTM IN PREGNANCY

dr. Aswin Boy Pratama, SpOG

FETOMATERNAL SUBSPECIALITY EDUCATION PROGRAM

Nama : dr. Aswin Boy Pratama, SpOG

Telah menyelesaikan kasus Kehamilan

Padang, April 2024

Pembimbing Peserta Pendidikan Subspesialis Obgyn

Dr.Dr.dr.Joserizal Serudji SpOG(K) dr. Aswin Boy Pratama,SpOG

KPS SUBSPESIALIS OBGYN

Bradycardia in pregnancy due to total atrioventricular block (TAVB) is a rare

Thus far, the recommendation is to implant pacemakers among those showing

2.3 Next Pregnancy

You might also like