|Year : 2013 | Volume
| Issue : 2 | Page : 94-96
Safety profile in a parturient with permanent pacemaker who underwent successive lower segment cesarean section under spinal anesthesia
Parul Jindal, Ruchi Kapoor, Gurjeet Khurana, Nidhi Agarwal
Department of Anaesthesiology, Critical Care, Himalayan Institute of Medical Sciences, HIHT University, Dehradun, Uttarakhand, India
|Date of Web Publication||19-Dec-2013|
Department of Anaesthesiology, Pain Management and ICU, Himalayan Institute of Medical Sciences, Jolly Grant, Dehradun, Uttarakhand
Source of Support: None, Conflict of Interest: None
We present an unusual case of a young parturient who was diagnosed to have a complete heart block during her first pregnancy and permanent pacemaker was implanted. She underwent an elective cesarean section under subarachnoid block without any complications. The same patient presented after 15 months for emergency cesarean section. The surgery was again performed successfully under spinal anesthesia. The maternal and fetal outcome was excellent.
Keywords: Complete heart block, permanent pacemaker, pregnancy, spinal anesthesia
|How to cite this article:|
Jindal P, Kapoor R, Khurana G, Agarwal N. Safety profile in a parturient with permanent pacemaker who underwent successive lower segment cesarean section under spinal anesthesia. J Obstet Anaesth Crit Care 2013;3:94-6
|How to cite this URL:|
Jindal P, Kapoor R, Khurana G, Agarwal N. Safety profile in a parturient with permanent pacemaker who underwent successive lower segment cesarean section under spinal anesthesia. J Obstet Anaesth Crit Care [serial online] 2013 [cited 2020 Jan 21];3:94-6. Available from: http://www.joacc.com/text.asp?2013/3/2/94/123305
| Introduction|| |
Parturient with the congenital heart block maybe asymptomatic but can present with sudden vascular collapse, especially during labor.  Bradycardia, hypotension, arrhythmias, cardiac arrest or even sudden death are some of the complications, which have to be considered. 
We present an unusual case of 28-year-old female with congenital complete heart block who had permanent pacemaker placed during her first pregnancy, underwent cesarean section and presented for emergency cesarean section again after 15 months.
| Case Report|| |
A 28-year-old parturient presented with an emergency with scar tenderness at 38 weeks of gestation. The details of her previous surgery were retrieved from her old medical records. The patient had ventricular septal defect at birth, which had closed spontaneously. During her previous pregnancy, complete heart block was diagnosed and permanent pacemaker (VVI-Metronic) was implanted under local anesthesia, the procedure was uneventful.
The surgery was carried out under spinal anesthesia with 10 mg of heavy bupivacaine after a preload 500 mL colloid solution. There were no hypotensive episodes and no vasopressors were required. The baby had an Agar score 9 at 1, 3, 5 min. She was discharged on 7 th post-operative day.
After 7 months of her first delivery, she conceived again and visited our hospital. She continued her pregnancy under special antenatal and cardiac care. Her last visit was 10 days back when complete assessment was done.
The electrocardiogram (ECG) done in emergency show mostly sinus rhythm with atrial triggered ventricular pacing at a rate of 72 bpm. On examination, in operating room her pulse rate was 64/min, regular and blood pressure was 120/76 mmHg. Cardio respiratory system was normal. Informed consent was taken from the patient and merits and demerits of anesthesia techniques employed were explained. A 16 gauge cannula was inserted in the left forearm and she was preloaded with 6% hydroxyethylstarch (volulyte) 500 mL. Oxygen was delivered by face mask at 5 L/min continued until post-operative period. A wedge was placed under right buttock to give a lateral until the baby was delivered.
Monitoring included electrocardiogram, pulse oximeter and non-invasive blood pressure. The availability of a pacemaker magnet was available in the operating room during the surgery. In a sitting position, under all aseptic precautions subarachnoid block was performed in L3-L4 space 2.0 mL of 0.5% heavy bupivacaine was given and 0.5 mL of fentanyl (25 μg). The level of the block was T6, the surgery was started and a healthy male baby with an Apgar score of 9 at 1, 3 and 5 min was delivered. Oxytocin was administered 1 unit every 30 s to a total of 5 units. There was no episode of hypotension and no vasopressors were administered. There were no other adverse events intraoperatively. The estimated blood loss was 500 mL and intraoperatively 1 L crystalloid was transfused. Patient was shifted to post-operative ward and oxygen therapy was continued. Continuous ECG monitoring, pulse oximeter, hemodynamic parameters and urine output was monitored. IV paracetomol 1 g six hourly and IV tramadol 100 mg prn up to a maximum of three doses per day was continued for 48 h. She had completely uneventful recovery and was discharged on 7 th post-operative day.
| Discussion|| |
Advances in cardiology and cardiovascular surgery have increased use of permanent pacemakers in young adults so that there are more women with pacemakers becoming pregnant. The prevalence of heart disease in pregnancy has remained relatively constant over the last several decades; reported incidence is between 0.4% and 4.1%. ,
While reviewing the literature, we came across a few cases where the obstetric patients with permanent pacemaker have undergone emergency lower segment cesarean section (LSCS). Most of the Anesthetist have administered general anesthesia successfully in such patients, regional anesthesia has generally been avoided as it is associated with hemodynamic instability, which can be detrimental in patients with cardiovascular problems. ,,] Combined spinal epidural and epidural anesthesia technique have been described, but we did not administer epidural anesthesia as the patient was posted for emergency LSCS, there were cost restrains and the expected duration of surgery was not very long. General anesthesia was not administered as both inhalational and intravenous (IV) anesthetic agents may alter the hemodynamic status to some extent exposing them to potential danger.
Even though, patient was asymptomatic during the first pregnancy, permanent pacemaker may have been inserted by the Cardiologist as per the newer guidelines, which recommend permanent pacemaker implantation (PPI), for all congenital complete heart blocks (class 2a/b) as trials have shown that there is a subgroup of patients who may have sudden cardiac arrest for which there are no predictors available. ,,
Pre-operative evaluation is an important aspect. Along with a detailed history thorough physical examination should be done. Routine biochemical and hematological investigations should be performed as indicated on individual basis. A 12 lead electrocardiograms, well-penetrated X-ray chest (for visualization of continuity of leads) and measurement of serum electrolytes (especially K+) should be performed.  Potassium equilibrium across the cell membrane determines the resting membrane potential. An acute increase in potassium causes less negative resting membrane potential. In this situation, the pacemaker continues to pace. However, the occurrence of ventricular tachycardia is a real possibility if pacing impulse is emitted into repolarizing myocardial tissue. An acute decrease in potassium leads to loss of pacing. , Most pacemakers are sensitive to direct or indirect electromagnetic interference (EMI).  Direct sources like electrocautery or dental pulp vitality tester or indirect sources like mechanical ventilator, orthopedic saw are potential source of mechanical interferences that could affect pacemaker. Fatal arrhythmia and even death have been reported with the use of electrocautery leading to failure of pacemaker. 
According to the recent guidelines bipolar cautery is preferred as it causes less EMI. If unipolar cautery is to be used the grounding plate should be placed as close to the operative site and as far as possible from the pacemaker, usually on the thigh and should have good contact with skin. , Despite precautions, pacemaker failure can still occur and in certain clinical circumstances placement of a temporary IV pacemaker may be indicated. The device should always be rechecked after the surgery  as was done in the present case.
Majeed et al.  have reported elective cesarean section in a patient with complete heart block under combined spinal epidural anesthesia. They administered 2.5 mL of 0.5% bupivacaine (2.5 mg) and 0.5 mL of fentanyl (25 μg) for the spinal block. An infusion of metaraminol was administered at a rate of 2 mg/h.
In another case report by Kumar,  spinal anesthesia was given in the L3-L4 interspace with a combination of a 1.0 mL hyperbaric 0.5% bupivacaine with 0.5 mL fentanyl (25 μg). They achieved a spinal level of T-6. Intraoperatively, the first episode of hypotension after the spinal anesthesia was treated by increasing the pacing rate to 70 beats/min and the second episode was treated by 3 mg of IV ephedrine.
In the present, patient there was no episode of hypotension probably due to colloid preload. We recommend that the anesthetic technique that least alters the cardiac stability should be wisely planned and executed for the procedure.
| Conclusion|| |
Spinal anesthesia is a safe technique for emergency cesarean section in a pregnant patient with permanent pacemaker.
| Acknowledgments|| |
We would like to express our gratitude and appreciation to our colleagues in Gynecology and Obstetric Department who are doing incredible work.
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