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Management of Cardiac Pacemakers in a Pregnant Patient

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DOI: 10.4236/ojog.2015.51009    4,112 Downloads   5,020 Views   Citations


Introduction: Despite the increasing use of permanent cardiac pacemakers in a younger patient population, there are little data related to pregnancy. We present our experience in managing a pregnant patient with a pre-existing pacemaker and review the existing literature to establish management guidelines. Case: A 27-year-old G1 P0 presented for prenatal care in the first trimester of pregnancy. She had a past medical history of bradycardia, hypotension and syncope that required dual chamber cardiac pacemaker placement 6 years earlier, and one episode of left upper extremity venous thrombosis related to replacement of the pacemaker wire 4 years earlier. In the early second trimester, the patient began experiencing light-headedness and breathlessness with exertion. The rate settings of the pacemaker were increased with resolution of the patient’s symptoms. The patient underwent primary cesarean section at 39 weeks gestation with delivery of a healthy term infant. Preoperative anesthesia consultation was obtained. The postoperative course was uneventful. Pre-pregnancy pacemaker settings were re-established after the postpartum period. Discussion: The current literature on managing pregnant patients with pre-existing pacemakers is quite limited. Such patients require a multidisciplinary approach to care. Normal physiologic changes in pregnancy may necessitate rate adjustments. Other than routine thromboprophylaxis, no other anticoagulation is needed. Route of delivery is generally based on obstetric indications. During surgery consider using bipolar electrocautery in place of unipolar electrocautery, to reduce electromagnetic interference. Also, the placement of the grounding pad should be as far away from the pacemaker as possible. It should be anticipated that the patient will return to her baseline cardiac status postpartum and therefore pacemaker settings can be adjusted accordingly.

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The authors declare no conflicts of interest.

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Grover, S. , Sheth, P. , Haines, D. , Khan, M. and Gonik, B. (2015) Management of Cardiac Pacemakers in a Pregnant Patient. Open Journal of Obstetrics and Gynecology, 5, 60-69. doi: 10.4236/ojog.2015.51009.


[1] Coolen, J., et al. (2011) Permanent Pacemakers in Pregnancy. Clinical and Experimental Obstetrics & Gynecology, 38, 297-298.
[2] Tateno, S., et al. (2003) Arrhythmia and Conduction Disturbances in Patients with Congenital Heart Disease during Pregnancy: Multicenter Study. Circulation Journal, 67, 992-997.
[3] Eddy, W.A. and Frankenfeld, R.H. (1977) Congenital Complete Heart Block in Pregnancy. American Journal of Obstetrics & Gynecology, 128, 223-225.
[4] Ginns, H.M. and Hollinrake, K. (1970) Complete Heart Block in Pregnancy Treated with an Internal Cardiac Pacemaker. BJOG: An International Journal of Obstetrics and Gynaecology, 77, 710-712.
[6] Wood, M.A. and Ellenbogen, K.A. (2002) Cardiology Patient Pages. Cardiac Pacemakers from the Patient’s Perspective. Circulation, 105, 2136-2138.
[7] Epstein, A.E., et al. (2008) ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) Developed in Collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Journal of the American College of Cardiology, 51, e1-e62.
[8] Hall, G.A. (2005) Textbook of Medical Physiology. 11th Edition, Saunders, Philadelphia.
[9] Clapp, J.F. and Capeless, E. (1997) Cardiovascular Function Before, During, and After the First and Subsequent Pregnancies. The American Journal of Cardiology, 80, 1469-1473.
[10] Elkayam, U. and Gleicher, N. (1998) Cardiac Problems in Pregnancy: Diagnosis and Management of Maternal and Fetal Heart Disease. 3rd Edition, Wiley-Liss, Vol. 3: 1.
[11] Brodsky, M.A., Sato, D.A., Oster, P.D., Schmidt, P.L., Chesnie, B.M. and Henry, W.L. (1986) Paroxysmal Ventricular Tachycardia with Syncope during Pregnancy. The American Journal of Cardiology, 58, 563-564.
[12] Upshaw Jr., C.B. (1970) A Study of Maternal Electrocardiograms Recorded during Labor and Delivery. American Journal of Obstetrics Gynecology, 107, 17-27.
[13] Liebson, P.R., Mann, L.I., Evans, M.I., Duchin, S. and Arditi, L. (1975) Cardiac Performance during Pregnancy: Serial Evaluation Using External Systolic Time Intervals. American Journal of Obstetrics Gynecology, 122, 1-8.
[14] Burg, J.R., Dodek, A., Kloster, F.E. and Metcalfe, J. (1974) Alterations of Systolic Time Intervals during Pregnancy. Circulation, 49, 560-564.
[15] Rubler, S., Damani, P.M. and Pinto, E.R. (1977) Cardiac Size and Performance during Pregnancy Estimated with Echocardiography. American Journal of Cardiology, 40, 534-540.
[16] Toogood, G. (2007) Pacemaker Therapies in Cardiology. Australian Family Physician, 36, 518-9, 521-4.
[17] Bernstein, A.D., Daubert, J.-C., Fletcher, R.D., Hayes, D.L., Luderitz, B., Reynolds, D.W., et al. (2002) The Revised NASPE/BPEG Generic Code for Antibradycardia, Adaptive-Rate, and Multisite Pacing. Pacing and Clinical Electrophysiology, 25, 260-264.
[18] Escher, D.J. (1973) Types of Pacemakers and Their Complications. Circulation, 47, 1119-1131.
[19] Hidaka, N., Chiba, Y., Fukushima, K. and Wake, N. (2011) Pregnant Women with Complete Atrioventricular Block: Perinatal Risks and Review of Management. Pacing and Clinical Electrophysiology, 34, 1161-1176.
[20] Janower, M.L. (1964) Electrical Pacemakers and Ventricular Arrhythmias. Journal of the American Medical Association, 190, 775.
[21] Nora, J.J. and Nora, A.H. (1987) Maternal Transmission of Congenital Heart Diseases: New Recurrence Risk Figures and the Questions of Cytoplasmic Inheritance and Vulnerability to Teratogens. American Journal of Cardiology, 59, 459-463.
[22] Wallis, H. and Thorne, S. (2006) Congenital Heart Disease and Pregnancy. Women’s Health, 2, 743-752.
[23] Whittemore, R., Hobbins, J.C. and Engle, M.A. (1982) Pregnancy and Its Outcome in Women with and without Surgical Treatment of Congenital Heart Disease. American Journal of Cardiology, 50, 641-651.
[24] Thaman, R., Curtis, S., Faganello, G., Szantho, G.V., Turner, M.S., Trinder, J., et al. (2011) Cardiac Outcome of Pregnancy in Women with a Pacemaker and Women with Untreated Atrioventricular Conduction Block. Europace, 13, 859-863.
[25] Benrey, J. (1991) Indications and Choices in Pacemaker Therapy. Texas Heart Institute Journal, 18, 170-178.
[26] Beckman, C.R.B., Ling, F.W., Barzansky, B.M., Herbert, N.P., Laube, D.W. and Smith, R.P. (2010) Obstetrics and Gynecology. 6th Edition, Lippincott Williams and Wilkins, Philadelphia.
[27] Karavidas, A., Lazaros, G., Matsakas, E., Kouvousis, N., Samara, C., Christoforatou, E. and Zacharoulis, A. (2004) Early Pacemaker Lead Thrombosis Leading to Massive Pulmonary Embolism. Echocardiography, 21, 429-432.
[28] Kinney, E.L., Allen, R.P., Weidner, W.A., Pierce, W.S., Leaman, D.M. and Zelis, R.F. (1979) Recurrent Pulmonary Emboli Secondary to Right Atrial Thrombus around a Permanent Pacing Catheter: A Case Report and Review of the Literature. Pacing and Clinical Electrophysiology, 2, 196-202.
[29] Bilge, M., Guler, N. and Eryonucu, B. (1999) Recurrent Pulmonary Emboli and Thrombus Attached to a Permanently Implanted Pacemaker Wire in Pregnancy. Acta Cardiologica, 54, 97-99.
[30] Harvey, R.A. and Champe, P.C. (2012) Lippincott’s Illustrated Reviews: Pharmacology. 5th Edition, Lippincott Williams & Wilkins, Philadelphia.
[31] Stout, M.J. and Odibo, A.O. (2013) Anticoagulation in Pregnant Patients with Mechanical Heart Valves: Clinical Considerations. Clinics in Laboratory Medicine, 33, 357-365.
[32] Chan, W.S., Anand, S. and Ginsberg, J.S. (2000) Anticoagulation of Pregnant Women with Mechanical Heart Valves: A Systematic Review of the Literature. Archives of Internal Medicine, 160, 191-196.
[33] Loftus, C.M. and Committee, A.P. (1996) Neurosurgical Aspects of Pregnancy. In: Loftus, C.M., Ed., Neurological Topics Series, American Association of Neurological Surgeons, Park Ridge, 225.
[34] Middleton, E.B. and Lee, Y.C. (1971) Pregnancy Associated with Cardiac Pacemaker Generator Implanted in Abdominal Wall: A Case Report. Obstetrics Gynecology, 38, 272-275.
[35] Shouse, E.E. and Acker Jr., J.E. (1964) Pregnancy and Delivery in a Patient with External-Internal Cardiac Pacemaker. Obstetrics Gynecology, 24, 817-818.
[36] Kurjak, A. and Chervenak, F.A., Eds. (2006) Textbook of Perinatal Medicine. 2nd Edition, CRC Press, Boca Raton, 2304.
[37] Sornalatha, M. and Arthi, R. (2013) An Algorithm for Extracting Non-Invasive Fetal ECG from the Maternal ECG. International Journal of Engineering Science and Innovative Technology, 2, 302-310.
[38] Kligfield, P., Gettes, L.S., Bailey, J.J., Childers, R., Deal, B.J., Hancock, E.W., et al. (2007) Recommendations for the Standardization and Interpretation of the Electrocardiogram. Journal of the American College of Cardiology, 49, 1109-1127.
[39] Hunter, S. and Robson, S.C. (1992) Adaptation of the Maternal Heart in Pregnancy. British Heart Journal, 68, 540-543.
[40] Matorras, R., Diez, J., Saez, M., Montoya, F., Aranguren, G. and Rodriguez-Escudero, F.J. (1991) Repeat Pregnancy Associated with Cardiac Pacemaker. International Journal of Gynecology & Obstetrics, 36, 323-327.
[41] Mendelson, M.A. (2008) Pregnancy in the Woman with Preexisting Cardiovascular Disease. The Global Library of Women’s Medicine.
[42] Ng, Y.T., Cheung, M.W. and Hui, Y.L. (1997) Anesthetic Management of a Parturient Implanted with a Permanent Pacemaker—A Case Report. Acta Anaesthesiologica Sinica, 35, 107-111.
[43] Simpson, J. (1993) Anesthesia and the Patient with Co-Existing Heart Disease. Little Brown & Co, Boston, 474.
[44] Parer, J.T. (2002) Uteroplacental Circulation and Respiratory Gas Exchange. In: Hughes, S.C., Levinson, G. and Rosen, M.A., Eds., Shnider and Levinson’s Anesthesia for Obstetrics, 4th Edition, Lippincott Williams & Wilkins, Philadelphia, 706.
[45] Amikam, S., Abramovici, H., Brandes, J.M., Peleg, H. and Riss, E. (1981) Pregnancy in the Presence of an Implanted Pacemaker. International Surgery, 66, 369-371.
[46] Baron, J.-F., Decaux-Jacolot, A., Edouard, A., Berdeaux, A. and Samii, K. (1986) Influence of Venous Return on Baroreflex Control of Heart Rate during Lumbar Epidural Anesthesia in Humans. Anesthesiology, 64, 188-193.
[47] Caramella, J.P., Mentre, B., Jattiot, F., Strouk, R. and Delétang, D. (1987) Reprogrammation d’un stimulateur cardiaque induite par le bistouri électrique. Annales Fran?aises d’Anesthésie et de Réanimation, 6, 214-216.
[48] Batra, Y.K. and Bali, I.M. (1978) Effect of Coagulating and Cutting Current on a Demand Pacemaker during Transurethral Resection of the Prostate: A Case Report. Canadian Anaesthetists’ Society Journal, 25, 65-66.
[49] Mangar, D., Atlas, G.M. and Kane, P.B. (1991) Electrocautery-Induced Pacemaker Malfunction during Surgery. Canadian Journal of Anesthesia, 38, 616-618.
[50] Smirnova, L.M., Glukhova, P.A., Pavlova, S.S. and Ivanova, I.G. (1982) Pregnancy and Labor in Patients with Artificial Pacemakers. Akusherstvo I Ginekologiia, 5, 31-34.
[51] Laurens, P., Haiat, R., Gavelle, P., Maurice, P. and Chiche, P. (1976) Isotop Cardiac Pacemaker during Pregnancy. 3 Cases. La Nouvelle Presse Médicale, 5, 2997-3000.
[52] Jaffe, R., Gruber, A., Fejgin, M., Altaras, M. and Ben-Aderet, N. (1987) Pregnancy with an Artificial Pacemaker. Obstetrical & Gynecological Survey, 42, 137-139.

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