Maternal conduction disorders and bradycardia during pregnancy
- Louise Harris, MBChB
Louise Harris, MBChB
- Professor of Medicine
- University Health Network, Toronto General Hospital
- Sing-Chien Yap, MD, PhD
Sing-Chien Yap, MD, PhD
- Cardiac Electrophsyiologist
- Erasmus Medical Center
- University Medical Center Rotterdam
- Candice Silversides, MD, MS, FRCPC
Candice Silversides, MD, MS, FRCPC
- Section Editor — Congenital Heart Disease
- Associate Professor of Medicine
- University of Toronto
- Section Editors
- Hugh Calkins, MD
Hugh Calkins, MD
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Johns Hopkins Medical Institutions
- N A Mark Estes, III, MD
N A Mark Estes, III, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Tufts University School of Medicine
Arrhythmias and conduction disorders are the most common cardiac complications encountered during pregnancy in women with and without structural heart disease [1-3]. They may manifest for the first time during pregnancy, and in other cases, pregnancy can trigger exacerbations in women with pre-existing arrhythmias [1,4-6]. Women with established arrhythmias or structural heart disease are at highest risk of developing arrhythmias during pregnancy. Due to surgical advances, there has been an increase in the number of women of childbearing age with congenital heart disease and this group of women is at particularly high risk for arrhythmias (figure 1) [1,2,7-11]. Because of these associations, any woman who presents with an arrhythmia should have a clinical work up (including an electrocardiogram and a transthoracic echocardiogram) for evidence of structural heart disease.
In general, the approach to the treatment of conduction disturbances and bradycardia in pregnant women is similar to that in the nonpregnant patient. Treatment strategies during pregnancy are hampered by the lack of randomized trials in this cohort of women. Choice of therapy, for the most part, is based on limited data from case reports, observational studies, and clinical experience.
The prevalence, clinical presentation, and management of conduction disorders and bradycardia during pregnancy will be reviewed here. Electrocardiographic characteristics of sinus bradycardia and conduction disorders are discussed in detail elsewhere. (See "ECG tutorial: Rhythms and arrhythmias of the sinus node" and "ECG tutorial: Atrioventricular block".)
Issues relating to supraventricular and ventricular arrhythmias, as well as cardiac arrest during pregnancy, are discussed separately. (See "Cardiopulmonary arrest in pregnancy" and "Supraventricular arrhythmias during pregnancy" and "Ventricular arrhythmias during pregnancy".)
Palpitations occur frequently during pregnancy and are a common indication for cardiac evaluation during pregnancy. The differential diagnosis of palpitations is extensive and the diagnostic evaluation of pregnant women with palpitations does not differ from nonpregnant women. (See "Overview of palpitations in adults".)
- Siu SC, Sermer M, Colman JM, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation 2001; 104:515.
- Drenthen W, Pieper PG, Roos-Hesselink JW, et al. Outcome of pregnancy in women with congenital heart disease: a literature review. J Am Coll Cardiol 2007; 49:2303.
- Drenthen W, Boersma E, Balci A, et al. Predictors of pregnancy complications in women with congenital heart disease. Eur Heart J 2010; 31:2124.
- Lee SH, Chen SA, Wu TJ, et al. Effects of pregnancy on first onset and symptoms of paroxysmal supraventricular tachycardia. Am J Cardiol 1995; 76:675.
- Doig JC, McComb JM, Reid DS. Incessant atrial tachycardia accelerated by pregnancy. Br Heart J 1992; 67:266.
- Silversides CK, Harris L, Haberer K, et al. Recurrence rates of arrhythmias during pregnancy in women with previous tachyarrhythmia and impact on fetal and neonatal outcomes. Am J Cardiol 2006; 97:1206.
- Siu SC, Sermer M, Harrison DA, et al. Risk and predictors for pregnancy-related complications in women with heart disease. Circulation 1997; 96:2789.
- Drenthen W, Pieper PG, Ploeg M, et al. Risk of complications during pregnancy after Senning or Mustard (atrial) repair of complete transposition of the great arteries. Eur Heart J 2005; 26:2588.
- Drenthen W, Pieper PG, van der Tuuk K, et al. Cardiac complications relating to pregnancy and recurrence of disease in the offspring of women with atrioventricular septal defects. Eur Heart J 2005; 26:2581.
- Drenthen W, Pieper PG, Roos-Hesselink JW, et al. Pregnancy and delivery in women after Fontan palliation. Heart 2006; 92:1290.
- Blomström-Lundqvist C, Scheinman MM, Aliot EM, et al. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias). Circulation 2003; 108:1871.
- Shotan A, Ostrzega E, Mehra A, et al. Incidence of arrhythmias in normal pregnancy and relation to palpitations, dizziness, and syncope. Am J Cardiol 1997; 79:1061.
- MENDELSON CL. Disorders of the heartbeat during pregnancy. Am J Obstet Gynecol 1956; 72:1268.
- COPELAND GD, STERN TN. Wenckebach periods in pregnancy and puerperium. Am Heart J 1958; 56:291.
- Sherer DM, Nawrocki MN, Thompson HO, Woods JR Jr. Type I second-degree AV block (Mobitz type I, Wenckebach AV block) during ritodrine therapy for preterm labor. Am J Perinatol 1991; 8:150.
- Matta BF, Magee P. Wenckebach type heart block following spinal anaesthesia for caesarean section. Can J Anaesth 1992; 39:1067.
- Eddy WA, Frankenfeld RH. Congenital complete heart block in pregnancy. Am J Obstet Gynecol 1977; 128:223.
- Thaman R, Curtis S, Faganello G, et al. Cardiac outcome of pregnancy in women with a pacemaker and women with untreated atrioventricular conduction block. Europace 2011; 13:859.
- Tateno S, Niwa K, Nakazawa M, et al. Arrhythmia and conduction disturbances in patients with congenital heart disease during pregnancy: multicenter study. Circ J 2003; 67:992.
- Suri V, Keepanasseril A, Aggarwal N, et al. Maternal complete heart block in pregnancy: analysis of four cases and review of management. J Obstet Gynaecol Res 2009; 35:434.
- Dalvi BV, Chaudhuri A, Kulkarni HL, Kale PA. Therapeutic guidelines for congenital complete heart block presenting in pregnancy. Obstet Gynecol 1992; 79:802.
- Michaëlsson M, Jonzon A, Riesenfeld T. Isolated congenital complete atrioventricular block in adult life. A prospective study. Circulation 1995; 92:442.
- Kenmure AC, Cameron AJ. Congenital complete heart block in pregnancy. Br Heart J 1967; 29:910.
- Avasthi K, Gupta S, Avasthi G. An unusual case of complete heart block with triplet pregnancy. Indian Heart J 2003; 55:641.
- European Society of Gynecology (ESG), Association for European Paediatric Cardiology (AEPC), German Society for Gender Medicine (DGesGM), et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J 2011; 32:3147.
- Jaffe R, Gruber A, Fejgin M, et al. Pregnancy with an artificial pacemaker. Obstet Gynecol Surv 1987; 42:137.
- Sharma JB, Malhotra M, Pundir P. Successful pregnancy outcome with cardiac pacemaker after complete heart block. Int J Gynaecol Obstet 2000; 68:145.
- Ramsewak S, Persad P, Perkins S, Narayansingh G. Twin pregnancy in a patient with complete heart block. A case report. Clin Exp Obstet Gynecol 1992; 19:166.
- Hidaka N, Chiba Y, Kurita T, et al. Is intrapartum temporary pacing required for women with complete atrioventricular block? An analysis of seven cases. BJOG 2006; 113:605.
- Hidaka N, Chiba Y, Fukushima K, Wake N. Pregnant women with complete atrioventricular block: perinatal risks and review of management. Pacing Clin Electrophysiol 2011; 34:1161.
- Keepanasseril A, Maurya DK, Suriya Y, Selvaraj R. Complete atrioventricular block in pregnancy: report of seven pregnancies in a patient without pacemaker. BMJ Case Rep 2015; 2015.
- Jordaens LJ, Vandenbogaerde JF, Van de Bruaene P, De Buyzere M. Transesophageal echocardiography for insertion of a physiological pacemaker in early pregnancy. Pacing Clin Electrophysiol 1990; 13:955.
- Lau CP, Lee CP, Wong CK, et al. Rate responsive pacing with a minute ventilation sensing pacemaker during pregnancy and delivery. Pacing Clin Electrophysiol 1990; 13:158.
- Amikam S, Abramovici H, Brandes JM, et al. Pregnancy in the presence of an implanted pacemaker. Int Surg 1981; 66:369.
- Güdal M, Kervancioğlu C, Oral D, et al. Permanent pacemaker implantation in a pregnant woman with the guidance of ECG and two-dimensional echocardiography. Pacing Clin Electrophysiol 1987; 10:543.
- ACOG Committee on Obstetric Practice. ACOG Committee Opinion. Number 299, September 2004 (replaces No. 158, September 1995). Guidelines for diagnostic imaging during pregnancy. Obstet Gynecol 2004; 104:647.
- Damilakis J, Theocharopoulos N, Perisinakis K, et al. Conceptus radiation dose and risk from cardiac catheter ablation procedures. Circulation 2001; 104:893.
- Kühne M, Schaer B, Reichlin T, et al. X-ray-free implantation of a permanent pacemaker during pregnancy using a 3D electro-anatomic mapping system. Eur Heart J 2015; 36:2790.