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Mobitz type II second-degree atrioventricular block with superimposed preeclampsia: A case report of a multidisciplinary approach to a complex obstetric anesthesia management.
Abstract Number: SU-49
Abstract Type: Case Report/Case Series
In labor and delivery, circulatory changes normally tolerated by healthy women can lead to cardiovascular decompensation in parturients with complex cardiac abnormalities. Optimal strategies for anesthetic management of these patients are not clearly defined [1,2,3,4]. In this case report, we describe the anesthetic management of a pregnant patient diagnosed with superimposed preeclampsia and multiple cardiac abnormalities including Mobitz type II second-degree arterioventricular (AV) block.
A 37-year-old G3P2 obese patient was admitted to the labor and delivery unit for elevated blood pressure readings noted during her clinic visit. The patient had a past medical history of two prior cesarean sections (C/S), second-degree 2:1 AV block, moderate aortic stenosis, mild coarctation of the aorta, and chronic hypertension. At baseline, the patient’s heart rate remained in the 20s to 40s. The patient reported dyspnea and fatigue attributed to her extended work hours. Her cardiologist recommended permanent pacemaker placement but the patient refused.
Following her admission, the patient was diagnosed with superimposed preeclampsia with severe features refractory to medical management, therefore a repeat C/S was deemed appropriate. After multidisciplinary discussions among members of the Obstetric, Cardiology, Cardiac and Obstetric Anesthesia teams, a repeat C/S was performed under epidural anesthesia. A pre-procedural arterial line was placed for continual hemodynamic monitoring. The patient received a lumbar epidural catheter, which was slowly dosed to avoid rapid hemodynamic changes. As the patient’s specific arrhythmia is an indication for temporary transvenous pacing , a pacing electrode was introduced in the OR via a 6 French Cordis. Appropriate capture was confirmed with the assistance of the cardiac anesthesia team. The C/S was performed without incident but persistent bradycardia continued. The patient was then transferred to the cardiac ICU for postoperative monitoring and discharged home on PPD 4 after an uneventful recovery.
Hemodynamic changes during labor and delivery can unmask or exacerbate cardiovascular symptoms leading to significant maternal and fetal morbidity and mortality in parturients with cardiac abnormalities and preeclampsia. Anesthetic management of pregnant women with cardiovascular disease requires a multidisciplinary approach and careful monitoring. We argue that placement of an arterial line and transvenous pacing electrodes with central access provided an additional safety margin in the event that the patient’s persistent bradycardia progressed to a complete heart block and/or hemodynamic instability.
1. BMJ Case Rep. 2015; doi: 10.1136/bvr-2014-208618.
2. BJOG. 2006;113(5):605-7. Epub 2006 Mar 27.
3. Pacing Clin Electrophysiol. 2011;34(9):1161-76.
4. Indian J Anaesth. 2012;56(1):72-4.
5. Semin Cardiothorac Vasc Anesth. 2015; pii: 1089253215584923.