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Brugada in labour; not too fast
Abstract Number: F1C-6
Abstract Type: Case Report/Case Series
A 23-year-old woman with presumed Brugada Syndrome presented in labour. She was diagnosed 1 year earlier after an out of hospital ventricular fibrillation cardiac arrest, had made a full neurological recovery and an implantable cardioverter defibrillator(ICD) had been fitted. She missed several antenatal appointments (including anaesthetic clinic) but prior cardiology correspondence advised prompt treatment of fevers and infection, to ensure normal electrolytes, to consider reprogramming the ICD before caesarian section to avoid electrical interference, and avoidance of drugs mentioned on www.brugadadrugs.org. This website strongly suggests avoiding the anaesthetic drugs bupivacaine and propofol, and preferably avoiding lidocaine and ketamine. She presented to a district general hospital in established early labour at 39 weeks and required urgent transfer to specialist level care due to the lack of cardiology support on site. An epidural was avoided and she laboured normally with N2O analgesia and delivered a health boy by vaginal birth. She proceeded to suffer severe postpartum haemorrhage secondary to trauma and atony resulting in a 4 litre blood loss. She had a general anaesthetic with Thiopentone and suxamethonium and an intrauterine balloon was placed which controlled the bleeding and avoided diathermy. Blood loss was replaced by blood products and she was extubated and sent to recovery where it was noted she was having runs of nonsustained polymorphic ventricular tachycardia(NSVT). Her Mg level of 0.7 was replaced. Further monitoring in the coronary care unit and ICD interrogation revealed frequent runs of NSVT thought to be triggered by ventricular ectopics (VE)- R on T wave phenomenon. She then underwent two VE ablations. Eventually the ICD was upgraded to dual chamber to allow atrial pacing with a base rate higher than her sinus.
Brugada syndrome is a genetic channelopathy that is characterised by specific electrocardiographic changes in the right precordial leads and a susceptibility to malignant ventricular arrhythmias in the presence of a structurally normal heart. The physiological changes of pregnancy and labour combined with the pharmacological effects of obstetric analgesia and anaesthesia may precipitate ventricular and atrial arrhythmia with a risk of shock from ICD. A recent expert consensus statement recommends avoidance of all drugs that may aggravate the condition but this list is exhaustive and precludes the use of many analgesics and anaesthetics familiar to the obstetric anaesthetist. Data on the exact safety of these drugs are limited to individual case reports or case series and evidence is conflicting. A less didactic approach to labour analgesia and anaesthesia would seem more pragmatic. A diagnosis such as Brugada can have a major impact on management. Early antenatal specialist multidisciplinary involvement and delivery plan is advocated to prevent potential delays in management.