Download Cardioversion in late pregnancy : a case report

(Acta Anaesth. Belg., 2014, 65, 105-107)
Cardioversion in late pregnancy : a case report
V. Singh, P. Bhakta, J. Hashmi and N. Zaidi
Abstract : About 1% of all pregnancies are complicated
by maternal cardiac diseases. Among the various cardiac
pathologies complicating pregnancy, arrhythmias are the
most common. Most of them are diagnosed for the first
time during pregnancy. Tachyarrhythmias are the commonest form of arrhythmias reported during pregnancy.
Risk factors for this are the presence of organic heart
­disease, various hormonal and hemodynamic changes
during pregnancy. Fortunately most of these arrhythmias
are benign and require no intervention. Treatment ­options
must take into consideration hemodynamic status of
mother, gestational age and the possible teratogenic
effect of medications on the fetus. We are hereby
­
­reporting a case of successful electrical cardioversion
performed in a woman at 37th week of gestation due to
resistant symptomatic atrial fibrillation.
Keys words : Cardioversion ; late pregnancy ; case
report.
About 1% of all the pregnancies are complicated by maternal cardiac diseases (1), of which arrhythmias are the most common. Tachyarrhythmias
are the commonest form of arrhythmias reported
during pregnancy (2, 3). We are hereby reporting a
case of electrical cardioversion (ECV) performed
due to persistence of symptoms in a case of resistant
atrial fibrillation (AF) in a woman at the 37th week
of pregnancy.
Case Report
Thirty-seven-year-old primigravida presented
to our emergency department at 27th weeks of
­gestation with complain of palpitation. She had no
significant past medical illness and was hemo­
dynamically stable. Abdominal ultrasound examination confirmed fetal viability and growth of the
fetus which were consistent with her duration of the
pregnancy. Her initial transthoracic echocardiogram was within normal limit. Blood investigations
were done to rule out anemia, hyperthyroidism and
electrolyte abnormality. Her electrocardiogram
(ECG) showed AF and she was started on metopro-
lol and therapeutic dose of low molecular weight
heparin (LMWH).
After six weeks, her ECG showed rate controlled AF. Foetal maturity was confirmed at thirtyfourth weeks of gestation by abdominal ultrasound
examination. After multidisciplinary meeting it was
decided to do transoesophageal echocardiography
(TOE) to rule out any left atrial thrombus followed
by elective ECV to revert her back to sinus rhythm
as she was still symptomatic with complain of palpitation.
She was admitted the night before the procedure. LMWH was withheld twenty-four hours before the procedure in anticipation of any emergency
cesarean section which may arise with cardioversion. In the operating theatre standard monitoring
was applied. To assess fetal wellbeing continuous
cardiotocogram (CTG) was also used. Obstetrician
was on standby for any emergency cesarean section
if such situation arises. Difficult airway trolley was
kept in the operation theater.
Patient was given acid aspiration prophylaxis
with intravenous ranitidine (50 mg) and oral sodium
citrate (0.3 Molar, 30 ml) 15 minutes before the
procedure. General anesthesia was induced using
modified rapid sequence induction technique with
propofol (2.5 mg/kg) and rocuronium (1 mg/kg).
Airway was secured with a cuffed endotracheal
tube. Anesthesia was maintained with oxygen, air
and sevoflurane. Ventilation was controlled using
intermittent positive pressure technique. TOE revealed normal cardiac anatomy. She responded to a
single synchronised shock of 150 Joules (Fig. 1).
Dr. Vikash Singh, Registrar ; Dr. Pradipta Bhakta, Specialist
Registrar ; Dr. Junaid Hashmi, Registrar ; Dr. Nadeem
­Zaidi, Consultant.
(*) Department of Anaesthesia & Intensive care, Our Lady of
Lourdes Hospital, Drogheda, Ireland.
Corresponding address : Dr. Pradipta Bhakta, Department of
Anaesthesia & Intensive Care, James Connolly Hospital,
Dublin, Ireland. Tel. : 00 353 894137596.
E-mail : [email protected]
© Acta Anæsthesiologica Belgica, 2014, 65, n° 3
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et al.
Fig. 1. — Synchronised shock delivery and revert ion of sinus rhythm
She was extubated after adequate reversal of neuromuscular blockade with injection sugammadex
(16 mg/kg) and was transferred to post anesthesia
care unit after ensuring adequate hemodynamic
­stability and fetal wellbeing. She was discharged on
the next day. Her anticoagulant was continued for
four weeks. She subsequently gave birth to a healthy
baby at forty weeks of gestation delivered by
­cesarean section.
Discussion
Symptomatic arrhythmias during pregnancy
affect the wellbeing of both the mother and the
­fetus. Treatment options depend upon the type of
arrhythmias, maternal hemodynamic status, and
possible side effects on the fetus (4, 5). ECV in
pregnancy is considered safe and effective treatment modality when the pharmacological intervention fails to control the symptoms or the symptoms
are life threatening (5, 6). Timing of the procedure
is very important as ECV during pregnancy may
precipitate transient fetal bradyarrhythmias which
may require emergency cesarean section. It may
also precipitate premature labour as hypertonic
uterus and amniotic fluid act as good conductors of
electricity (7, 8). Placement of pads anterioposteriorly rather than anterolaterally further minimises
this risk.
Our patient was treated with metoprolol initially for rate control as per recommendation (5).
Heart rate of our patient responded to the medical
therapy, but her AF persisted and she continued to
be symptomatic due to palpitation. Once fetal maturity was ensured it was decided to perform electrical
cardioversion for reversion of her heart rhythm to
which she responded. As the AF was more than
48 hours she was anticoagulated with LMWH as
oral anticoagulant is mostly contraindicated in
pregnancy (5). Pharmacological cardioversion is
­
another way of reverting AF to sinus rhythm. But in
pregnancy most of such drugs are contraindicated
due to teratogenic effect. ECV in that context is safe
if properly conducted. We thus opted for ECV in
our in our case over pharmacological cardioversion.
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cardioversion in late pregnancy107
Conclusion
Our case report proves that if properly performed with all precaution using multidisciplinary
approach, electrical cardioversion is safe and effective treatment option for atrial fibrillation occurring
in pregnancy.
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© Acta Anæsthesiologica Belgica, 2014, 65, n° 3
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