Management of Cardiac Pacemakers in a Pregnant Patient

Abstract

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.