Long QT syndrome: anaesthetic management at delivery

We describe the anaesthetic management of a spontaneous vaginal delivery at 39 weeks' gestation in a 22-year-old patient with congenital long QT syndrome. With a strong family history of sudden deaths, the patient had an initial QT interval corrected for rate (QTc) of >600 ms. Following a once-daily 50-mg dose of atenolol over the previous 11 months, her QTc remained prolonged at 560 ms. To minimise any increase in catecholamine levels and consequent risk of malignant ventricular arrhythmias, a combined spinal-epidural technique was selected using intrathecal diamorphine and levobupivacaine, with intravenous and oral magnesium and potassium supplementation. Levobupivacaine was substituted for routine racemic bupivacaine to decrease the risk of drug-induced cardiotoxicity. Delivery outcome was successful and uneventful. We outline the pathophysiology, risks and treatments of long QT syndrome, and discuss the analgesic management of this patient in labour with congenital long QT syndrome.