Management of complete heart block during pregnancy

A 22-year-old second gravida presented to the antenatal clinic at 28 weeks of gestation with frequent fainting attacks (2-3 episodes/day), palpitations and dyspnea (New York Heart Association Functional Classification II). Her pulse rate was 40 b.p.m. A 12-lead electrocardiogram and 24-h Holter revealed complete heart block. A transvenous permanent pacemaker (ventricular demand rate-responsive), paced at a rate of 60 pulses/min, was successfully implanted. A multidisciplinary approach was taken and the patient delivered a healthy baby boy of 2.8 kg at 38 weeks. She remained asymptomatic and was discharged in good condition. Management varies from expectant management to temporary pacemaker insertion to permanent pacing during pregnancy. In a young patient with sinus bradycardia, the primary criterion for a pacemaker is the concurrent observation of a symptom (e.g., syncope) with bradycardia (e.g., heart rate 35-40 b.p.m. or asystole for 3 s). Symptomatic pregnant women should always be counseled for a permanent pacemaker.