32 – Complete Heart Block in a Pregnant Patient




32 Complete Heart Block in a Pregnant Patient


Anita Macnab and Kirsty MacLennan



Scenario in a Nutshell



Complete heart block in patient for TOP with known Mobitz type II requiring pacing.


Stage 1: Assessment of stable patient with known Mobitz type II heart block.


Stage 2: Bradycardia with adverse features necessitating medical management.


Stage 3: Bradycardia unresponsive to medical management, requires transcutaneous pacing.


Stage 4: Plan for temporary pacing wire insertion.



Target Learner Groups


All members of the multidisciplinary obstetric team: anaesthetists, midwives, obstetricians, HDU nurses (if part of the usual team), operating department practitioners and cardiologists.

















Specific learning opportunities
Knowledge of appropriate medical management of bradyarrhythmia
Knowledge of risk factors for complete heart block
Recognition of need for pacing
Knowledge of transcutaneous pacing set-up
















































Suggested learners (to represent their normal roles) In the room from the start Available when requested
Anaesthetic CT2 √
Anaesthetic ST3+ √
Obstetric ST3+ √
Midwife Coordinator √
Midwife in room √
Operating Department Practitioner (ODP)/anaesthetic nurse √
Cardiology ST √
Suggested facilitators
Faculty to play role of antenatal midwife handing over √


Details for Facilitators



Patient Demographics









Name: Chloe


Age: 39


Gestation: 21


Booking weight: 80 kg


Parity: P0



Scenario Summary for Facilitators



Patient admitted to delivery suite for termination of pregnancy for severe fetal cardiac anomalies at 21 weeks pregnant.


She has a past history of Mobitz type II heart block.


She had mifepristone 24 hours ago and has received one dose of misoprostol PV on the delivery suite.


She complains of chest tightness, is bradycardic at 35 bpm and hypotensive.


She remains unresponsive to medical management (atropine/isoprenaline/adrenaline) and requires transcutaneous pacing and transfer for a temporary pacing wire.



Set-up Overview for Facilitators

























  • Clinical setting


  • On delivery suite, on a delivery bed




  • Patient position


  • Semi-recumbent




  • Initial monitoring in place


  • None




  • Other equipment


  • No IV access



  • All equipment available as per local unit set-up




  • Useful manikin features


  • Palpable pulses



  • Pacing



Medical Equipment


For core equipment checklist, see Chapter 9.



























Additional equipment specific to scenario
Arterial line Resuscitation trolley with defibrillator Pads for pacing
Drugs:
Atropine Drugs for sedation
Ephedrine
Adrenaline
Isoprenaline


Information Given to the Learners













  • SBAR handover from faculty (playing the role of a midwife from the antenatal ward) to midwife and anaesthetic trainee on delivery suite




  • Time: 10:00



  • Situation: This patient, with a known heart problem, is having TOP for fetal cardiac anomalies at 21 weeks.



  • Background: 39-year-old, primipara who is 21+0 weeks pregnant. She has had one dose of mifepristone 24 hours ago and I have just given her misoprostol PV now. She has Mobitz type II heart block and has a letter in her notes from her last cardiology appointment 6 months ago. She is otherwise well with no allergies.



  • Assessment: I have brought her to the delivery suite for monitoring of her cardiac condition during her induction and delivery.



  • Recommendation: We need a plan for her care. Would you like to see the letter from cardiology? (See Figure 32.1.)





Figure 32.1 Letter from Cardiology Clinic.


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Oct 24, 2020 | Posted by in OBSTETRICS | Comments Off on 32 – Complete Heart Block in a Pregnant Patient

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