Cardiac arrhythmias may require device intervention.
For pregnant women with important symptomatic bradycardia or atrioventricular block, it may be nec- essary to insert a temporary, or even a permanent, pacemaker. Pacemaker insertion does carry the risk of radiation exposure to the fetus but the procedure can be carried out under echocardiographic guidance alone.
[ 69 ] Implantable cardioverter defi brillators can have a life-saving role in nonpregnant patients and have been shown to be well tolerated throughout pregnancy.[ 91 ] Th ere have been reports of implantable cardioverter defi brillator insertion during pregnancy without any fetal compromise. Th e radiation risks of the procedure can be further reduced by the use of transesophageal echocardiography for lead placement,[ 33 ] and a case reported in 2012 achieved implantable cardioverter defi brillator implantation during pregnancy without fl uoroscopy using 3D navigation cardiac mapping with electrophysiology catheters only. [ 92 ] In addi- tion to lethal arrhythmias, there may be supraven- tricular arrhythmias that can be dealt with using cardiac electrophysiology mapping and ablation tech- niques, thus avoiding the potential deleterious eff ects of antiarrhythmic medication. New techniques have been described that allow ablation procedures dur- ing pregnancy using 3D mapping, transesophageal
echocardiography, or intracardiac echocardiography with little or no X-ray exposure. [ 93 , 94 ]
Th e thrombophilic nature of pregnancy results in an increased risk of pulmonary thromboembolism. Th e presence of a large thrombus in leg or pelvic vessels and the wish to suspend anticoagulation at time of deliv- ery may call for the insertion of an inferior vena caval fi lter. Th ese have been used successfully in pregnancy.
Since the period of risk will be short, use of a removable temporary inferior vena caval fi lter is preferred unless there is another cause of thrombophilia. [ 95 ]
Insertion of an intra-aortic balloon pump can frequently stabilize a patient in acute cardiovascular collapse to a degree suffi cient to allow defi nitive ther- apy for the underlying problem. Th ere are no series reports of the use of intra-aortic balloon pumping in pregnancy but several case reports have clearly docu- mented successful application in this setting and there is no specifi c contraindication to its use in hemo- dynamically unstable pregnant women.[ 82 , 85 , 86 , 96 ] When intra-aortic balloon pumping is insuffi cient to rescue the woman, consideration can be given to the use of left and right ventricular assist devices (LVADs and RVADs). Th ere has been a report of successful pregnancy in a woman who already had a LVAD in situ as bridge to transplantation when she presented with an unplanned pregnancy.[ 97 ] Th e only documented cases of insertion of such a device (or a biventricular assist device) have been in peripartum cardiomyop- athy aft er delivery,[ 96 ] and in one case to rescue a young woman who remained unstable aft er emer- gency aortocoronary bypass surgery for acute myo- cardial infarction. She was not known to have been pregnant at the time of her collapse and there was sub- sequent fetal demise.[ 98 ] Extracorporeal membrane oxygenation support has been described in one case for the treatment of maternal arrhythmic cardiogenic shock. Although the mother survived, the fetus was lost.[ 99 ] Use of these devices is undertaken only in the most extreme circumstances to save the life of the mother, and fetal concerns must therefore be consid- ered secondary.
Removal of cardiac tumors during pregnancy has been recently reported without maternal or fetal death.
[ 100 ] It should be possible to delay excision of a benign myxoma until aft er delivery unless there are signifi cant arrhythmias, infl ow obstruction, or embolic phenom- ena linked to the myxoma. Th e surgical risk to the fetus relates to the previously discussed risks of cardiopul- monary bypass .
Section 2: Antenatal Care: General Considerations
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© Cambridge University Press 2016.
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