title: Peri-operative management of hysterostomy in a parturient with complete heart block, placenta accreta and intrauterine death.
abstract: BACKGROUND
  Complete heart block in pregnancy has serious implications particularly during the period of delivery. This is more so if the delivery is an operative one as the presence of heart block may produce haemodynamic instability in the intra operative period. We report a unique case of a pregnant mother with complete heart block undergoing hysterostomy, complicated by placenta accreta and intrauterine death.
  
  
  METHODS
  A 37 year old Malaysian Chinese parturient was admitted at 25 weeks gestation following a scan which suggested intrauterine death and placenta accreta. She was diagnosed to have congenital complete heart block after her first delivery eight years previously but a pacemaker was never inserted. These medical conditions make her extremely likely to experience massive bleeding and haemodynamic instability. Among the measures taken to optimise her pre-operatively were the insertion of a temporary intravenous pacemaker and embolization of the uterine arteries to minimize peri-operative blood loss. She successfully underwent surgery under general anesthesia, which was relatively uneventful and was discharged well on the fourth post-operative day.
  
  
  CONCLUSIONS
  Congenital heart block in pregnancies in the presence of potential massive bleeding is best managed by a team, with meticulous pre-operative optimization. Suggested strategies would include insertion of a temporary pacemaker and embolization of the uterine arteries to reduce the risk of the patient getting into life threatening situations.
authors.affiliation: Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia.
authors.forename: Vineya
authors.initials: V
authors.lastname: Rai
authors.affiliation: Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia.
authors.forename: Ina I
authors.initials: II
authors.lastname: Shariffuddin
authors.affiliation: Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia.
authors.forename: Yoo K
authors.initials: YK
authors.lastname: Chan
authors.affiliation: Department of Medicine Based, School of Medicine, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia.
authors.forename: Rajesh K
authors.initials: RK
authors.lastname: Muniandy
authors.affiliation: Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia.
authors.forename: Kang K
authors.initials: KK
authors.lastname: Wong
authors.affiliation: Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia.
authors.forename: Sukcharanjit
authors.initials: S
authors.lastname: Singh
mesh_terms: D000328:Adult; D000768:Anesthesia, General / Q000379:methods; D016063:Blood Loss, Surgical / Q000517:prevention & control; D004621:Embolization, Therapeutic / Q000379:methods; D005260:Female; D005313:Fetal Death / Q000209:etiology*; D006327:Heart Block / Q000150:complications* / Q000151:congenital / Q000601:surgery; D006801:Humans; D007044:Hysterectomy / Q000379:methods*; D010138:Pacemaker, Artificial; D010921:Placenta Accreta / Q000503:physiopathology*; D011247:Pregnancy; D011249:Pregnancy Complications, Cardiovascular / Q000503:physiopathology / Q000601:surgery
keywords: Complete heart block; Hysterectomy; Hysterostomy; Pregnancy