Congenital heart block and maternal systemic lupus erythematosus

Communications

Volume 130 Number5

8. Gardner, G. H., Green, of the broad ligament, 1957.

R. R., and Peckhaus, B.: Turnouts AM. J. OBSTET. GYNECOL. 73: 536.

Congenital heart block and maternal systemic lupus erythematosus STACY GEORGE WARREN

BERUBE,

M.D.,

LISTER,

JR.,

CAPTAIN,

MC,

USA

M.D.*

H.

TOEWS.

M.D.,

K.

GREASY,

M.D.

MAJOR,

MC,

USA ROBERT MICHAEL

A.

HEYMANN,

M.D.

Cardiovascular Research Institute and Departments of Pediatrics and Obstetrics, Gynecology and Reproductive Sciaces, University of Calijorniu, San Francisco, Cal$omia, and the Department of Pediuttis, Madigan Army Medical Center, Tacoma, Washington CONCENITALATRIOVENTRICULARBLOCK

(CAVB)

is a rare cause of fetal bradycardia. If mistaken for fetal distress, it may lead to inappropriate obstetric intervention and delivery of a premature infant. In this report we present two infants with CAVB. The diagnosis in one was made only following emergency delivery for suspected fetal distress. The second was diagnosed antepartum and the fetus was monitored in utero for some weeks prior to delivery. Both cases occurred in mothers with systemic lupus erythematosus (SLE). In Case 1, L. C., a 1,780 gram female infant, was delivered at 32 weeks’ gestation to a 23-year-old mother with SLE requiring no treatment. Gestation was uncomplicated and the fetal heart rate determined at antepartum examinations prior to the day of delivery was approximately 140 beats per minute. The mother presented on the day of delivery with petechiae of the lower extremity and a fetal heart rate of 66 beats per minute was first noted; because fetal distress was suspected, an emergency cesarean section was performed. The infant had Apgar scores of 4 and 8 at one and five minutes, respectively. Electrocardiogram showed a ventricular rate of 64 beats per minute, an atrial rate of 110 beats per minute, CAVB, and a narrow QRS complex with a frontal plane axis of + 120”. Hyaline membrane disease developed and necessitated ventilatory support for five days. Recovery was uneventful. Serum antinuclear antibodies three days post partum were positive: 1:80 (infant), 1: 160 (mother). The platelet and white blood cell count, hematocrit, and urinalysis of the infant were normal. She developed disThe

views

reflected

and are not necessarily

in this paper are those of the authors those of the Surgeon General, United

States Army. Reprint requests: Dr. Michael A. Heymann, 1403-HSE, University of California. San Francisco, California 94143. *Research trainee supported by Training Grants HL-0525 1 from the National H&t, Lung, and Brood Institute and HD-00397 from the National Institute of Child Health and Human Development. 000%9378/78/05130-0595$00.20/O@

1978 The C. V. Mosby

Co.

in brief

595

coid lupus erythematosus on the forehead and groin at one and a half months; this disappeared by six months. CAVB persisted but growth and development were normal. In Case 2, B. M., a 3,220 gram male infant, was born at term to a 28-year-old prim&avid mother with SLE diagnosed 10 years prior to the pregnancy. The primary manifestations of the SLE-arthralgia, fever, and focal glomerulonephritis-were well controlled with 10 mg. of prrdnisone daily throughout pregnancy. Four weeks before delivery, on routine examination, the fetal heart rate was difficult to count. The fetai electrocardiogram, obtained by using maternal abdominal electrodes, showed a regular ventricular rate of 60 beats per minute, and CAVB was diagnosed. Labor occurred spontaneously at 41 weeks of gestation. Throughout labor, the fetal electrocardiogram was monitored with scalp electrodes. At the onset of labor, the fetal heart rate was 35 to 40 beats per minute; this rose progressively to 70 beats per minute by delivery. Fetal scalp blood samples, obtained repeatedly, were within normal limits. At birth, the infant was vigorous with Apgar scores of 8 at one and five minutes. Electrocardiogram showed a ventricular rate of 60 beats per minute, an atrial rate of 150 beats per minute, CAVB, a narrow QRS complex, and a frontal plane axis of + 100”. Occasional unifocal premature ventricular beats occurred. The chest radiogram and echocardiogram were normal. The infant is now 15 months old and developing normally. without evidence of SLE. The ventricular rate is 75 beats per minute; the atria1 rate is 140 beats per minurc. These

two

cases

emphasize

that

CAVB.

which

can he

diagnosed before birth, should be considered when the fetal heart rate is slow and regular. By distinguishing CAVB from bradycardia caused by asphyxia, unnecessary emergency delivery may be prevented. During labor, fetal assessment in the presence of CAVB is difficult since the standard criteria of fetal heart rate monitoring may not be useful in predicting fetal wellbeing; however, the atria1 rate may serve as a guide. Scalp blood sampling is valuable in providing evidence of no fetal asphyxia despite the slow heart rate. Occasionally, neonates may require emergency treatment because of severe bradycardia with CAVB. It is essential to identify and treat other factors, e.g., hypoxemia, hypothermia, and vagal stimulation. which may contribute further to slowing of the ventricular rate. Then, if necessary, ephedrine, isoproterenol, or epinephrine may be administered.’ Because of transplacentally acquired maternal antibodies, transient thrombocytopenia, leukopenia, anemia, and discoid lupus erythematosus may occur in the infants.2-4 Some author+ ’ have suggested that these antibodies may cause CAVB as well. Hogg’ described extensive myocardial fibroelastosis and degenerative changes in an infant of a mother with SLE. However, CAVB in combination with maternal SLE is rare, even if the association is underestimated because single cases are not reported. Since autopsy specimens of myocardium from patients with different types of CAVB all show localized areas of fibrosis.’ it is unlikeiv

596

Communications

in brief

March 1, 1978 Am. J. Obstet. Gynecol.

that a causal relationship with SLE could be concluded without careful pathologic examination for lesions specifically associated with SLE. At present, this information is not available. However, the relationship of CAVB to maternal SLE is supported by these two additional cases. REFERENCES

1. Hoffman, J. I. E.: Bull. N. Y. Acad. Med. 47: 885, 1971. 2. Nathan, D. J.. and Snapper, I.: Am. J. Med. 25: 647, 1958. 3. Beck, J. S., Oakley, C. L., and Rowell, N. E.: Arch. Dermatol. 93: 656, 1966. 4. Jackson, R.: Pediatrics 33: 425, 1964. 5. Hull, D., Binns, B. A. O., and Joyce, D.: Arch. Dis. Child. 41: 688, 1966. 6. Carter, J. B., Blieden, L. C., and Edwards, J. E.: Arch. Pathol. 97: 51, 1974. 7. Hogg, G. R.: Am. J. Clin. Pathol. 28: 648, 1957. 8. Lev, M., Silverman, J., Fitzmaurice, F. M., et al.: Am. J. Cardiol. 27: 481, 19’71.

Meconium aspiration syndrome following cesarean section BONITA MICHAEL WATSON

S. CARSON, M.D. A. SIMMONS, M.D. A. BOWES, JR., M.D.

Division of Petinatal Obstetrics-Gynecology, Denver, Colorah

Medicine, Univenity

Deportmenti of Pediahicr of Colorado

Medical

and

Center,

SEVERE MECONIUM ASPIRATION syndrome has virtually disappeared from our hospital with the consistent use of intrapartum nasopharyngeal suctioning and immediate postdelivery suctioning of the trachea with the use of direct vision.’ Infants delivered by cesarean section have required more postdelivery suctioning than have those who had deep nasopharyngeal suctioning performed while the thorax was still compressed in the birth canal. We report here a case of meconium aspiration syndrome following cesarean section. A 23-year-old mother, gravida 2, para 1, was admitted to Colorado General Hospital in labor at 43% weeks’ gestation. She had terminated her prenatal care two weeks previously. There had been spotting for three weeks prior to delivery. Artificial rupture of the membranes on admission revealed very thick meconium in the amniotic fluid. Because the fetal heart rate was 107 beats per minute and began to fall, an emergency cesarean section was performed. The obstetrician attempted unsuccessfully to suction the baby’s nasopharynx with a DeLee suction trap. Immediately after delivery, intubation and suctioning produced thick meconium but, because of a falling heart rate, positive-pressure ventilation was administered before reintubation and additional suctioning. A total Reprint requests: Dr. Bonita S. Carson, Division of Perinatal Medicine, B-198, University of Colorado Medical Center, 4200 E. Ninth Ave., Denver, Colorado 80262.

of four intubations were eventually required until no meconium could be suctioned through the endotracheal tube. The female infant weighed 3,650 grams and had Apgar scores of 1 at one minute and 7 at five minutes. For the first hour of life the infant was pink and exhibited only mild tachypnea. A chest roentgenogram at that time showed hyperexpansion and pneumomediastinum but no infiltrates; by three hours of age, there were bilateral alveolar infiltrates present. Over the next 12 hours, respiratory distress increased and the baby became progressively more hypoxemic and hypercarbic. She required ventilatory support and intravenous tolazoline to maintain oxygenation, as well as dopamine to correct hypotension. She was weaned from the respirator on the seventh day and by the nineteenth day she was breathing room air. She was discharged after a 34 day hospital stay necessitated by feeding difficulties and resolving respiratory distress. At seven weeks of age, she was smiling and alert and, except for slightly increased muscle tone, had a normal examination. An attempt was made at this delivery to suction the baby prior to breathing but without the apparent mechanical advantage of thoracic compression from the birth canal2 In addition, there were technical difficulties in the use of the DeLee suction catheter during the cesarean section delivery. After delivery, suctioning was performed only once before positive pressure was applied to carry out the resuscitation. While it is important to provide ventilation if the infant is severely compromised, the hazards of forcing meconium further into the lungs must be considered. The five-minute Apgar score of 7 in this baby suggests that there may have been time to suction the trachea more thoroughly prior to the application of positive pressure. Our current approach to aspiration of nasopharyngeal fluid at cesarean section includes one of two methods. The first is standard use of the DeLee suction trap after placement of the mouthpiece behind the surgeon’s mask by a circulating nurse. An alternative method that is quite satisfactory is the use of wall suction attached to the DeLee tray by means of the innermost portion of the standard sump suction tip. The latter method provides more continuous suction with greater negative pressure, which may be important in removing the tenacious nasopharyngeal meconium-laden secretions at the time of cesarean section. Upon delivery of the baby’s head through the uterine incision, first the nasopharynx and then the oral pharynx are aspirated in the manner described above. This is done prior to the delivery of the thorax through the uterine incision. We suspect that the pressure on the thorax of the infant during cesarean section is less effective in expelling lung fluid than that during vaginal delivery. For this reason we believe that meticulous mechanical aspiration of meconium from the nasopharynx before delivery of the thorax and subsequent direct visualization of the larynx and aspiration of any remaining meconium after delivery are imperative in reducing the incidence of meconium aspiration pneumonitis. 0002-9378/78/05130-0596$00.20/O

@ 1978

The

C. V. Mosby

Co.