Labour and delivery in Long QT Syndrome BJ Vowles, FMM Bryden, Anaesthetic Department, Princess Royal Maternity Unit, Glasgow, UK Introduction Labour & Delivery Post-delivery • 22 year old primigravida • Presented to high risk clinic at 22 weeks gestation • Diagnosis: Congenital Long QT Syndrome (LQTS) • Heterozygous for KCNQ1 gene – responsible for Long QT1 • Family history of sudden cardiac death • No personal history of cardiac symptoms • No regular treatment / intervention • Baseline ECG at 23 weeks gestation – QTc = 446ms (Normal <470ms) • Other PMHx: Thrombocytopenia, Penicillin allergy • Presented at term in spontaneous labour at 8:30am • Patient in possession of a list of medicines to avoid that prolong QT and/or cause Torsades de Pointes (Azert Inc.) • Early decision by obstetric team not to augment labour with syntocinon • Oxytocin featured on list of drugs to avoid • Also felt that epidural analgesia was unsuitable as would slow progress of labour • Analgesia initially managed with 7.5mg IM Diamorphine • 50mg IM Cyclizine for anti-emesis • ECG monitoring commenced – initially showing bigeminy. QTc = 457ms • Electrolytes all within normal range; Platelets 107 • Monitored in Obstetric HDU for 48 hours • Initial ECG demonstrated frequent ventricular ectopics • QTc = 432ms • Electrolytes normal • Beta-blocker commenced as per Cardiology instructions Planning for Labour & Delivery Cardiology: • No special considerations during pregnancy or delivery • To commence Bisoprolol 2.5mg PO once daily for 9 months from day of delivery ECG on admission to labour ward at term: Anaesthetics: • 1st choice regional technique for labour analgesia and delivery if platelets allow • ECG monitoring during labour • No clear plan for systemic drugs Obstetrics: • No clear plan for labour / delivery documented Discussion • Many lists of drugs available with differing advice on which drugs to avoid in Long QT Syndrome • Some (including the one given to our patient) state that syntocinon should be avoided despite no definitive evidence of harm with this drug in patients with Long QT syndrome • Review of the anaesthetic implications of Long QT syndrome in pregnancy describes 9 case reports documenting the management strategies used for patients during labour and delivery1 • Successful delivery with GA, spinal and epidural anaesthesia • No case reports comment on the use of drugs to increase uterine tone • Case reports in non-pregnant women with a long QT interval undergoing gynaecological procedures have demonstrated ventricular tachycardia following administration of intravenous syntocinon2 • In normal women a 10 unit bolus of oxytocin prolonged the QTc with a return to normal within 3 minutes3 Conclusions Baseline ECG in cardiology clinic at 23 weeks: • Analgesia unsatisfactory and parturient requested epidural analgesia • Decision to proceed with this to decrease stress & therefore risk of arrhythmia • Lumbar epidural inserted at 12:00pm with no immediate complications • Initial top-up 15ml 0.1% L-bupivacaine with 2µg/ml Fentanyl • Infusion commenced at 10ml/hr – 0.1% L-bupivacaine with 2µg/ml Fentanyl • Bilateral block to cold at level of T9 • Further midwife top-up of 5ml 0.25% L-bupivacaine given at 3:00pm • Failure to progress – decision to proceed to caesarean section at 18:50 • Successful epidural top-up – 20ml 0.5% L-bupivacaine + 3mg Diamorphine • 5 units Syntocinon administered by slow IV infusion in 100ml 0.9% Saline over 20 minutes followed by 500µg IM ergometrine • 50mg IM cyclizine & 10mg IV metoclopramide used for anti-emesis Many thanks to our patient and her family for giving permission to the presentation and publication of this case report. Thanks also to Dr Bryden and the anaesthetic department at PRMU for their support. • Lack of published evidence on use of uterotonics in patients with Long QT syndrome during labour and delivery • This patient required a case conference prior to admission so that informed decisions could be made regarding management of labour and delivery • Short trial of syntocinon may have altered mode of delivery and avoided need for operative delivery References 1. Drake E, Preston R, Douglas J. Brief review: anaesthetics implications of long QT syndrome in pregnancy. Can J Anaesth. 2007; 54(7): 561 -72 2. Liou SC, Chen C, Wong SY, Wong KM. Ventricular tachycardia after oxytocin injection in patients with prolonged Q -T syndrome - report of two cases. Acta Anaesthesiol Sin 1998; 36: 49 -52 3. Charbit B, Funck-Bretano C, Samain E, Jannier-Guillou V, Albaladejo P, Marty J. Qt interval prolongation after oxytocin bolus during surgical induced abortion. Clin Pharmacol Ther 2004; 76:359-64