We present a case of a pregnant woman with systemic lupus erythematosus (SLE) who was diagnosed with asymptomatic complete heart block (CHB) during pregnancy. To evaluate possible risks and benefits of pacemaker (PM) implantation, a multidisciplinary counselling board was held. Its recommendation was to perform PM implantation to prevent intra-uterine growth restriction from insufficient cardiac output using a fluoroscopic protective shield. The procedure was performed without complications and established permanent pacing on onwards ECG examinations. The patient subsequently gave birth to a healthy newborn. After a retrospective clinical case evaluation and review of relevant literature, a presumptive association between CHB and the primary diagnosis was proposed. Above that, pregnant women with SLE who develop hypertension are commonly treated with methyldopa, which may cause conduction abnormalities. Clinical recommendations for young female patients expecting pregnancy are lacking in this area. Careful diagnostic and treatment approaches should be used in the management of possible SLE-related complications in women of child-bearing age, focusing on preventable events.

Department of Biochemistry Faculty of Medicine Masaryk University Kamenice 5 625 00 Brno Czech Republic

Department of Gynecology and Obstetrics University Hospital Brno and Faculty of Medicine Masaryk University Jihlavska 20 625 00 Brno Czech Republic

Department of Internal Medicine and Cardiology University Hospital Brno and Faculty of Medicine Masaryk University Jihlavska 20 625 00 Brno Czech Republic

Department of Laboratory Medicine Masaryk Memorial Cancer Institute Zluty Kopec 7 656 53 Brno Czech Republic

Department of Laboratory Methods Faculty of Medicine Masaryk University Kamenice 5 625 00 Brno Czech Republic

See more in PubMed

Holmqvist F., Daubert J.P. First-degree AV block-an entirely benign finding or a potentially curable cause of cardiac disease? Ann. Noninvasive Electrocardiol. 2013;18:215–224. doi: 10.1111/anec.12062. PubMed DOI PMC

Wogan J.M., Lowenstein S.R., Gordon G.S. Second-degree atrioventricular block: Mobitz type II. J. Emerg. Med. 1993;11:47–54. doi: 10.1016/0736-4679(93)90009-V. PubMed DOI

Al Taweel M., Al Mukhaylid S., Alsultan N. Congenital Complete Heart Block in Adults. J. Adv. Med. Med. Res. 2022;34:245–248. doi: 10.9734/jammr/2022/v34i1931458. DOI

Fischbach P.S., Frias P.A., Strieper M.J., Campbell R.M. Natural history and current therapy for complete heart block in children and patients with congenital heart disease. Congenit. Heart Dis. 2007;2:224–234. doi: 10.1111/j.1747-0803.2007.00106.x. PubMed DOI

Pruetz J.D., Miller J.C., Loeb G.E., Silka M.J., Bar-Cohen Y., Chmait R.H. Prenatal diagnosis and management of congenital complete heart block. Birth Defects Res. 2019;111:380–388. doi: 10.1002/bdr2.1459. PubMed DOI PMC

De Carolis S., Garufi C., Garufi E., De Carolis M.P., Botta A., Tabacco S., Salvi S. Autoimmune Congenital Heart Block: A Review of Biomarkers and Management of Pregnancy. Front. Pediatr. 2020;8:607515. doi: 10.3389/fped.2020.607515. PubMed DOI PMC

Brucato A., Jonzon A., Friedman D., Allan L.D., Vignati G., Gasparini M., Stein J.I., Montella S., Michaelsson M., Buyon J. Proposal for a new definition of congenital complete atrioventricular block. Lupus. 2003;12:427–435. doi: 10.1191/0961203303lu408oa. PubMed DOI

Barra S.N.C., Providencia R., Paiva L., Nascimento J., Marques A.L. A review on advanced atrioventricular block in young or middle-aged adults. Pacing Clin. Electrophysiol. 2012;35:1395–1405. doi: 10.1111/j.1540-8159.2012.03489.x. PubMed DOI

Bamgboje A., Akintan F.O., Gupta N.M., Kaur G., Pekler G., Mushiyev S. Lyme Carditis: A Reversible Cause of Acquired Third-Degree AV Block. Am. J. Case Rep. 2021;22:e927885. doi: 10.12659/AJCR.927885. PubMed DOI PMC

Fanouriakis A., Kostopoulou M., Alunno A., Aringer M., Bajema I., Boletis J.N., Cervera R., Doria A., Gordon C., Govoni M., et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann. Rheum. Dis. 2019;78:736–745. doi: 10.1136/annrheumdis-2019-215089. PubMed DOI

Aringer M., Costenbader K., Daikh D., Brinks R., Mosca M., Ramsey-Goldman R., Smolen J.S., Wofsy D., Boumpas D.T., Kamen D.L., et al. 2019 European League Against Rheumatism/American College of Rheumatology Classification Criteria for Systemic Lupus Erythematosus. Arthritis Rheumatol. 2019;71:1400–1412. doi: 10.1002/art.40930. PubMed DOI PMC

Soma-Pillay P., Nelson-Piercy C., Tolppanen H., Mebazaa A. Physiological changes in pregnancy. Cardiovasc. J. Afr. 2016;27:89–94. doi: 10.5830/CVJA-2016-021. PubMed DOI PMC

Costedoat-Chalumeau N., Amoura Z., Villain E., Cohen L., Piette J.C. Anti-SSA/Ro antibodies and the heart: More than complete congenital heart block? A review of electrocardiographic and myocardial abnormalities and of treatment options. Arthritis Res. Ther. 2005;7:69–73. doi: 10.1186/ar1690. PubMed DOI PMC

Claus R., Hickstein H., Külz T., Lenschow U., Meiske D., Kotitschke A., Thiesen H.J., Lorenz P. Identification and management of fetuses at risk for, or affected by, congenital heart block associated with autoantibodies to SSA (Ro), SSB (La), or an HsEg5-like autoantigen. Rheumatol. Int. 2006;26:886–895. doi: 10.1007/s00296-005-0101-4. PubMed DOI

Villuendas R., Martínez-Morillo M., Juncà G., Teniente-Serra A., Diez C., Heredia S., Riveros-Frutos A., Bayés-Genís A., Olivé A. Usefulness of cardiac screening in patients with systemic lupus erythematosus and anti-Ro/SSA antibodies. Lupus. 2021;30:1596–1602. doi: 10.1177/09612033211027928. PubMed DOI

Natsheh A., Shimony D., Bogot N., Nesher G., Breuer G.S. Complete heart block in lupus. Lupus. 2019;28:1589–1593. doi: 10.1177/0961203319881198. PubMed DOI

Petri M. Pregnancy and Systemic Lupus Erythematosus. Best Pract. Res. Clin. Obstet. Gynaecol. 2020;64:24–30. doi: 10.1016/j.bpobgyn.2019.09.002. PubMed DOI

Munguia-Realpozo P., Mendoza-Pinto C., Benito C.S., Escarcega R.O., Garcia-Carrasco M., Martinez S.M., Morales I.E., Romero J.L.G., Ruiz-Arguelles A., Cervera R. Systemic lupus erythematosus and hypertension. Autoimmun. Rev. 2019;18:102371. doi: 10.1016/j.autrev.2019.102371. PubMed DOI

Rosen B., Ovsyshcher I.A., Zimlichman R. Complete atrioventricular block induced by methyldopa. Pt 1Pacing Clin. Electrophysiol. 1988;11:1555–1558. doi: 10.1111/j.1540-8159.1988.tb06273.x. PubMed DOI

Cokkinos V., Vorides M. Impairment of Atrioventricular Conduction by Methyldopa. CHEST J. 1978;74:697. doi: 10.1378/chest.74.6.697a. PubMed DOI

Hunter S., Robson S.C. Adaptation of the maternal heart in pregnancy. Br. Heart J. 1992;68:540–543. doi: 10.1136/hrt.68.12.540. PubMed DOI PMC

Dalvi B.V., Chaudhuri A., Kulkami H.L., Kale P.A. Therapeutic guidelines for congenital complete heart block presenting in pregnancy. Pt 2Obstet. Gynecol. 1992;79:802–804. PubMed

Hidaka N., Chiba Y., Kurita T., Satoh S., Nakano H. Is intrapartum temporary pacing required for women with complete atrioventricular block? An analysis of seven cases. BJOG. 2006;113:605–607. doi: 10.1111/j.1471-0528.2006.00888.x. PubMed DOI

Adekanye O., Srinivas K., Collis R.E. Bradyarrhythmias in pregnancy: A case report and review of management. Int. J. Obstet. Anesth. 2007;16:165–170. doi: 10.1016/j.ijoa.2006.10.003. PubMed DOI

Thaman R., Curtis S., Faganello G., Szantho G.V., Turner M.S., Trinder J., Sellers S., Stuart G.A. Cardiac outcome of pregnancy in women with a pacemaker and women with untreated atrioventricular conduction block. Europace. 2011;13:859–863. doi: 10.1093/europace/eur018. PubMed DOI

Suri V., Keepanasseril A., Aggarwal N., Vijayvergiya R., Chopra S., Rohilla M. Maternal complete heart block in pregnancy: Analysis of four cases and review of management. J. Obstet. Gynaecol. Res. 2009;35:434–437. doi: 10.1111/j.1447-0756.2008.00961.x. PubMed DOI

Carrión-Camacho M.R., Marín-León I., Molina-Doñoro J.M., González-López J.R. Safety of Permanent Pacemaker Implantation: A Prospective Study. J. Clin. Med. 2019;8:35. doi: 10.3390/jcm8010035. PubMed DOI PMC

Mandal S., Mandal D., Sarkar A. Complete Heart Block and Pregnancy Outcome: An Analysis from Eastern India. SOJ Gynaecol. Obstet. Womens Health. 2015;1:5. doi: 10.15226/2381-2915/1/1/00104. DOI

Pedrinazzi C., Gazzaniga P., Durin O., Tovena D., Inama G. Implantation of a permanent pacemaker in a pregnant woman under the guidance of electrophysiologic signals and transthoracic echocardiography. J. Cardiovasc. Med. 2008;9:1169–1172. doi: 10.2459/JCM.0b013e3283100edc. PubMed DOI

Jordaens L.J., Vandenbogaerde J.F., Van De Bruaene P., De Buyzere M. Transesophageal echocardiography for insertion of a physiological pacemaker in early pregnancy. Pacing Clin. Electrophysiol. 1990;13:955–957. doi: 10.1111/j.1540-8159.1990.tb02138.x. PubMed DOI

Guo P., Qiu J., Wang Y., Chen G., Proietti R., Fadhle A.S., Zhao C., Wen Wang D. Zero-fluoroscopy permanent pacemaker implantation using Ensite NavX system: Clinical viability or fanciful technique? Pacing Clin. Electrophysiol. 2018;41:122–127. doi: 10.1111/pace.13248. PubMed DOI

Kojic E.M., Hardarson T., Sigfusson N., Sigvaldason H. The prevalence and prognosis of third-degree atrioventricular conduction block: The Reykjavik study. J. Intern. Med. 1999;246:81–86. doi: 10.1046/j.1365-2796.1999.00521.x. PubMed DOI

Tselios K., Gladman D.D., Harvey P., Su J., Urowitz M.B. Severe brady-arrhythmias in systemic lupus erythematosus: Prevalence, etiology and associated factors. Lupus. 2018;27:1415–1423. doi: 10.1177/0961203318770526. PubMed DOI

Ploux S., Strik M., Caillol T., Ramirez F.D., Abu-Alrub S., Marchand H., Buliard S., Haïssaguerre M., Bordachar P. Beyond the wrist: Using a smartwatch electrocardiogram to detect electrocardiographic abnormalities. Arch. Cardiovasc. Dis. 2022;115:29–36. doi: 10.1016/j.acvd.2021.11.003. PubMed DOI

Yerasi C., O’Donoghue S., Satler L.F., Waksman R. Apple Watch detecting high-grade block after transcatheter aortic valve implantation. Eur. Heart J. 2020;41:1096. doi: 10.1093/eurheartj/ehz854. PubMed DOI