Successful pregnancy outcome in a primigravida with sick sinus syndrome on permanent pacemaker and previous cerebrovascular accident

Yoolia Persis

Physician Assistant, OBG OPD, Kauvery Hospital, Hosur, Tamil Nadu

Abstract

Pregnancy complicated by cardiac conduction disorders requiring permanent pacemaker implantation is uncommon and presents unique obstetric and anesthetic challenges. The presence of a prior stroke further increases maternal risk. We report the case of a 25-year-old primigravida at term gestation with sick sinus syndrome, status post permanent pacemaker implantation, and a history of young-onset stroke, who underwent an elective lower segment caesarean section under spinal anesthesia with favorable maternal and neonatal outcomes.

Key words: Sick sinus syndrome; Permanent pacemaker implantation; Pregnancy caesarean section

Introduction

We present a case of 25 years old primigravida at 37 weeks+ 4days of gestation with a history of ischemic stroke resulting a right sided hemiparesis, status post left fronto –temporo –parietal craniotomy and cranioplasty, and sick sinus syndrome managed with permanent pacemaker. Her pregnancy is complicated by intercurrent lower respiratory tract infection & post-operative electrolyte imbalance. Through careful antenatal surveillance, multidisciplinary planning and timely elective lower segment caesarean section delivery under regional anesthesia, both maternal and neonatal outcomes were favourable.

This case underscores the importance of individualized care and coordinated multidisciplinary effort in achieving successful outcomes in complex high-risk pregnancies.

Sick sinus syndrome – is a group of cardiac rhythm disorder caused by dysfunctional Sino atrial (SA Node) resulting in appropriate heart rate regulation

Permanent pacemaker implantation is a small device place inside the that helps the heartbeat at a normal and regular heart rate when the heart’s own electrical system is too low or not working properly.

Image extracted from MediFee.com

Stroke happens when blood flow to the brain suddenly stops, causing brain damage. This can lead to weakness of the body, difficulty speaking, or loss of movements on one side.

Image extracted from Pinterest com

Patient information –A 25 years old primigravida, married for 2 years was admitted at 37 weeks + 4 days of gestation for safe confinement.

Presenting complaints

  • Cough with low grade fever for 2 days
  • Lower backache
  • Able to perceive fetal movements

Menstrual history

  • Previous irregular cycle (30-45 days)’
  • LMP-24/08/2024, EDD-31/05/2025

Obstetric history

  • Gravida 1, para 0,
  • Natural conception, Booked and immunized at Kauvery hospital on prophylactic ecospirin 150 mcg since conception

Antenatal investigation

  • NT scan – Normal,
  • Double marker – Low risk,
  • Anomaly scan – Normal
  • Growth scans – Normal

Past medical & surgical history

  • Young stroke (2022) with residual right hemiparesis
  • Underwent left fronto –temporo –parietal craniotomy (Dec 2022)
  • Diagnosed with sick sinus syndrome with junctional bradycardia, permanent pacemaker (VVIR mode) implanted in Jan 2023
  • Cranioplasty performed in 2023
  • No H/o DM/Hypertension / Bronchial asthma /Tuberculosis.

On examination

Conscious, oriented, afebrile, Mild dysarthria (+), Residual right sided weakness with dystonic posturing of right hand

Vital signs

  • Bp – 110/70 mmHg
  • Pulse rate – 60 bpm
  • SpO2 – 98% In RA
  • Respiratory rate – 20b/min

Systemic examination

  • CVS-S1, S2 Normal
  • RS – Bilateral air entry (+)
  • CNS – Residual right sided weakness
  • PA – Uterus~ 36 weeks, relaxed, cephalic, FHR (+)140 bpm regular
  • PS/PV – Not done

Investigation on admission

Hemoglobin11.0g/dl
Blood GroupA positive
S. Creatinine0.4g/dl
S. Urea11.3g/dl
Potassium3.7mmol/L
Chloride108mmol/L
Sodium133mmol/L
Ultrasound (30.04.2025)Single live intra uterine gestation. 35 weeks + 4days, Cephalic presentation, Placenta – Anterior high, Liquor – Normal, EFW - 2393+/- 239gms, Doppler – Normal.

Diagnosis

  • Primi gravida at 37 weeks + 4days of gestation
  • Sick Sinus syndrome status post permanent pacemaker (VVIR mode)
  • Old right sided stroke
  • Lower Respiratory tract infection.

Management

After getting written consent and multidisciplinary consultation involving obstetrics, cardiology, neurology, anesthesia and physician, the patient was planned for elective caesarean section.

Surgical procedure

Elective caesarean section was performed under spinal anesthesia

Preoperatively, pacemaker mode was changed from (Ventricular Pacing, Ventricular Sensing, Inhibited response) VVIR to VOO at 80bpm, as per cardiology advice. (VOO refers to a specific, asynchronous pacemaker mode in which the pacemaker paces the Ventricle, has no sensing capabilities, and has no response to sensed activity). She delivered a live Female baby. Intra operative period was uneventful.

Postoperative period Course:

Post Operatively, Pacemaker mode changed as per cardiologist advice(60bpm).

Post operatively, the patient was kept under ICU observation with continuous cardiac monitoring. Patient developed desaturation and tachypnea managed with supplemental oxygen, nebulization, Chest physiotherapy with Incentive spirometry. Continuous monitoring is done to watch for further desaturation. After 24 hr of observation, she was shifted to ward with same line management.

On POD -1

Neurologist review obtained, advised to start on LMVH and to continue physiotherapy at ward.

On POD -1, Patient developed persistent cough and noisy breathing (+), tachypnea and persistent desaturation

Cardiologist and Physician review obtained for breathlessness, suspected LRTI and Volume overload advised to start diuretics and to continue IV Antibiotics and stop IV Fluids, she was shifted to ICU for further management.

CT chest report – Bilateral lower lobe collapse noted. Moderate cardiomegaly with external pacemaker noted in-situ. Left upper lobe subsegmental collapse noted.

On POD – 2

Repeat blood investigation done showed – Hypokalemia (Potassium 2.2mmol/L), Urea – 12.5mg/dl, Creatinine – 0.5mg/dl, in view of deranged electrolytes level started on KCL correction

On POD -3

Repeat investigations showed gradual normalization of renal parameters and electrolytes.

BNP levels were Normal. LMWH was withheld due to mild hematuria.

Physician review obtained for persistent LRTI advised to escalate higher IV antibiotics and to continue nebulization and incentive spirometry.

Surgical wound was cleaned and Dressing done.

On POD -4

The patient showed clinical improvement with reduced tachypnea, cough, Hematuria settled.

She was shifted back to ward and managed with same line management.

On POD -5

As the patient was symptomatically better, the patient was discharged in stable condition with appropriate medications and follow up advice.

Discussion

Pregnancy in women with sick sinus syndrome and permanent pacemaker implantation prior to conception significantly improves maternal outcomes. Regional anesthesia, when carefully planned, is considered safe.

This case also emphasizes the importance of prompt recognition and management of postpartum respiratory complications and electrolytes imbalance.

Conclusion

At just 25 years of age, she carried more than a pregnancy; she carried a history that could have defined her limits. Instead, it became a testament to resilience, teamwork, and modern medicine.

When she conceived naturally, her pregnancy was immediately recognized as high risk, demanding meticulous planning and unwavering vigilance. From the very beginning, she was closely followed by a multidisciplinary team—obstetricians, cardiologists, neurologists, anaesthetists, and physicians—each playing a crucial role in safeguarding both mother and baby.

Day by day, she regained strength. Her confidence returned, and she was discharged hemodynamically stable, neurologically unchanged from baseline, and holding her baby in her arms. This was not just a discharge. It was a victory.

She walked out of the hospital not just as a patient, but as a mother, a survivor, and a symbol of hope. Heartfelt thanks to everyone who played an important role in her antenatal and postnatal care.

“We don’t wait for miracles. We deliver them—together.”

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