PRENATAL DIAGNOSIS, VOL.

8,53-57 (1988)

FETAL BRADYARRHYTHMIA:
DIAGNOSIS AND OUTCOME
J. W. WLADIMIROFF, P. A. STEWART, AND H. M. TONGE
Department of Obstetrics and Gynaecology, Erasmus University Rotterdam. The Netherlands

SUMMARY
Seventeen patients were referred to our ultrasound unit because of fetal bradyarrhythmia
(< 100 bpm). Duration of pregnancy varied between 21 and 40 weeks. Bradyarrhythmia
was diagnosed as atrioventricular block (n= 12), mild sinus bradycardia (n= 3), and irregular
bradycardia ( n = 2 ) . The association with maternal collagen disease was 29 per cent and
with cardiac structural defects 59 per cent. The overall mortality was 41 per cent. There
were three abnormal karyotypes (17 per cent) and four cases of cardiac compromise (23
per cent).
Prognosis depends on the nature of the bradyarrhythmia and recognition of associated
pathology such as cardiac structural defects, abnormal karyotype and degree of cardiac
compromise.

KEY WORDS Fetal bradyarrhythmia Congenital cardiac defect Maternal collagen disease

INTRODUCTION
Detailed information can now be obtained on normal and abnormal fetal cardiac
anatomy as early as 16-18 weeks of gestation using high resolution real-time
ultrasound equipment (Sahn et al., 1980; Kleinman et al., 1980; Allan et al., 1981,
1984; Wladimiroff er al., 1984). M-Mode echography allows accurate diagnosis of
fetal cardiac rate and rhythm (Allan et al., 1983; Stewart et al., 1983; Crawford
et al., 1985; Copel and Kleinman, 1986). Both techniques are essential in establish-
ing the correct prognosis and in providing appropriate further obstetric manage-
ment of cardiac arrhythmias. This report describes the diagnosis, the incidence of
associated pathology, obstetric management, and fetal outcome in fetal
brad yarrhythmias.

MATERIALS AND METHODS

Between January 1982 and January 1986 a total of 17 patients were referred to
our ultrasound unit because of persistent fetal bradyarrhythmia (c100 bpm). Preg-
nancy duration varied between 21 and 40 weeks. In each patient the following exam-
inations were performed :
(a) Assessment of cardiac structure, rate, and rhythm using a two-dimensional
phased array real-time system (Hewlett-Packard, 77020A) or a mechanical
sector scanner (Diasonics, CardioVue loo), both with real-time directed M-

Addressee for correspondence: J. W. Wladimiroff, M.D., Professor of Obstetrics and Gynaecology,

Academic Hospital Rotterdam-Dijkzigt, Erasmus University Rotterdam, Dr. Molewaterplein 40,3015
GD Rotterdam. The Netherlands.

0 197-385 1/S8/010053-O5$05.00 Received8 December 1986

@ 1988 by John Wiley & Sons, Ltd. Revised 6 May 1987
Accepted 25 May 1987
 J . W. WLADIMIROFF E T A L .

mode recording facilities. Problems with respect to visualization of the heart

may arise when the spine is anterior (shadowing), during excessive fetal move-
ments, maternal obesity, and oligohydramnios. In the present study standard
cardiac scans were short axis, long axis, and four chamber views (Wladimiroff
et al., 1984; DeVore, 1985).
A search for possible signs of cardiac compromise such as pericardial effusion,
increase in size of the right heart, or ascites.
A search for associated defects and karyotyping in amniotic fluid when a struc-
tural cardiac defect was established.
Serological studies for maternal collagen disease when no structural defects
were found.
After completion of these diagnostic procedures, further management was dis-
cussed with the neonatologist and pediatric cardiologist. In the presence of a lethal
cardiac or associated defect, termination of pregnancy was offered depending on
gestational age, or abstention from surgical intervention in the pregnancy was
advised. In the case of a good prognosis, a careful follow-up was offered with the
aim of delivering an infant in optimal condition.
After delivery, all fetuses in this study were examined clinically, ultrasonically
(and where necessary underwent other appropriate diagnostic procedures), or at
postmortem to enable correlation with the prenatal ultrasonic findings.

RESULTS
Pertinent data are presented in Table 1. Persistent bradyarrhythmia was diagnosed
as complete atrioventricular block (n = 1 I), second degree atrioventricular block
(n= I), sinus bradycardia (n = 3), and irregular bradycardia (n = 2). One of the latter
two fetuses displayed a complete atrioventricular septal defect (No. 5) and a
wandering pacemaker was diagnosed postnatally. Ventricular rate in all 17 fetuses
varied between 43 and 96 bpm (mean 67.1 bpm).
In five of our patients, bradycardia was associated with maternal collagen
disease, in one case maternal symptoms becoming apparent 3 months after delivery.
In ten patients (59 per cent), bradycardia was associated with cardiac structural
defects. Twice a structural defect was suspected but not correctly defined (Nos. 3
and 6); in one case (No. 3), this was due to excessive maternal weight (104 kg)
and advanced gestation (40 weeks). Within the group of cardiac structural abnor-
malities, there were three abnormal karyotypes (17 per cent) (Nos. 2, 6 , and 7),
i.e. 47XYY, trisomy 13, and trisomy 21. Cardiac compromise resulting in right
heart dilatation, pericardial effusion, or even ascites was observed in four cases
(23 per cent) (Nos. 7,8,9, and 16).
The overall mortality was 41 per cent and nearly entirely confined to the group
of bradyarrhythmias associated with cardiac structural defects. There were two
intrauterine deaths at 29 weeks (Nos. 7 and 8) and one neonatal death on day 3
(No. 6 ) .Two pregnancies (Nos. 9 and 10) were terminated on request of the parents
at 21 and 26 weeks because of complex cardiac structural abnormalities. In case
No. 1, the infant died at 8 months from a complete atrioventricular septal defect,
and associated spina bifida. One infant with complete heart block (No. 16) died
 Table 1. Gestational age at the time of diagnosis and pre- and postnatal findings in 17 patients with fetal bradyarrhythmia

Patient, type of Gestational age Mean Prenatal findings Postnatal findings

bradyatrhy thmia (weeks) at referral FHR (bpm)

1. Sinus bradycardia 36 95 CAVSD (severe maternal obesity) Died at 8/12, CAVSD + spina bifida
2. Sinus bradycardia 36 60 TOF, trisomy 21 TOF, trisomy 21
3. Sinus bradycardia 40 96 AS (severe maternal obesity) PS
4. Irregular bradycardia 34 90 No pathology Infant alive and well-
prob. recurrence sick sinus
syndrome 3
5. Irregular bradycardia 29 84 CAVSD CAVSD, wandering pacemaker 3-
r
6. 2" A-V block 35 60 VSD, trisomy 18 Died postpartum, TOF, trisomy 18 ms
7. 3" A-V block 29 45 Complex CHD, 47XYY, right IUD, complex CHD, 47XYY
heart dilatation G<
8. 3" A-V block 29 54 Complex CHD ascites
+ IUD, complex CHD asplenia
+ 3-
9. 3" A-V block 21 53 Complex CHD + ascites TOP, complex CHD asplenia
+ s
10. 3" A-V block 26 62 Complex CHD TOP, complex CHD E
11. 3" A-V block 34 57 Maternal collagen disease Infant alive and well
12. 3" A-V block 34 69 Maternal collagen disease Infant alive and well
3z
13. 3" A-V block 33 65 Maternal collagen disease Infant alive and well g
14. 3" A-V block 31 72 Maternal collagen disease Infant alive and well
15. 3' A-V block 35 62 No Pathology Infant alive and well, maternal
collegen disease at 3/12
16. 3" A-V block 33 43 Right heart dilatation Died on day 1 ;absent A-V
node on microscopy
17. 3' A-V block 36 70 RA tumour RA tumour

CHD=congenital heart disease; IUD intrauterine death; CAVSD =complete atrioventricular septal defect; TOP= termination of pregnancy; AS, PS =aortic,
pulmonary stenosis; VSD = ventricular septal defect; TOF = tetralogy of Fallot.
56 J. W. WLADIMIROFF ETAL.

soon after Caesarean section at 37 weeks due to an absent A-V node (microscopy)
in the presence of normal macroscopic anatomy. The ten remaining patients
delivered at term either vaginally (n = 5 ) or by Caesarean section (n= 5 ) depending
on the referring gynaecologist.

DISCUSSION
Until recently, bradyarrhythmia was frequently considered as a sign of fetal distress
resulting in emergency Caesarean section. Since the advent of combined two-
dimensional real-time and M-mode recording systems, it has become clear that
intrauterine cardiac arrhythmias are disorders of the conducting system and are
associated with a variety of fetal outcomes. In the present study, the bradyarrhyth-
mias consisted mainly of variable degrees of congenital atrioventricular block. The
clinical problems related to bradyarrhythmia are two-fold :
(a) the association with maternal collagen disease (5/17 = 29 per cent), in one case
maternal symptoms becoming apparent 3 months after delivery;
(b) the association with cardiac structural defects (10/17=59 per cent), which in
our study was of a serious nature in the majority of cases.
The present data also demonstrate that the outcome of fetuses with a combina-
tion of major cardiac structural abnormality and bradyarrhythmia is poor, whereas
in the presence of normal cardiac anatomy the outcome is generally good.
A common cardiac defect in the presence of complete atrioventricular block is
atrial isomerism (Crawford et af.,1985). In isomerism, paired organs such as lungs
and atria have bilateral morphologically right or morphologically left character-
istics. In our series, two of the five patients with complete atrioventricular block
and congenital heart disease (patients 8 and 9 in Table 1) were suspected of having
atrial isomerism prenatally, and an unusual combination of left atrial isomerism
and asplenia was diagnosed at post mortem (Stewart et al., 1984).
The presence of three fetuses with an abnormal karyotype in our material sup-
ports an earlier observation in which a close relationship between abnormal
karyotype and congenital heart disease was established (Wladimiroff e f af., 1985).
The limited occurrence of cardiac compromise (23 per cent) in our study confirms
Doppler ultrasound data on blood flow in the fetal descending aorta (Tonge et af.,
1987),in which it is suggested that at lower heart rates cardiac output is maintained
through an increase in stroke volume. The only four cases of fetal cardiac compro-
mise developed at heart rates between 45 and 55 bpm, and might be presumed to
have occurred from inadequate ventricular output due to poor filling rather than
from poor ventricular output related to heart rate alone.
Vaginal delivery is increasingly being carried out in the presence of bradyarrhyth-
mia without associated pathology. It should be realized, however, that conventional
heart rate monitoring is not feasible in the presence of atrioventricular block. Atrial
rate monitoring may be employed in the assessment of fetal condition. This should
be combined with repeated fetal scalp pH analysis in the presence of adequate cervi-
cal dilatation.
It can be concluded that in the presence of a fetal bradyarrhythmia, a correct
prognosis can only be made following a proper definition of the exact nature of
 FETAL BRADYARRHYTHMIA 57

the bradyarrhythmia.as established by echocardiography, the recognition of associ-

ated pathology such as cardiac structural defects/abnormal karyotype, a n d degree
of cardiac compromise.

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