Review

Supraventricular arrhythmia in pregnancy

Heart: first published as 10.1136/heartjnl-2021-320451 on 27 January 2022. Downloaded from http://heart.bmj.com/ on April 3, 2024 by guest. Protected by copyright.
Karishma P Ramlakhan ‍ ‍,1,2 Robert M Kauling,1 Nicole Schenkelaars,2 Dolf Segers,3
Sing-­Chien Yap,1 Martijn C Post,4,5 Jérôme Cornette,2 Jolien W Roos-­Hesselink ‍ ‍1
1
Department of Cardiology, ABSTRACT Supraventricular arrhythmias are more common
Erasmus MC, University Medical The physiological changes during pregnancy predispose than ventricular arrhythmias and will be the focus
Center Rotterdam, Rotterdam,
The Netherlands a woman for the development of new-­onset or of this review.7
2
Department of Obstetrics and recurrent arrhythmia. Supraventricular arrhythmia Atrial fibrillation or flutter (AF, 31–59 per
Fetal Medicine, Erasmus MC is the most common form of arrhythmia during 100 000 pregnancies) is the most frequently
- Sophia Children’s Hospital, pregnancy and, although often benign in nature, can reported arrhythmia in pregnancy, with a growing
University Medical Center prevalence in the past two decades that may
Rotterdam, Rotterdam, The be concerning. We describe three complex cases of
Netherlands supraventricular arrhythmia during pregnancy and be partly explained by the increasing maternal
3
Department of Cardiology, review the currently available literature on the subject. age.7 9 Non-­AF supraventricular tachycardia (SVT)
Amphia Hospital, Breda, The In pregnancies complicated by arrhythmia, a plan for is reported in 22–33 per 100 000 pregnancies,5 7 10
Netherlands including atrioventricular (nodal) re-­ entry tachy-
4
Department of Cardiology, Sint
follow-­up and both maternal and fetal monitoring
Antonius Hospital, Nieuwegein, during pregnancy, delivery and post partum should be cardia (AV(N)RT) and atrial tachycardia.
The Netherlands made in a multidisciplinary team. Diagnostic modalities Although most arrhythmias are benign, they are
5
Department of Cardiology, should be used as in non-­pregnant women if there associated with increased maternal mortality (OR
University Medical Center
is an indication. All antiarrhythmic drugs cross the 13 for AF and OR 6 for SVT).7 Appropriate workup
Utrecht, Utrecht, The
placenta, but when necessary, medical treatment and multidisciplinary management are therefore
Netherlands
should be used with consideration to the fetus and important, but the literature to guide clinical deci-
Correspondence to the mother’s altered pharmacodynamics and kinetics. sions is scarce. In this review, we describe three
Dr Jolien W Roos-­Hesselink, Electrical cardioversion is safe during pregnancy, and complex cases seen in a tertiary referral centre and
Department of Cardiology, electrophysiological study and catheter ablation can provide a step-­by-­step guide for the management of
Erasmus MC, Rotterdam, Zuid-­ supraventricular arrhythmias during pregnancy.
Holland, Netherlands; be performed in selected patients, preferably with
​j.​roos@​erasmusmc.​nl zero-­fluoroscopy technique. Sometimes, delivering the
fetus (if viable) is the best therapeutic option. In this
Received 14 October 2021 CASE SERIES
review, we provide a framework for the workup and
Accepted 30 December 2021 Case 1
Published Online First
clinical management of supraventricular arrhythmias
A primigravid woman aged 34 years presented
27 January 2022 in pregnant women, including cardiac, obstetric and
at the emergency department of an affiliated
neonatal perspectives.
secondary care centre with complaints of palpita-
tions at 37 weeks of gestation. She previously had
INTRODUCTION an uneventful pregnancy, had no relevant history of
Anatomical, haemodynamic and hormonal changes cardiac disease, but was known with Crohn’s disease
in the maternal physiology make pregnancy a and hypothyroidism. Her ECG showed a regular
high-­risk period for the occurrence of new-­onset SVT of 220 bpm. A short RP narrow complex
arrhythmia, or the recurrence of pre-­ existing tachycardia was observed, consistent with AVNRT
arrhythmia. The maternal intravascular volume or atrioventricular re-­ entry tachycardia (AVRT)
expands up to 45% throughout pregnancy, to (figure 1). She showed no signs of congestion.
compensate for a fall in systemic vascular resis- The patient was admitted and repeatedly treated
tance that facilitates the formation of the uteropla- with adenosine intravenously, with only temporary
cental circulation.1 The volume expansion causes conversion to sinus rhythm. A cumulative dosage
atrial and ventricular stretch, which in combina- of 7.5 mg of metoprolol intravenously and 50 mg
tion with a physiologically increased heart rate metoprolol orally were given next, without success.
and contractility, increased sympathetic activity After 4 hours of sustained tachycardia, intravenous
and altered catecholamine sensitivity creates an verapamil was administered to a total amount of
arrhythmogenic state.2–4 Arrhythmia risk peaks 10 mg. The heart rate decreased to 180 bpm, but
in the third trimester.5 Maternal risk factors are stable sinus rhythm was not achieved. The patient
previous arrhythmia, advanced maternal age, remained haemodynamically stable and the fetal
African ancestry and congenital heart disease, in heart rate pattern on the cardiotocogram (CTG)
which surgical scars and aberrant cardiac anatomy was reassuring.
© Author(s) (or their compound the situation.6–8 In consultation with our tertiary care centre, we
employer(s)) 2022. Re-­use
Data on the prevalence of arrhythmia during decided to eliminate the most-­likely trigger of the
permitted under CC BY-­NC. No
commercial re-­use. See rights pregnancy are scarce and conflicting, and lack tachycardia: the pregnancy itself. An uneventful
and permissions. Published clarity because complaints of palpitations are emergency caesarean section was performed, six-­
by BMJ. common and predominantly benign.4 Arrhythmia and-­a-­half hours after the patient’s first presenta-
To cite: Ramlakhan KP, was observed in 68 per 100 000 pregnancy-­related tion. After induction of general anaesthesia, the
Kauling RM, hospitalisations, which probably underestimates patient spontaneously converted and remained in
Schenkelaars N, et al. Heart the total prevalence considering the additional sinus rhythm. A son of 3206 g (67th percentile)
2022;108:1674–1681. cases of arrhythmia without hospitalisation.7 was born with initially low Apgar scores of 4/5/8
1674   Ramlakhan KP, et al. Heart 2022;108:1674–1681. doi:10.1136/heartjnl-2021-320451
 Review

Heart: first published as 10.1136/heartjnl-2021-320451 on 27 January 2022. Downloaded from http://heart.bmj.com/ on April 3, 2024 by guest. Protected by copyright.
Figure 1 ECG of a woman aged 34 years presenting at 37 weeks of gestation with a regular supraventricular tachycardia of 220 bpm with a
retrograde P wave, suggestive of an atrioventricular (nodal) re-­entry tachycardia. Hyperthyroidism and an atrioventricular re-­entry tachycardia with
concealed bypass were later discovered.

at 1/5/10 min, based on transient respiratory insufficiency due would increase the risk of bleeding complications during the
to the anaesthesia. After 4 days in the neonatology ward, he was caesarean section. Because the fetal heart trace on the CTG
discharged in good health. In the mother, a hyperthyroidism remained reassuring, we decided to postpone the delivery for
due to oversupplementation of her levothyroxine was diagnosed 1 week. Fraxiparine 0.8 mL subcutaneous twice daily was started
and treated accordingly. One year later, the patient was seen after the ECV and stopped again 24 hours before the uncompli-
for preconception counselling and although no recurrence of cated caesarean section. A healthy boy of 3550 g (81st percen-
the AV(N)RT had occurred, an electrophysiological (EP) study tile) was born with Apgar scores of 9/10. Coumadin was started
was performed. An orthodromic AVRT with a left posteroseptal 48 hours after surgery and continued for 4 weeks.
accessory pathway could be induced and was successfully ablated. Two months post partum, the patient suffered from recur-
rent palpitations after she decreased the beta-­blocker dosage on
Case 2 her own initiative. The echocardiogram showed an increase of
A woman aged 35 years, gravida 2 para 1, first presented in a the mean gradient of the mitral valve prosthesis to 10 mm Hg,
secondary hospital with AF at 12 weeks of gestation. She was with normal right ventricular pressure (figure 2C). Holter moni-
known with Marfan syndrome and had undergone an ascending toring for 48 hours showed no recurrence of AF, but considering
aorta replacement and implantation of a mitral bioprosthesis (for the progressive mitral valve prosthesis stenosis and markedly
regurgitation) in 2004, followed by a bioprosthesis replacement increased size of the left atrium, we decided to restart Coumadin
in 2014. Her current AF was treated with a trans-­oesophageal for the associated thromboembolic risk. One year after delivery,
echo-­guided electrocardioversion (ECV) and Coumadin, after she had a new episode of AF which could be terminated by ECV.
which she was referred to our centre for further follow-­up. At An exercise echocardiogram was performed and showed an
20 weeks of gestation, a transthoracic echocardiogram showed increase in the mean gradient of the mitral valve prosthesis from
normal systolic function of the left ventricle, but a moderate 9 mm Hg at rest to 16 mm Hg during exercise. After discussion
stenosis of the mitral valve prosthesis with a mean gradient in the multidisciplinary heart team, she underwent a re-­opera-
of 7 mm Hg (figure 2A). A recent prepregnancy MRI of the tion and a mechanical mitral valve prosthesis (considering her
thoracic aorta showed normal aortic dimensions and good status family was complete) was inserted successfully. No complica-
of her ascending aorta graft, so imaging was not repeated. Our tions occurred during hospitalisation and at latest follow-­up, 3
multidisciplinary pregnancy heart team considered her to be in months after surgery.
class II–III following the modified WHO (mWHO) maternal
cardiovascular risk classification.11 According to the European Case 3
Society of Cardiology (ESC) guidelines on delivery in women A primigravid woman aged 38 years presented at 16 weeks
with arrhythmia, she was at low risk for haemodynamic compro- of gestation at a secondary hospital with palpitations that had
mise during delivery and rhythm surveillance level 1 was recom- increased in intensity during pregnancy. She had no history of
mended, as for all stable SVT (table 1).11 An elective caesarean cardiac disease. She was diagnosed with an AV(N)RT and treated
section was planned at 39 weeks of gestation, because of a with metoprolol 12.5 mg twice daily without sufficient effect,
previous caesarean section. after which she was referred to our centre. Here, the ECG
However, at 37 weeks of gestation she presented with AF showed a regular SVT of 205 bpm with an intermediate axis and
with rapid ventricular response (figure 2B). Beta-­blockers were a narrow QRS complex (figure 3A). A mid-­RP narrow complex
started, and we decided there was an indication for ECV within tachycardia was observed, consistent with AVNRT, AVRT or
48 hours and to expedite the delivery. The ECV was successful, less likely atrial tachycardia. The arrhythmia terminated spon-
but the therapeutic anticoagulation that is required after ECV taneously, but afterwards many recurrences were observed,
Ramlakhan KP, et al. Heart 2022;108:1674–1681. doi:10.1136/heartjnl-2021-320451 1675
 Review

Heart: first published as 10.1136/heartjnl-2021-320451 on 27 January 2022. Downloaded from http://heart.bmj.com/ on April 3, 2024 by guest. Protected by copyright.

Figure 2 Transthoracic echocardiogram and ECG of a woman aged 35 years with Marfan syndrome and a mitral valve bioprosthesis, presenting
at 14 weeks of gestation with atrial fibrillation. (A) Transthoracic echo at 20 weeks of gestation showing parasternal and apical view of the
bioprosthesis. Continuous wave Doppler showing a mean peak gradient of 7 mm Hg. (B) ECG showing recurrent atrial fibrillation with rapid
ventricular response at 37 weeks of gestation. (C) Continuous wave Doppler at 2 months post partum, showing worsening mitral stenosis with a
mean PG of 10 mm Hg of the prosthetic valve and tricuspid regurgitation velocity of 2.4 m/s.

1676 Ramlakhan KP, et al. Heart 2022;108:1674–1681. doi:10.1136/heartjnl-2021-320451

 Review
We discuss the current knowledge on the subject, using the cases
Table 1 Recommended surveillance levels during delivery in women
and the figure as a framework.
with supraventricular arrhythmia

Heart: first published as 10.1136/heartjnl-2021-320451 on 27 January 2022. Downloaded from http://heart.bmj.com/ on April 3, 2024 by guest. Protected by copyright.
Low risk* Medium risk
Case 1
Indication PSVT, AF, Wolff-­Parkinson-­ Unstable SVT Although AV(N)RT in pregnancy are usually well tolerated, they
White syndrome
can become symptomatic or cause haemodynamic instability,
Surveillance ► Consult cardiologist ► Consultation with multidisciplinary
especially in the presence of underlying heart disease. After
during delivery ► Mode and location of team including arrhythmologists at
delivery on obstetric specialised centre primary examination with appropriate workup, vagal manoeu-
indication ► Mode and location of delivery on vres, pharmacological treatment with adenosine intravenously
obstetric indication are the first choice of treatment in the acute setting in haemody-
► Monitor cardiac rhythm (3-­lead ECG) namically stable patients (figure 5). In case of insufficient effect
► Intravenous line or haemodynamic compromise, ECV is indicated, especially as
► Prepare for intravenous
in pregnancy some medication may be harmful.12
administration of adenosine
► Prepare for intravenous
administration of a beta-­blocker Drugs
► External cardioverter defibrillator All antiarrhythmic drugs (AAD) cross the placenta, although data
at site
on fetal toxicity are often limited. If possible, drug therapy may
Based on the 2018 ESC guidelines for the management of cardiovascular diseases be avoided or postponed until after the first trimester, in which
during pregnancy.11
*The risk of arrhythmia with haemodynamic compromise during delivery; the high-­
the teratogenic risk is highest, but therapy can be necessary and
risk category includes ventricular arrhythmia only and is therefore excluded in the justified in persisting arrhythmias.12 Due to the altered maternal
table. pharmacodynamics and kinetics, the required drug dosage may
AF, atrial fibrillation; ESC, European Society of Cardiology; PSVT, paroxysmal be either lower or higher (eg, digoxin, due to increased clearance
supraventricular tachycardia; SVT, supraventricular tachycardia. and volume of distribution) than in non-­pregnant women. Table 2
lists the safety during pregnancy and lactation of commonly used
drugs for rhythm and rate control and anticoagulation.
provoked by light physical activity. There were no signs of In case 1, adenosine and verapamil were used, both of which
congestion. An echocardiogram showed that there was no struc- prolong the effective refractory period of the AV node and have
tural heart disease. a success rate of 90% in terminating acute attacks.13 Alternatively,
According to the ESC guidelines, our multidisciplinary preg- digoxin or beta-­blockers could be used to terminate or supress
nancy heart team classified her as mWHO II, as all supraventric- AV(N)RT. Adenosine can be safely administered in the same dosage
ular arrhythmia without underlying structural heart disease.11 as in non-­pregnant patients. There are few data on verapamil or
Rhythm-­surveillance level 1 was recommended during delivery diltiazem, but no teratogenicity or maternal side effects during
(table 1). An EP study with ablation was discussed, but we pregnancy are reported.14 Caution is warranted when combining
decided to first pursue pharmacological treatment and only class 1C or 1A because of potentially deleterious negative inotropic
perform an ablation in case of refractory complaints. Verapamil and chronotropic effects on mother and fetus.
120 mg once daily replaced the metoprolol, and she was advised In case 1, sinus rhythm was established only after the delivery,
to avoid excessive exertion. The dosage was gradually increased which shows the crucial role that pregnancy physiology has in
to 120 mg three times daily, with an acceptable but incomplete provoking the new onset or (frequent) recurrence of arrhythmia.
result on the frequency and intensity of her complaints. The The initial and additional assessment should also consider other
fetal status and growth were monitored regularly in the obstetric triggers, such as anaemia, stress or thyroid dysfunction (figure 5).
outpatient clinic with CTG and fetal ultrasound, and remained In AV(N)RT, there are usually no underlying cardiac abnormal-
ities. In case 1, both the hyperthyroidism and the concealed
reassuring. Labour was induced at 37 weeks of gestation because
bypass contributed to the arrhythmia. However, the delivery of
of the persisting complaints of arrhythmia. The patient had an
the child was the most important step and best option in this
uncomplicated delivery of a girl of 3585 g (90th percentile),
patient’s treatment, considering her pregnancy was at term
with Apgar scores of 9/10. Because of the maternal verapamil use
gestational age.
during pregnancy and lactation, the neonate was observed for
24 hours. The neonatal heart rate and ECG were normal, while
the serum verapamil levels were very low and below therapeutic Delivery and post partum
range (norverapamil <15 μg/L and verapamil <10 μg/L). Two Neurohormonal changes and pain during labour stimulate the
months post partum, an EP study with ablation was performed sympathetic nervous system, which increases the heart rate
due to persisting palpitations after delivery. A left lateral and contractility.15 The cardiac output is further increased by
concealed bypass with inducible AVRT was ablated (figure 4). exertion and fluid shifts. The timing and mode of delivery and
Unfortunately, the procedure was complicated by pericardial surveillance level should be individualised in a delivery plan by
effusion needing pericardiocentesis (figure 3B). Afterwards a multidisciplinary pregnancy heart team, considering cardiac,
she developed a postpericardiocentesis pericarditis, which was obstetric and fetal factors. The ESC guidelines consider parox-
treated with analgesia and colchicine. ysmal SVT, AF and Wolff-­Parkinson-­White syndrome to be low
risk, and consultation of a cardiologist is the only recommenda-
tion (table 1).11 Unstable SVTs are classified as medium risk and
DISCUSSION consultation of a specialised multidisciplinary team, including
We have described three cases of supraventricular arrhythmia arrhythmologists, is advised. The mode and location of the
during pregnancy where different forms of intervention were delivery are on obstetric indication, although continuous telem-
necessary. Figure 5 presents a step-­by-­step guide for the diagnosis etry, intravenous access and an external cardioverter defibrillator
and management of supraventricular arrhythmia in pregnancy. should be available.11
Ramlakhan KP, et al. Heart 2022;108:1674–1681. doi:10.1136/heartjnl-2021-320451 1677
 Review

Heart: first published as 10.1136/heartjnl-2021-320451 on 27 January 2022. Downloaded from http://heart.bmj.com/ on April 3, 2024 by guest. Protected by copyright.
Figure 3 ECG and echocardiogram of a woman aged 38 years at 16 weeks of gestation, presenting with atrioventricular (nodal) re-­entry
tachycardia (AV(N)RT). (A) ECG of a regular supraventricular tachycardia of 205 bpm with an intermediate axis and a narrow QRS complex. A
retrograde P wave was observed 120 ms behind the QRS complex, suggestive of an AV(N)RT. (B) Subcostal view of an echocardiogram after an
electrophysiological (EP) study with ablation for a left lateral concealed bypass atrioventricular re-­entry tachycardia, showing moderate pericardial
effusion as complication of the EP study.

Due to physiological fluid shifts or complications such as it because of structural heart disease. In general, the recur-
postpartum haemorrhage, haemodynamic changes in the first rence rate during pregnancy for women with previous AF is
days post partum may trigger arrhythmia and even heart failure, 25%–52%8 and the incidence of AF for women with structural
especially in case of prepregnancy decreased ejection fraction or heart disease is 1.3%.17 The recurrence rate of SVT during preg-
valvular disease. Monitoring by 3-­lead ECG and vital functions nancy is 50%.8 However, the risk may be higher in patients with
should be continued for at least 24–48 hours after delivery for more complex cardiac disease, ranging from 0.8% in patients
women with a medium-­risk or high-­risk pregnancy.16 with an atrial septal defect to 15.6% in patients with transpo-
sition of the great arteries.18 Besides the recurrence rates, the
Preconception counselling preconception counselling should educate the patient about the
In case 1, the patient received preconception counselling before symptoms suggestive of arrhythmia and what they should do in
she started her second pregnancy, and subsequently her AVRT case of complaints. There might be a role for haemodynamic
could be ablated before she got pregnant. This illustrates the testing as part of preconception counselling, however, data are
added value of preconception counselling in women with scarce on what kind of tests are the most informative and what
a history of arrhythmia, or an increased risk of developing the cut-­off values should be to base clinical decisions on.
1678 Ramlakhan KP, et al. Heart 2022;108:1674–1681. doi:10.1136/heartjnl-2021-320451
 Review

Heart: first published as 10.1136/heartjnl-2021-320451 on 27 January 2022. Downloaded from http://heart.bmj.com/ on April 3, 2024 by guest. Protected by copyright.
Figure 4 Electrophysiological study and ablation in a woman with persisting palpitations post partum. (A) Location of catheters in left anterior
oblique (LAO) view. The ablation catheter (*) is positioned at the site of successful ablation of the left lateral concealed bypass. (B) Intracardiac
electrograms during RV apical pacing at a cycle length of 600 ms. There is an eccentric retrograde atrial activation during RV pacing with earliest
activation at the distal coronary sinus. Note the short local ventricular to atrial interval at the site of successful ablation (ABL 1–2). ABL, ablation
catheter; CS, coronary sinus; RF, radiofrequency; RV, right ventricle.

Case 2 Electric cardioversion

Contrary to other types of supraventricular arrhythmia, AF in a In case of sustained supraventricular arrhythmia or haemody-
young woman with a structurally normal heart is uncommon and namic instability, ECV is recommended as in non-­ pregnant
additional cardiac assessment to rule out any underlying struc- women (figure 5).11 20 No deleterious effects of ECV on fetal
tural heart disease is essential (figure 5).19 The most important haemodynamics are reported21 and the risk of inducing fetal
risk factors are a history of AF (OR 7.1), mitral valve disease arrhythmias or inducing premature labour is deemed very low,
(OR 6.9) and left-­sided cardiac lesions (OR 2.9).17 but it is recommended to perform CTG monitoring directly after

Figure 5 Flow chart of the diagnosis and treatment of supraventricular arrhythmia during pregnancy. *Flecainide is relatively contraindicated in
women with structural heart disease, and is also contraindicated in case of atrial flutter due to risk of 1:1 AV conduction. AVNRT, atrioventricular
nodal re-­entry tachycardia; AVRT, atrioventricular re-­entry tachycardia; CTG, cardiotocogram; DOAC, direct oral anticoagulants; EP, electrophysiological;
Hb, haemoglobin; Ht, haematocrit; LMWH, low molecular weight heparin; NT-­proBNP, N-­terminal pro b-­type natriuretic peptide; SR, sinus rhythm; SVT,
supraventricular tachycardia; VKA, vitamin K antagonist.
Ramlakhan KP, et al. Heart 2022;108:1674–1681. doi:10.1136/heartjnl-2021-320451 1679
 Review

Table 2 Drugs used in the treatment of arrhythmia and their safety during pregnancy and lactation
Drug class Drug name Safety during pregnancy Compatible with breast feeding?

Heart: first published as 10.1136/heartjnl-2021-320451 on 27 January 2022. Downloaded from http://heart.bmj.com/ on April 3, 2024 by guest. Protected by copyright.
Rhythm/Rate control      
Beta-­blockers Metoprolol, propranolol, Considered safe, but may cause risk of fetal bradycardia, hypoglycaemia and Yes; propranolol, metoprolol and
bisoprolol, atenolol intrauterine growth restriction. labetalol are preferable
Atenolol: not preferable, possible teratogenicity in first trimester.
Calcium-­channel blockers Verapamil, diltiazem Probably safe, induces tocolysis and may cause maternal hypotension and Yes
subsequent fetal distress.
Diltiazem: limited human data, possible teratogenicity in animals.
Cardiac glycosides Digoxin Considered safe, preferable in treating arrhythmia. Increased renal clearance may Yes
necessitate higher dosage to maintain therapeutic levels.
Antiarrhythmic drugs Adenosine Considered safe. Yes
Antiarrhythmic drugs Amiodarone Unsafe, may cause fetal thyroid disorders, but use in acute treatment may be No
warranted.
Antiarrhythmic drugs Flecainide Commonly used in the intrauterine treatment of fetal tachycardia in the second Unknown
and third trimester, but safety in the first trimester is unclear due to reports of
teratogenicity in animals.
Antiarrhythmic drugs Lidocaine Considered safe, may cause fetal bradycardia and acidosis. Yes
Antiarrhythmic drugs Procainimide Considered safe. Yes
Antiarrhythmic drugs Quinidine May cause fetal thrombocytopenia and preterm labour due to an oxytocic effect in Yes
high doses.
Antiarrhythmic drugs Sotalol Considered safe, may cause fetal bradycardia and hypoglycaemia. No
Anticoagulation      
Direct oral anticoagulants Apixaban, dabigatran Contraindicated due to teratogenicity in animal studies and bleeding risks. No
Antiplatelet drugs Acetylsalicylic acid, Aspirin: considered safe in a low dose (<150 mg). Aspirin: yes
clopidogrel Clopidogrel: limited human data show no harm, use for shortest duration possible. Clopidogrel: unknown
Heparins Low molecular weight Safe for the fetus, but may cause maternal bleeding complications, in particular Yes
heparin, unfractioned during delivery; plan dosage accordingly.
heparin
Vitamin K antagonists Acenocoumarol, Use in the first trimester may cause embryopathy and miscarriage, use at time of Yes
fenprocoumon, warfarin delivery may cause maternal and fetal bleeding complications.
Based on the 2018 ESC guidelines for the management of cardiovascular diseases during pregnancy,11 Drugs in Pregnancy and Lactation31 and the FDA Pregnancy and Lactation
Labelling Rule, Drugs and Lactation Database (LactMed).
ESC, European Society of Cardiology; FDA, Food and Drug Administration.

ECV.22 If the cardioversion must be postponed, drug therapy for Case 3

rate control should be instated and the patient could be observed In case 3, a high dosage of verapamil was necessary to supress
for 24 hours to see if drug therapy is sufficient as treatment. the AVRT, of which the fetal effects are unknown. Therefore,
However, this increases the duration of maternal tachycardia regular follow-­up was performed of the fetal heart rate and
and AADs may have fetal effects (table 2). growth during pregnancy, and post partum the neonate was
observed for 24 hours in the neonatology ward.
Anticoagulation
It is not clear whether the same rules for stroke-­prediction risk Fetal and neonatal monitoring
stratification can be used as in non-­pregnant patients,20 because There are few data on the offspring risks after supraventricular
pregnancy should be considered a prothrombotic state because arrhythmia during pregnancy. Paroxysmal SVT is associated with
of a physiological increase in clotting factors and a decrease in low birth weight (OR 1.7), but the attributable effect of the SVT
anticoagulant and fibrinolytic factors.15 In women with congen- versus the medication used is unclear.24 Consequently, there is no
ital heart disease underlying the arrhythmia, thromboembolic consensus on the requirements for fetal monitoring, which may
risk is increased even in those with a low CHADS2/CHA2DS2 depend on the type of SVT, the gestational age and the effects of
VASc (congestive heart failure, hypertension, age, diabetes, the type of medication used (table 2). Beta-­blockers, for example,
previous stroke/transient ischemic attack (vascular disease)) may cause intrauterine growth restriction, which requires regular
scores, and therapeutic anticoagulation should be considered.23 monitoring of fetal growth, and also fetal bradycardia and hypogly-
Patients with moderate mitral stenosis, like in case 2, may have caemia, which requires neonatal monitoring post partum.25
an increased risk of developing intra-­atrial thrombi and if there In case 3, an EP study was considered but postponed until after
is also severe left atrial enlargement or spontaneous contrast, the delivery. The procedure was complicated by pericardial effu-
we advise low molecular weight heparin (LMWH) in a prophy- sion that required pericardiocentesis, which illustrates the risks,
lactic dose. Careful timing of anticoagulation around the period as this complication would have been even more dramatic during
of delivery is crucial because of the bleeding risk. In case 2, we pregnancy.
postponed the delivery to allow for enough time after stopping
the LMWH and waited for 48 hours to restart Coumadin post EP study and catheter ablation
partum. Coumadin was restarted considering the combination of EP study and ablation could be considered in highly selected
the congenital heart disease and pregnancy as thrombogenic risk patients with drug-­refractory SVT.11 12 After multidisciplinary
factors in this patient. team consultation, a careful risk-­benefit discussion with the
1680 Ramlakhan KP, et al. Heart 2022;108:1674–1681. doi:10.1136/heartjnl-2021-320451
 Review
patient should be conducted. EP study might be considered 5 Li J-­M, Nguyen C, Joglar JA, et al. Frequency and outcome of arrhythmias complicating
in patients presenting with AV(N)RT, focal atrial tachycardia admission during pregnancy: experience from a high-­volume and ethnically-­diverse
obstetric service. Clin Cardiol 2008;31:538–41.

Heart: first published as 10.1136/heartjnl-2021-320451 on 27 January 2022. Downloaded from http://heart.bmj.com/ on April 3, 2024 by guest. Protected by copyright.
and cavotricuspid isthmus-­dependent atrial flutter, but not for 6 Tateno S, Niwa K, Nakazawa M, et al. Arrhythmia and conduction disturbances in
other macrore-­entry tachycardia or AF.26 27 If possible, catheter patients with congenital heart disease during pregnancy: multicenter study. Circ J
ablation should be performed only in experienced high-­volume 2003;67:992–7.
centres, and either be postponed to the second trimester to 7 Vaidya VR, Arora S, Patel N, et al. Burden of arrhythmia in pregnancy. Circulation
2017;135:619–21.
avoid radiation exposure in the first trimester, or use a zero-­
8 Silversides CK, Harris L, Haberer K, et al. Recurrence rates of arrhythmias during
fluoroscopy technique as a successful and safe alternative to pregnancy in women with previous tachyarrhythmia and impact on fetal and neonatal
conventional fluoroscopy.26 28 29 Overall frequency of cardiac outcomes. Am J Cardiol 2006;97:1206–12.
tamponade after EP study is 0.6%.30 9 Lee M-­S, Chen W, Zhang Z, et al. Atrial fibrillation and atrial flutter in pregnant
Women-­A population-b­ ased study. J Am Heart Assoc 2016;5:e003182.
10 Lee K-­T, Chang S-­H, Kuo C-­F, et al. Incidence and time course of symptomatic
paroxysmal supraventricular tachycardia during pregnancy: a nation-­wide database
CONCLUSIONS
study. Acta Cardiol Sin 2020;36:44–9.
Pregnancy creates an arrhythmogenic environment and the preg- 11 Regitz-­Zagrosek V, Roos-­Hesselink JW, Bauersachs J, et al. 2018 ESC guidelines
nant population is increasingly at risk of arrhythmias. Starting at for the management of cardiovascular diseases during pregnancy. Eur Heart J
the initial presentation, a multidisciplinary approach is crucial to 2018;39:3165–241.
balance maternal cardiac, obstetric and fetal considerations. In 12 Brugada J, Katritsis DG, Arbelo E, et al. 2019 ESC guidelines for the management
of patients with supraventricular tachycardiaThe Task force for the management of
any case, optimal maternal health is a prerequisite for good fetal patients with supraventricular tachycardia of the European Society of cardiology
health, so diagnostic modalities and therapeutic options (such (ESC). Eur Heart J 2020;41:655–720.
as electrical or chemical cardioversion) should be used where 13 Goy J-­J, Fromer M. Antiarrhythmic treatment of atrioventricular tachycardias. J
necessary and not be avoided or delayed because of the fetus. Cardiovasc Pharmacol 1991;17:S41–40.
14 Byerly WG, Hartmann A, Foster DE, et al. Verapamil in the treatment of maternal
Knowledge of the physiology of pregnancy helps to predict the
paroxysmal supraventricular tachycardia. Ann Emerg Med 1991;20:552–4.
effects and consequences of interventions and drug therapy. A 15 Ramlakhan KP, Johnson MR, Roos-­Hesselink JW. Pregnancy and cardiovascular
good secondary assessment for underlying causes of arrhythmia, disease. Nat Rev Cardiol 2020;17:718–31.
such as structural heart disease or endocrine disorders, should 16 Ruys TPE, Roos-­Hesselink JW, Hall R, et al. Heart failure in pregnant women with
not be forgotten. However, often the pregnancy itself is the most cardiac disease: data from the ROPAC. Heart 2014;100:231–8.
17 Salam AM, Ertekin E, van Hagen IM, et al. Atrial Fibrillation or Flutter During
important contributor to the burden of arrhythmia, and the Pregnancy in Patients With Structural Heart Disease: Data From the ROPAC (Registry
delivery of the child is sometimes a viable therapeutic option. on Pregnancy and Cardiac Disease). JACC Clin Electrophysiol 2015;1:284–92.
18 Drenthen W, Pieper PG, Roos-­Hesselink JW, et al. Outcome of pregnancy in
Contributors Study design: KPR, RMK, NS, JC, JWR-­H. Data collection: KPR, RMK, women with congenital heart disease: a literature review. J Am Coll Cardiol
NS, DS, S-­CY, MCP. Manuscript draft: KPR, RMK, NS. Critical revision, editing and 2007;49:2303–11.
approval of the final manuscript: all authors. 19 Szekely P, Snaith L. Atrial fibrillation and pregnancy. Br Med J 1961;1:1407–10.
20 Hindricks G, Potpara T, Dagres N, et al. 2020 ESC guidelines for the diagnosis and
Funding The authors have not declared a specific grant for this research from any management of atrial fibrillation developed in collaboration with the European
funding agency in the public, commercial or not-­for-­profit sectors. association for Cardio-­Thoracic surgery (EACTS): the task force for the diagnosis
Competing interests None declared. and management of atrial fibrillation of the European Society of cardiology (ESC)
developed with the special contribution of the European heart rhythm association
Patient and public involvement Patients and/or the public were not involved in
(EHRA) of the ESC. Eur Heart J 2021;42:373–498.
the design, or conduct, or reporting, or dissemination plans of this research.
21 Wang Y-­C, Chen C-­H, Su H-­Y, et al. The impact of maternal cardioversion on fetal
Patient consent for publication Consent obtained directly from patient(s). haemodynamics. Eur J Obstet Gynecol Reprod Biol 2006;126:268–9.
22 Barnes EJ, Eben F, Patterson D. Direct current cardioversion during pregnancy should
Ethics approval When exclusively describing an individual case history, it is not
be performed with facilities available for fetal monitoring and emergency caesarean
required to obtain Ethics Committee approval or official exemption by Dutch national
section. BJOG 2002;109:1406–7.
law. All patients gave their written informed consent, reviewed their own case
23 Masuda K, Ishizu T, Niwa K, et al. Increased risk of thromboembolic events in
description and images and saw the final version of the manuscript.
adult congenital heart disease patients with atrial tachyarrhythmias. Int J Cardiol
Provenance and peer review Not commissioned; externally peer reviewed. 2017;234:69–75.
Open access This is an open access article distributed in accordance with the 24 Chang S-­H, Kuo C-­F, Chou I-­J, et al. Outcomes associated with paroxysmal
Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which supraventricular tachycardia during pregnancy. Circulation 2017;135:616–8.
permits others to distribute, remix, adapt, build upon this work non-­commercially, 25 Fitton CA, Steiner MFC, Aucott L, et al. In-­utero exposure to antihypertensive
and license their derivative works on different terms, provided the original work is medication and neonatal and child health outcomes: a systematic review. J Hypertens
properly cited, appropriate credit is given, any changes made indicated, and the use 2017;35:2123–37.
is non-­commercial. See: http://creativecommons.org/licenses/by-nc/4.0/. 26 Driver K, Chisholm CA, Darby AE, et al. Catheter ablation of arrhythmia during
pregnancy. J Cardiovasc Electrophysiol 2015;26:698–702.
ORCID iDs 27 Katritsis DG, Boriani G, Cosio FG, et al. European heart rhythm association (EHRA)
Karishma P Ramlakhan http://orcid.org/0000-0002-6741-2603 consensus document on the management of supraventricular arrhythmias, endorsed
Jolien W Roos-­Hesselink http://orcid.org/0000-0002-6770-3830 by heart rhythm Society (HRS), Asia-­Pacific heart rhythm Society (APHRS), and
Sociedad Latinoamericana de Estimulación cardiaca Y Electrofisiologia (SOLAECE).
Europace 2017;19:465–511.
REFERENCES 28 Chen G, Wang Y, Proietti R, et al. Zero-­fluoroscopy approach for ablation of
1 de Haas S, Ghossein-­Doha C, van Kuijk SMJ, et al. Physiological adaptation of supraventricular tachycardia using the Ensite NavX system: a multicenter experience.
maternal plasma volume during pregnancy: a systematic review and meta-­analysis. BMC Cardiovasc Disord 2020;20:48.
Ultrasound Obstet Gynecol 2017;49:177–87. 29 Koźluk E, Piątkowska A, Kiliszek M, et al. Catheter ablation of cardiac arrhythmias in
2 Brodsky M, Doria R, Allen B, et al. New-­onset ventricular tachycardia during pregnancy without fluoroscopy: a case control retrospective study. Adv Clin Exp Med
pregnancy. Am Heart J 1992;123:933–41. 2017;26:129–34.
3 Meah VL, Cockcroft JR, Backx K, et al. Cardiac output and related haemodynamics 30 Fink T, Sciacca V, Feickert S, et al. Outcome of cardiac tamponades in interventional
during pregnancy: a series of meta-­analyses. Heart 2016;102:518–26. electrophysiology. Europace 2020;22:1240–51.
4 Shotan A, Ostrzega E, Mehra A, et al. Incidence of arrhythmias in normal pregnancy 31 Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation. Philadelphia:
and relation to palpitations, dizziness, and syncope. Am J Cardiol 1997;79:1061–4. Lippincott Williams & Wilkins, 2009.

Ramlakhan KP, et al. Heart 2022;108:1674–1681. doi:10.1136/heartjnl-2021-320451 1681