Management of Arrhythmias During Pregnancy

Publication Date: May 19, 2023

Introduction

Introduction

Key Points

  • This clinical practice document is intended to provide comprehensive guidance to cardiac electrophysiologists (EPs), cardiologists, and other health care professionals on the management of cardiac arrhythmias in pregnant patients, including arrhythmias that occur in the mother and in the fetus.
  • The primary goals of this document are as follows:
    • Introduce general concepts related to arrhythmias in both the patient and the fetus during pregnancy.
    • Discuss optimal approaches to diagnosis and evaluation of arrhythmias during pregnancy.
    • Review approaches to treatment of arrhythmias in the pregnant patient, including invasive and noninvasive treatments.
    • Identify disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients.
    • Provide recommendations for management of fetal arrhythmias.

Top 10 Take-home Messages

1. The most common arrhythmias seen in pregnant patients are generally benign, including sinus arrhythmia, supraventricular tachycardia (SVT), and premature beats, whereas life-threatening arrhythmias, such as hemodynamically significant supraventricular tachycardia or ventricular tachycardia (VT), are significantly less common.

2. Atrial fibrillation (AF) is increasingly becoming the most common newly diagnosed sustained arrhythmia during pregnancy. Some therapeutic decisions for atrial fibrillation, such as a rate-control strategy versus rhythm control strategy, should be based on hemodynamic tolerance and underlying substrate as in nonpregnant patients, whereas others, such as anticoagulation therapy protocols, are specific to pregnancy.

3. Care of arrhythmias in the pregnant patient should involve a multidisciplinary engagement of cardiologists and/or electrophysiologists, pediatric electrophysiologists, maternal-fetal medicine subspecialists, anesthesiologists, and neonatologists to optimize outcomes for both the mother and the fetus/newborn.

4. When arrhythmias occur in pregnancy, both the mother and the fetus may be affected; thus, shared decision-making should include a discussion of the risks and benefits to both the mother and the fetus of antiarrhythmic drugs, specific procedures, and monitoring, as well as the risks of withholding such therapies.

5. Fetal arrhythmia management decisions should be considered in the context of any concomitant maternal arrhythmias or diagnoses (eg, fetal bradycardia in mothers with long QT syndrome [LQTS]). Treatment of fetal arrhythmias generally involves either maternal systemic administration of antiarrhythmic agents; rarely, such as in cases of fetal hydrops, direct fetal intramuscular (IM) injection or intraperitoneal injection of antiarrhythmic drugs may be necessary.

6. Management of hemodynamically significant maternal arrhythmias should emphasize the prompt use of the most effective therapy available (cardioversion, antiarrhythmic drug infusion, or catheter ablation) to terminate the ongoing arrhythmia and/or prevent recurrent arrhythmias, with appropriate fetal monitoring, and measures to minimize radiation exposure when catheter ablation is pursued.

7. Procedures such as catheter ablation and implantable devices, if indicated for arrhythmias with hemodynamic compromise or for sudden death prevention, can be performed at experienced centers with maximum possible mitigation of radiation exposure to the fetus, which is best achieved by overall reduction of total maternal radiation, since covering the maternal abdomen with a lead apron alone is generally of no benefit.

8. Due to the overall risk of aortocaval compression in pregnant patients, particularly in the third trimester, avoidance of prolonged supine positioning is warranted, especially during invasive procedures, with preference given to a left lateral tilt position to optimize hemodynamics.

9. Use of antiarrhythmic drugs during pregnancy and the postpartum period should largely be similar to use in nonpregnant patients with some exceptions for the sake of fetal safety: selecting drugs with the longest record of safe use during pregnancy and lactation; using the lowest effective dose; and periodically reevaluating the continued need for the same dose/type of antiarrhythmic, including during the postpartum period, in light of potential drug concentration in breast milk.

10. For parents with a suspected or known inherited arrhythmia syndrome, genetic screening and counseling should be provided, ideally by genetic counselors or providers who are trained or specialize in genetics, to assess potential fetal risks and for therapeutic optimization.

Definitions

Table 1. Terms Used in This Consensus Statement That Are Specific to Pregnancy

Cardio- obstetrics team
A group ideally composed of maternal-fetal medicine subspecialists, cardiologists and/or electrophysiologists (pediatric electrophysiologist when fetal arrhythmias are present), with experience managing pregnant patients. Neonatologists and anesthesiologists may also be involved close to the time of delivery. While the team may vary depending on the resources at a given facility, at a minimum it should include a high-risk obstetrician and a cardiologist with expertise in arrhythmias in pregnancy.

Close to term
The term “close to term”, as used in this document, is purposely vague and not intended to represent a gestational age (GA). The determination of a close-to-term fetus implies viability and considers a number of factors, such as severity and potential consequences of the arrhythmias, biological factors, and the site-specific availability of the medical expertise and technology to support a preterm infant. “Close to term” could fall within the gestational categories defined by the American College of Obstetricians and Gynecologists (ACOG): “late preterm” as 34 0/7 to 36 6/7 weeks of gestation, “early term” as 37 0/7 to 38 6/7 weeks of gestation, “full term” as 39 0/7 to 40 6/7 weeks of gestation, “late term” as 41 0/7 to 41 6/7 weeks of gestation, and “post term” as 42 0/7 weeks of gestation and beyond.

Supine hypotensive syndrome
Supine hypotensive syndrome is a condition in which, while lying flat, a pregnant patient may become light-headed or syncopal due to compression of the inferior vena cava by the gravid uterus cava leading to reduction in venous return and resultant hypotension.

General Concepts for the Management of Arrhythmias During Pregnancy

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 Overarching Principles

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Procedural Considerations for Arrhythmia Management During Pregnancy

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Cardioversion During Pr...

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Diagnosis of Pregnant Patients With Palpitations

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Diagnosis and Management of Pregnant Patients With Syncope

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Management of Specific Arrhythmias During Pregnancy

...Specific Arrhythmias During Pregnancy...

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...Acute SVT During Pregnancy...

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.... In hemodynamically stable pregnant...

...In hemodynamically unstable pregnant patients...

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...ent of Nonacute Atrial Ectopy and SVT...

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...patients with symptomatic SVT in the a...

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Management of Pregnant Patients With Bradycardia and/or Heart Block

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...pregnant and postpartum patients with as...


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