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An Overview of Arrhythmias in Pregnancy Cover

An Overview of Arrhythmias in Pregnancy

Methodist DeBakey Cardiovascular Journal
Volume 20 (2024): Issue 2
By: ,  ,  ,   and    
Open Access
|Mar 2024
Figures & tables

Figures & Tables

Table 1

Atrial fibrillation recommendations during pregnancy: 2023 Guidelines summary. AF: atrial fibrillation; DCCV: direct current cardioversion; IV: intravenous

AF RECOMMENDATIONS DURING PREGNANCY: 2023 GUIDELINES SUMMARY
Rhythm Control:
DCCV is safe in pregnancy and should be performed similar to a nonpregnant patient. Fetal monitoring is used during DCCV.
In the absence of structural heart disease, pharmacological cardioversion with agents with a history of safe use (IV procainamide) may be used during pregnancy.
For maintenance of normal sinus rhythm, agents with a history of safe use (flecainide and sotalol) are reasonable during pregnancy.
Rate Control:
Rate control can be achieved using agents with a history of safe use (propranolol, metoprolol, digoxin) as first-line agents.
Anticoagulation: Shared Decision Making is important
Current tools that predict stroke risk in AF are not validated in pregnancy. Most data is extrapolated from managing valvular heart disease patients.
First Trimester:
Warfarin ≤ 5 mg or low molecular weight heparin or unfractionated heparin
Second Trimester:
Warfarin or low molecular weight heparin
Third Trimester:
Warfarin until a week before delivery
Switch to unfractionated heparin (or low molecular weight heparin) and stop 4-6 hours pre-delivery
Figure 1

General management of pregnant patients with paroxysmal supraventricular tachycardia and atrial fibrillation. CARPREG: Cardiac Disease in Pregnancy; ZAHARA: Zwangerschap bij Aangeboren Hartafwijking; mWHO: modified World Health Organization: ECG: electrocardiogram; FDA: Food and Drug Administration; CV: cardiovascular.

Table 2

Safety of antiarrhythmic drugs during pregnancy and breastfeeding. CNS: central nervous system; FDA: Food and Drug Administration; FGR: fetal growth restriction; FVII: factor VII; IUGR: intrauterine growth restriction; IV: intravenous; SVT: supraventricular tachycardia

DRUG NAMECOMPLICATIONS TO FETAL & NEONATALCOMPLICATIONS TO PREGNANT WOMENFDA RISK CATEGORYVAUGHAN-WILLIAMS CLASSTERATOGENICUSE DURING LACTATION
AdenosineConsider fetal monitoring, possible small risk of transient fetal bradycardia

  • Dyspnea

  • Bradycardia

  • Pregnant women may respond to lower doses due to a reduction in adenoside deaminase

CN/ANoSafe due to short half-life
Digoxin

  • Low birth weight

  • Fetal death in toxicity

Miscarriage
Monitor maternal levels for toxicity		CN/ANoSafe
Lidocaine

  • Fetal distress may occur in fetal toxicity

  • Bradycardia

  • Acidosis

  • Central nervous system toxicity

  • –

B1BNoSafe
Sotalol

  • Transient fetal bradycardia

  • Hypoglycemia

  • B-blocker effects

  • Torsades de pointes

  • –

BIIINoSafe, but caution advised
Verapamil

  • Safe (1st choice class IV drug)

  • Trend toward decreased FGR

  • Fetal bradycardia

  • Heart block

Maternal hemodynamic (hypotension) instability if infused rapidly.CIVNoSafe, but caution advised
Flecainide

  • Concerns over its pro-arrhythmic potential in fetus have limited its use in past

Limited literature for treatment of maternal arrhythmias; however, maternal ingestion used to treat fetal SVTC1CNoSafe
Quinidine

  • Fetal VIIIn damage

  • Neonatal thrombocytopenia

  • Ototoxicity

  • Premature birth

  • Vestibulocochlear nerve toxicity

  • Torsades de pointe

Rarely, mild uterine contractionsC1ANoSafe
Procainamide

  • Possibly as safe as quinidine short term in pregnancy

  • Drug-induced lupus

  • Torsades de pointes

  • Gastrointestinal disturbance

  • Hypotension

  • Agranulocytosis

  • –

C1ANoSafe for short-term use, but caution advised
Propanolol

  • Neonatal bradycardia

  • Growth retardation

  • Apnea

  • Small risk of FGR

  • Hypoglycemia

  • –

CIINoSafe
Metoprolol

  • Neonatal bradycardia

  • Growth retardation

  • Apnea

  • Small risk of FGR

  • Hypoglycemia

  • –

CIINoSafe
Labetalol

  • –

  • IUGR

  • Bradycardia

  • Apnea

  • Hypoglycemia

  • Hyperbilirubinemia

UnknownUnknownUnknownSafe
Pindolol

  • –

  • –

BIINoSafe
BisoprololBradycardia
Hypoglycemia

  • –

CUnknownUnknownSafe
Disopyramide

  • –

  • Premature uterine contractions

C1ANoNo
Diltiazem

  • IUGR

  • Fetal death

  • Skeletal abnormalities

  • Fetal bradycardia

  • Heart block

  • Increased risk of FGR

  • Maternal hypotension

CIVUnknownSafe, but caution advised
Propafenone

  • –

  • –

C1CNoNo
Mexiletine

  • Bradycardia

  • CNS effects

  • Low Apgar score

  • –

C1BNoSafe, but caution advised
Ibutilide

  • Torsades de pointes

CIIIUnknownSafe
Nadolol

  • Small risk of apnea

  • FGR

  • Hypoglycemia

  • –

CIINoSafe
Atenolol

  • Greater risk of FGR

  • Cyanosis

  • Low birth weight

  • Growth retardation

  • Neonatal bradycardia

  • Hypoglycemia

  • Other 3 -blockers are preferred over atenolol

  • –

DIINoNo
Dofetilide

  • Human data lacking

  • Torsades de pointes

  • –

CIIIUnknownNo
Dronedarone

  • Vascular and limb abnormalities

  • Cleft palate

  • –

XIIIYesNo
Amiodarone

  • Only for short-term use in emergencies.

  • Fetal hypothyroidism

  • Growth retardation

  • Premature birth

  • Goiter

  • Growth retardation

  • Bradycardia

  • Prolonged QT interval

  • IUGR

  • Bradycardia

DIIIYesNo
Ivabradine

  • FGR

  • Bradycardia

  • Hypotension

  • Bradycardia

N/AN/AYesNo
B-blockers

  • Avoid atenolol in first trimester due to concern over IUGR

  • Bradycardia

  • Apnea

  • Hypoglycemia

  • Hyperbilirubinemia

  • –

UnknownUnknownUnknownSafe
Magnesium sulphate

  • Neuromuscular and/or respiratory depression

  • Skeletal abnormalities

  • –

DUnknownUnknownSafe
Carvedilol

  • –

  • –

CIINoSafe, but caution advised
Atropine

  • Fetal tachycardia

  • Decrease in beat-to-beat variability of the fetal heart rate

  • Tachycardia

CUnknownNoNo
Extensive Data/Safe to UseModerately Safe/Extensive ExperienceUse with Caution in PregnancyDo Not Use in PregnancySafety Data Lacking in Pregnancy
Figure 2

Management of supraventricular tachycardias and atrial fibrillation in pregnancy. LMWH: low molecular weight heparin; SVT: supraventricular tachycardia; IV: intravenous; VKA: vitamin K antagonist; DAOC: direct oral anticoagulant

Figure 3

Management of ventricular tachycardia, ventricular fibrillation, and sudden cardiac arrest in pregnancy. CPR: cardiopulmonary resuscitation; ACLS: advanced cardiac life support; IV: intravenous; ROSC: return of spontaneous circulation

DOI: https://doi.org/10.14797/mdcvj.1325 | Journal eISSN: 1947-6108
Journal RSS Feed
Language: English
Page range: 36 - 50
Submitted on: Dec 2, 2023
Accepted on: Dec 27, 2023
Published on: Mar 14, 2024
Published by: Houston Methodist DeBakey Heart & Vascular Center
In partnership with: Paradigm Publishing Services
Keywords:
antiarrhythmic,
maternal arrhythmias,
pregnancy,
cardioobstetrics

© 2024 Kamala P. Tamirisa, Estefania Oliveros, Shweta Paulraj, Adriana C. Mares, Annabelle Santos Volgman, published by Houston Methodist DeBakey Heart & Vascular Center
This work is licensed under the Creative Commons Attribution-NonCommercial 4.0 License.

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