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Akuttherapie mütterlicher und kindlicher Rhythmusstörungen während der Schwangerschaft

Acute treatment for maternal and child cardiac arrhythmias during pregnancy

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Intensivmedizin und Notfallmedizin

Summary

Atrial premature beats are frequently diagnosed during pregnancy (PR), supraventricular tachycardia (SVT) (atrial tachycardia, AV nodal reentrant tachycardia, circus movement tachycardia) less frequently. For acute therapy, electrical cardioversion with 50–100 Joules is indicated in all unstable patients (pts). In stable SVT the initial therapy includes vagal maneuvers to terminate breakthrough tachycardias. For short-term management, when vagal maneuvers fail, intravenous adenosine is the first choice drug and may safely terminate the arrhythmia. Ventricular premature beats are also frequently present during PR and benign in most pts; however, malignant ventricular tachyarrhythmias (sustained ventricular tachycardia [VT], ventricular flutter [VFlut], ventricular fibrillation [VF]) were observed less frequently. Electrical cardioversion is necessary in all pts with a hemodynamically unstable situation and life-threatening ventricular tachyarrhythmias; in hemodynamically stable pts, initial therapy with ajmaline, procainamide or lidocaine is indicated. In pts with syncopal VT, VF, VFlut or aborted sudden death an implantable cardioverter-defibrillator is indicated. In pts with symptomatic bradycardia, a pacemaker can be implanted using echocardiography at any stage of PR. The treatment of the pregnant patient with cardiac arrhythmias requires important modification of the standard practice of arrhythmia management. The goal of therapy is to protect the patient and fetus through delivery, after which chronic or definitive therapy can be admininstered.

Zusammenfassung

Supraventrikuläre Extrasystolen werden während einer Schwangerschaft (SWS) häufig beobachtet, supraventrikuläre Tachykardien (atriale Tachykardien, AV-Knoten-Reentry-Tachykardien, „circus-movement“ Tachykardien) dagegen eher seltener. Zur Akut-Therapie (AT) ist bei hämodynamischer Instabilität (HI) eine elektrische Kardioversion (KV) mit 50–100 Joules notwendig. Bei stabiler Hämodynamik (SH) sollten primär vagale Maneuver durchgeführt werden, bei Versagen vagaler Maßnahmen ist Adenosin das Medikament der 1. Wahl. Ventrikuläre Extrasystolen sind während einer SWS ebenfalls relativ häufig und bei den meisten Patientinnen (Pt) harmlos, maligne ventrikuläre Arrhythmien (ventrikuläre Tachykardien [KT], Kammerflattern [KFlat], Kammerflimmern [KF]) werden dagegen selten beobachtet. Als AT sollte bei HI eine elektrische KV erfolgen, bei SH kommen Ajmalin, Procainamid oder Lidocain in Betracht. Für Pt mit synkopaler KT, KF, KFlat oder überlebtem plötzlichen Tod ist der implantierbare Defibrillator eine therapeutische Alternative. Bei Pt mit symptomatischen Bradykardien kann unter Echokontrolle ein Schrittmacher-System in jedem Stadium der SWS implantiert werden. Trotz notwendiger Besonderheiten im therapeutischen Verhalten während einer SWS können alle supraventrikulären und/oder ventrikulären Arrhythmien adäquat behandelt werden und bei sorgfältiger Beachtung von Risiken, Nebenwirkungen und Komplikationen aller therapeutischen Maßnahmen können auch komplizierte Schwangerschaften erfolgreich beendet werden.

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  1. Medizinische Klinik II (Schwerpunkte Kardiologie und Angiologie), Ruhr-Universität Bochum, Hölkeskampring 40, 44625, Herne, Germany

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Trappe, HJ. Akuttherapie mütterlicher und kindlicher Rhythmusstörungen während der Schwangerschaft. Intensivmed 42, 671–682 (2005). https://doi.org/10.1007/s00390-005-0624-7

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