Atrial fibrillation during pregnancy: a 9-month period with limited options

Schwangerschaft und Vorhofflimmern: 9 Monate mit limitierten Möglichkeiten

Abstract

Pregnancy is a physiological condition with reversible hemodynamic, neurohormonal and coagulation changes to the maternal body during this 9‑month period. The occurrence of atrial fibrillation (AF) is altogether rare among pregnant women, but necessitates immediate treatment und further work-up. Despite numerous pharmacological and invasive therapeutic modalities for AF in non-pregnant patients, very few options are considered safe enough for the fetus and the mother during pregnancy. Commonly used medications such as beta blockers, calcium channel antagonists, antiarrhythmic drugs and anticoagulation therapy must be carefully individualized according to the week of gestation and possible underlying comorbidities of the mother, thus highlighting the importance of an interdisciplinary evaluation by a cardiologist and a gynecologist. The current review summarizes the existing knowledge and treatment options for AF in pregnancy and suggests a simplified algorithm for this clinical constellation.

Zusammenfassung

Die Schwangerschaft ist eine 9‑monatige physiologische Phase, die mit reversiblen hämodynamischen, neurohormonellen und hämostaseologischen Veränderungen des mütterlichen Körpers einhergeht. Vorhofflimmern (VHF) ist zwar insgesamt eine seltene Erkrankung bei schwangeren Frauen, erfordert jedoch eine schnelle Behandlung und weitere Abklärung. Für nichtschwangere Patientinnen stehen zahlreiche medikamentöse und invasive Behandlungsoptionen zur Verfügung; dagegen sind die Möglichkeiten bei schwangeren Frauen hinsichtlich der Sicherheit von Mutter und Fetus stark limitiert. Häufig verwendete Medikamente wie Betablocker, Kalziumkanalblocker, Antiarrhythmika und Antikoagulanzien müssen sehr vorsichtig und individualisiert gegeben werden; zu berücksichtigen sind dabei die aktuelle Schwangerschaftswoche und mögliche Komorbiditäten. Das unterstreicht die Notwendigkeit der interdisziplinären Evaluation durch einen Kardiologen und Gynäkologen. Die vorliegende Übersichtsarbeit fasst den aktuellen Wissensstand und die Behandlungsoptionen bei VHF während der Schwangerschaft zusammen. Des Weiteren wird ein vereinfachter Algorithmus für diese klinische Konstellation präsentiert.

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References

  1. 1.

    Chugh SS, Havmoeller R, Narayanan K, Singh D, Rienstra M, Benjamin EJ et al (2014) Worldwide epidemiology of atrial fibrillation: a global burden of disease 2010 study. Circulation 129(8):837–847

    PubMed  Article  Google Scholar 

  2. 2.

    Mou L, Norby FL, Chen LY, O’Neal WT, Lewis TT, Loehr LR, Soliman EZ, Alonso A (2018) Lifetime risk of atrial fibrillation by race and socioeconomic status: ARIC study (atherosclerosis risk in communities). Circ Arrhythm Electrophysiol. https://doi.org/10.1161/CIRCEP.118.006350

    Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Ko D, Rahman F, Schnabel RB, Yin X, Benjamin EJ, Christophersen IE (2016) Atrial fibrillation in women: epidemiology, pathophysiology, presentation, and prognosis. Nat Rev Cardiol 13:321–332

    PubMed  PubMed Central  Article  Google Scholar 

  4. 4.

    Chapman AB, Abraham WT, Zamudio S, Coffin C, Merouani A, Young D, Johnson A, Osorio F, Goldberg C, Moore LG, Dahms T, Schrier RW (1998) Temporal relationships between hormonal and hemodynamic changes in early human pregnancy. Kidney Int 54:2056–2063

    CAS  PubMed  Article  Google Scholar 

  5. 5.

    Mahendru AA, Everett TR, Wilkinson IB, Lees CC, McEniery CM (2014) A longitudinal study of maternal cardiovascular function from preconception to the postpartum period. J Hypertens 32:849–856

    CAS  PubMed  Article  Google Scholar 

  6. 6.

    Bader RA, Bader ME, Rose DF, Braunwald E (1955) Hemodynamics at rest and during exercise in normal pregnancy as studies by cardiac catheterization. J Clin Invest 34:1524–1536

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  7. 7.

    Robson SC, Hunter S, Boys RJ, Dunlop W (1989) Serial study of factors influencing changes in cardiac output during human pregnancy. Am J Physiol 256(pt 2):H1060–H1065

    CAS  PubMed  Google Scholar 

  8. 8.

    Hunter S, Robson SC (1992) Adaptation of the maternal heart in pregnancy. Br Heart J 68:540–543

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  9. 9.

    Jarvis SS, Shibata S, Bivens TB, Okada Y, Casey BM, Levine BD, Fu Q (2012) Sympathetic activation during early pregnancy in humans. J Physiol 590(pt 15):3535–3543

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  10. 10.

    Greenwood JP, Scott EM, Stoker JB, Walker JJ, Mary DA (2001) Sympathetic neural mechanisms in normal and hypertensive pregnancy in humans. Circulation 104:2200–2204

    CAS  PubMed  Article  Google Scholar 

  11. 11.

    Chesley LC (1972) Plasma and red cell volumes during pregnancy. Am J Obstet Gynecol 112:440–450

    CAS  PubMed  Article  Google Scholar 

  12. 12.

    Pritchard JA (1965) Changes in the blood volume during pregnancy and delivery. Anesthesiology 26:393–399

    CAS  PubMed  Article  Google Scholar 

  13. 13.

    Jepson JH (1968) Endocrine control of maternal and fetal erythropoiesis. Can Med Assoc J 98:844–847

    CAS  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Robson SC, Hunter S, Moore M, Dunlop W (1987) Haemodynamic changes during the puerperium: a Doppler and M‑mode echocardiographic study. Br J Obstet Gynaecol 94:1028–1039

    CAS  PubMed  Article  Google Scholar 

  15. 15.

    Umar S, Nadadur R, Iorga A, Amjedi M, Matori H, Eghbali M (2012) Cardiac structural and hemodynamic changes associated with physiological heart hypertrophy of pregnancy are reversed postpartum. J Appl Physiol (1985) 113:1253–1259

    Article  Google Scholar 

  16. 16.

    Ducas RA, Elliott JE, Melnyk SF, Premecz S, daSilva M, Cleverley K, Wtorek P, Mackenzie GS, Helewa ME, Jassal DS (2014) Cardiovascular magnetic resonance in pregnancy: insights from the Cardiac Hemodynamic Imaging and Remodeling in Pregnancy (CHIRP) study. J Cardiovasc Magn Reson 16:1

    PubMed  PubMed Central  Article  Google Scholar 

  17. 17.

    Gowda RM, Punukollu G, Khan IA, Wilbur SL, Navarro VS, Vasavada BC, Sacchi TJ (2003) Lone atrial fibrillation during pregnancy. Int J Cardiol 88(1):123–124

    PubMed  Article  Google Scholar 

  18. 18.

    Kirchhof P, Benussi S, Kotecha D et al (2016) 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS: the task force for the management of atrial fibrillation of the European Society of Cardiology (ESC). Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESCEndorsed by the European Stroke Organisation (ESO). Eur Heart J 37:2893–2962

    PubMed  Article  Google Scholar 

  19. 19.

    Bateman BT, Heide-Jorgensen U, Einarsdottir K et al (2018) beta-blocker use in pregnancy and the risk for congenital malformations: an international cohort study. Ann Intern Med 169:665–673

    PubMed  PubMed Central  Article  Google Scholar 

  20. 20.

    Bergman JEH, Lutke LR, Gans ROB et al (2018) Beta-blocker use in pregnancy and risk of specific congenital anomalies: a European case-malformed control study. Drug Saf 41:415–427

    CAS  PubMed  Article  Google Scholar 

  21. 21.

    Duan L, Ng A, Chen W et al (2017) beta-blocker exposure in pregnancy and risk of fetal cardiac anomalies. JAMA Intern Med 177:885–887

    PubMed  PubMed Central  Article  Google Scholar 

  22. 22.

    Yakoob MY, Bateman BT, Ho E et al (2013) The risk of congenital malformations associated with exposure to beta-blockers early in pregnancy: a meta-analysis. Hypertension 62:375–381

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  23. 23.

    Pruyn SC, Phelan JP, Buchanan GC (1979) Long-term propranolol therapy in pregnancy: maternal and fetal outcome. Am J Obstet Gynecol 135:485–489

    CAS  PubMed  Article  Google Scholar 

  24. 24.

    Duan L, Ng A, Chen W, Spencer HT, Lee MS (2018) Beta-blocker subtypes and risk of low birth weight in newborns. J Clin Hypertens (Greenwich) 20:1603–1609

    CAS  Article  Google Scholar 

  25. 25.

    Lydakis C, Lip GY, Beevers M, Beevers DG (1999) Atenolol and fetal growth in pregnancies complicated by hypertension. Am J Hypertens 12:541–547

    CAS  PubMed  Article  Google Scholar 

  26. 26.

    Alabdulrazzaq F, Koren G (2012) Fetal safety of calcium channel blockers. Can Fam Physician 58:746–747

    PubMed  PubMed Central  Google Scholar 

  27. 27.

    Wright JM, Page RL, Field ME (2015) Antiarrhythmic drugs in pregnancy. Expert Rev Cardiovasc Ther 13:1433–1444

    CAS  PubMed  Article  Google Scholar 

  28. 28.

    Magee LA, Schick B, Donnenfeld AE, Sage SR, Conover B, Cook L, McElhatton PR, Schmidt MA, Koren G (1996) The safety of calcium channel blockers in human pregnancy: a prospective, multicenter cohort study. Am J Obstet Gynecol 174(3):823–828

    CAS  PubMed  Article  Google Scholar 

  29. 29.

    Davis RL, Eastman D, McPhillips H et al (2011) Risks of congenital malformations and perinatal events among infants exposed to calcium channel and beta-blockers during pregnancy. Pharmacoepidemiol Drug Saf 20:138–145

    PubMed  Article  Google Scholar 

  30. 30.

    Hindricks G et al (2020) 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Eur Heart J 42(5):373–498. https://doi.org/10.1093/eurheartj/ehaa612

    Article  Google Scholar 

  31. 31.

    Rotmensch HH, Elkayam U, Frishman W (1983) Antiarrhythmic drug therapy during pregnancy. Ann Intern Med 98:487–497

    CAS  PubMed  Article  Google Scholar 

  32. 32.

    Chow T, Galvin J, McGovern B (1998) Antiarrhythmic drug therapy in pregnancy and lactation. Am J Cardiol 82:58i–62i

    CAS  PubMed  Article  Google Scholar 

  33. 33.

    Hill GD, Kovach JR, Saudek DE et al (2017) Transplacental treatment of fetal tachycardia: a systematic review and meta-analysis. Prenat Diagn 37:1076–1083

    CAS  PubMed  Article  Google Scholar 

  34. 34.

    Wright JM, Page RL, Field ME (2015) Antiarrhythmic drugs in pregnancy. Expert Rev Cardiovasc Ther 13:1433–1444

    CAS  PubMed  Article  Google Scholar 

  35. 35.

    Oudijk MA, Michon MM, Kleinman CS et al (2000) Sotalol in the treatment of fetal dysrhythmias. Circulation 101:2721–2726

    CAS  PubMed  Article  Google Scholar 

  36. 36.

    Magee LA, Downar E, Sermer M et al (1995) Pregnancy outcome after gestational exposure to amiodarone in Canada. Am J Obstet Gynecol 172:1307–1311

    CAS  PubMed  Article  Google Scholar 

  37. 37.

    Ovadia M, Brito M, Hoyer GL, Marcus FI (1994) Human experience with amiodarone in the embryonic period. Am J Cardiol 73:316–317

    CAS  PubMed  Article  Google Scholar 

  38. 38.

    Bremme KA (2003) Haemostatic changes in pregnancy. Best Pract Res Clin Haematol 16(2):153–168

    PubMed  Article  Google Scholar 

  39. 39.

    Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO (2012) VTE, thrombophilia, antithrombotic therapy, and pregnancy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 141(2 Suppl):e691S–e736S

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  40. 40.

    Galambosi PJ, Kaaja RJ, Stefanovic V, Ulander VM (2012) Safety of low-molecular-weight heparin during pregnancy: a retrospective controlled cohort study. Eur J Obstet Gynecol Reprod Biol 163(2):154–159

    CAS  PubMed  Article  Google Scholar 

  41. 41.

    Schindewolf M, Gobst C, Kroll H, Recke A, Louwen F, Wolter M et al (2013) High incidence of heparin-induced allergic delayed-type hypersensitivity reactions in pregnancy. J Allergy Clin Immunol 132(1):131–139

    CAS  PubMed  Article  Google Scholar 

  42. 42.

    Romualdi E, Dentali F, Rancan E, Squizzato A, Steidl L, Middeldorp S et al (2013) Anticoagulant therapy for venous thromboembolism during pregnancy: a systematic review and a meta-analysis of the literature. J Thromb Haemost 11(2):270–281

    CAS  PubMed  Article  Google Scholar 

  43. 43.

    Chaudhary RK, Nepal C, Khanal N, Pathak R, Giri S, Bhatt VR (2015) Management and outcome of heparin-induced thrombocytopenia in pregnancy: a systematic review. Cardiovasc Hematol Agents Med Chem 13(2):92–97

    CAS  PubMed  Article  Google Scholar 

  44. 44.

    Lindhoff-Last E, Kreutzenbeck HJ, Magnani HN (2005) Treatment of 51 pregnancies with danaparoid because of heparin intolerance. Thromb Haemost 93(1):63–69

    CAS  PubMed  Article  Google Scholar 

  45. 45.

    Raivio KO, Ikonen E, Saarikoski S (1977) Fetal risks due to warfarin therapy during pregnancy. Acta Paediatr Scand 66(6):735–739

    CAS  PubMed  Article  Google Scholar 

  46. 46.

    Vitale N, De Feo M, De Santo LS, Pollice A, Tedesco N, Cotrufo M (1999) Dose-dependent fetal complications of warfarin in pregnant women with mechanical heart valves. J Am Coll Cardiol 33(6):1637–1641

    CAS  PubMed  Article  Google Scholar 

  47. 47.

    Khamooshi AJ, Kashfi F, Hoseini S, Tabatabaei MB, Javadpour H, Noohi F (2007) Anticoagulation for prosthetic heart valves in pregnancy. Is there an answer? Asian Cardiovasc Thorac Ann 15(6):493–496

    PubMed  Article  Google Scholar 

  48. 48.

    Bapat P, Pinto LS, Lubetsky A, Aleksa K, Berger H, Koren G et al (2016) Examining the transplacental passage of apixaban using the dually perfused human placenta. J Thromb Haemost 14(7):1436–1441

    CAS  PubMed  Article  Google Scholar 

  49. 49.

    Bapat P, Pinto LS, Lubetsky A, Berger H, Koren G (2015) Rivaroxaban transfer across the dually perfused isolated human placental cotyledon. Am J Obstet Gynecol 213(5):710.e1–710.e6

    CAS  Article  Google Scholar 

  50. 50.

    Bapat P, Kedar R, Lubetsky A, Matlow JN, Aleksa K, Berger H et al (2014) Transfer of dabigatran and dabigatran etexilate mesylate across the dually perfused human placenta. Obstet Gynecol 123(6):1256–1261

    PubMed  Article  Google Scholar 

  51. 51.

    Pacheco LD, Hankins GDV, Saad AF, Saade GR (2019) Acute management of ischemic stroke during pregnancy. Obstet Gynecol 133(5):933–939

    PubMed  Article  Google Scholar 

  52. 52.

    Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL (2019) Guidelines for the early management of patients with acute Ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 50(12):e344–e418

    PubMed  Article  Google Scholar 

  53. 53.

    Zei PC, Quadros KK, Clopton P, Thosani A, Ferguson J, Brodt C, O’Riordan G, Ramsis M, Mitra R, Baykaner T (2020) Safety and efficacy of minimal- versus zero-fluoroscopy radiofrequency catheter ablation for atrial fibrillation: a multicenter, prospective study. J Innov Card Rhythm Manag 11(11):4281–4291

    PubMed  PubMed Central  Article  Google Scholar 

  54. 54.

    Li MM, Sang CH, Jiang CX, Guo XY, Li SN, Wang W, Zhao X, Tang RB, Long DY, Gao H, Dong JZ, Du X, Ma CS (2019) Maternal arrhythmia in structurally normal heart: prevalence and feasibility of catheter ablation without fluoroscopy. Pacing Clin Electrophysiol 42(12):1566–1572

    PubMed  Article  Google Scholar 

  55. 55.

    Driver K, Chisholm CA, Darby AE, Malhotra R, Dimarco JP, Ferguson JD (2015) Catheter ablation of arrhythmia during pregnancy. J Cardiovasc Electrophysiol 26(6):698–702

    PubMed  Article  Google Scholar 

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Correspondence to Priv. Doz. Dr. Harilaos Bogossian MD.

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K. Iliodromitis, J. Kociszewski and H. Bogossian declare that they have no competing interests.

For this article no studies with human participants or animals were performed by any of the authors. All studies mentioned were performed in accordance with the ethical standards indicated in each case.

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Iliodromitis, K., Kociszewski, J. & Bogossian, H. Atrial fibrillation during pregnancy: a 9-month period with limited options. Herzschr Elektrophys (2021). https://doi.org/10.1007/s00399-021-00751-w

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Keywords

  • AF
  • Maternal body
  • Fetal growth
  • Anticoagulation
  • Antiarrhythmic drugs

Schlüsselwörter

  • VHF
  • Mütterlicher Körper
  • Fetales Wachstum
  • Antikoagulation
  • Antiarrhythmika