Abstract
Maternal arrhythmias during pregnancy may jeopardize the health of both mother and fetus. The correct identification of the arrhythmia is critical in the pregnant patient. Treatment should be reserved for arrhythmias that are hemodynamically unstable or cause debilitating symptoms. When medications are deemed necessary, the physician should use as few drugs as possible at the lowest effective doses and choose drugs with a history of safe use in pregnancy. Resuscitation of a pregnant patient in cardiac arrest should be modified with regard to the normal physiologic changes of pregnancy. With careful management, most of these challenging patients will have excellent outcomes.
Similar content being viewed by others
References
Michaelsson, M., & Engle M. A. (1972). Congenital complete heart block: An international study of the natural history. Cardiovascular Clinics, 4(3), 85–101.
Rotmensch, H. H., Elkayam, U., & Frishman, W. (1983). Antiarrhythmic drug therapy during pregnancy. Annals of Internal Medicine, 98(4), 487–497.
Joglar, J. A., & Page, R. L. (1999). Treatment of cardiac arrhythmias during pregnancy: Safety considerations. Drug Safety, 20(1), 85–94.
Krauer, B., & Krauer F. (1977). Drug kinetics in pregnancy. Clinical Pharmacokinetics, 2(3), 167–181.
Dean, M., Stock, B., Patterson, R. J., & Levy, G. (1980). Serum protein binding of drugs during and after pregnancy in humans. Clin Pharmacology & Therapeutics, 28(2), 253–261.
Cox, J. L., Gardner, & M. J. (1993). Treatment of cardiac arrhythmias during pregnancy. Progress in Cardiovascular Diseases, 36(2), 137–178.
Mitani, G. M., Steinberg, I., Lien, E. J., Harrison, E. C., & Elkayam, U. (1987). The pharmacokinetics of antiarrhythmic agents in pregnancy and lactation. Clinical Pharmacokinetics, 12(4), 253–291.
Chen, S. S., Perucca, E., Lee, J. N., & Richens, A. (1982). Serum protein binding and free concentration of phenytoin and phenobarbitone in pregnancy. British Journal of Clinical Pharmacology, 13(4), 547–552.
Herngren, L., Ehrnebo, M., & Boreus, L. O. (1983). Drug binding to plasma proteins during human pregnancy and in the perinatal period. Studies on cloxacillin and alprenolol. Developmental Pharmacology and Therapeutics, 6(2), 110–124.
Shotan, A., Ostrzega, E., Mehra, A., Johnson, J. V., & Elkayam U. (1997). Incidence of arrhythmias in normal pregnancy and relation to palpitations, dizziness, and syncope. American Journal of Cardiology, 79(8), 1061–1064.
Tawam, M., Levine, J., Mendelson, M., Goldberger, J., Dyer, A., & Kadish, A. (1993). Effect of pregnancy on paroxysmal supraventricular tachycardia. American Journal of Cardiology, 72(11), 838–840.
Lee S. H., Chen, S. A., Wu, T. J., Chiang, C. E., Cheng, C. C., Tai, C. C., et al. (1995). Effects of pregnancy on first onset and symptoms of paroxysmal supraventricular tachycardia. American Journal of Cardiology, 76(10), 675–678.
Hunter, S., & Robson, S. (1997). Adaptation of the cardiovascular system to pregnancy. In: C. Oakley (Ed.), Heart disease in pregnancy (pp. 5–18). London: BMJ Publishing Group.
Nihoyannopoulos, P. (1997). Cardiovascular examination in pregnancy and the approach to diagnosis of cardiac disorder. In: C. Oakley (Ed.), Heart disease in pregnancy (pp. 52–62). London: BMJ Publishing Group.
Schwartz, D. B., & Schamroth, L. (1979). The effect of pregnancy on the frontal plane QRS axis. Journal of Electrocardiology, 12(3), 279–281.
Boyle, D. M., & Lloyd-Jones, R. L. (1966). The electrocardiographic ST segment in pregnancy. Journal of Obstetrics and Gynaecology of the British Commonwealth, 73(6), 986–987.
Oram, S., & Holt, M. (1961). Innocent depression of the S-T segment and flattening of the T-wave during pregnancy. Journal of Obstetrics and Gynaecology of the British Empire, 68, 765–770.
Grubb, B. P. (1998) Neurocardiogenic syncope. In: B. P. Grubb, & B. Olshansky (Eds.), Syncope: Mechanisms and management (pp. 73–106). Armonk, NY: Futura.
Grubb, B. P., Kosinski, D., Samoil, D., Pothoulakis, A., Lorton, M., & Kip, K. (1995). Postpartum syncope. Pacing and Clinical Electrophysiology, 18(5 Pt 1), 1028–1031.
Shalev, Y., Ben-Hur, H., Hagay, Z., Blickstein, I., Epstein, M., Ayzenberg O, et al. (1993). Successful delivery following myocardial ischemia during the second trimester of pregnancy. Clinical Cardiology, 16(10), 754–756.
Anderson, M. H. (1997). Rhythm disorders. In: C. Oakley (Ed.), Heart disease in pregnancy (pp. 248–281). London: BMJ Publishing Group.
Miller, R. W. (1988). Intrauterine radiation exposures and mental retardation. Health Physics, 55(2), 295–298.
Giles, D., Hewitt, D., Stewart, A., & Webb, J. (1956). Malignant disease in childhood and diagnostic irradiation in utero. Lancet, 271(6940), 447.
Doll, R., & Wakeford, R. (1997). Risk of childhood cancer from fetal irradiation. British Journal of Radiology, 70(830), 130–139.
Lee, M. S., Evans, S. J., Blumberg, S., Bodenheimer, M. M., & Roth, S. L. (1994). Echocardiographically guided electrophysiologic testing in pregnancy. Journal of the American Society of Echocardiography, 7(2), 182–186.
Dominguez, A., Iturralde, P., Hermosillo, A. G., Colin, L., Kershenovich, S., & Garrido, L. M. (1999). Successful radiofrequency ablation of an accessory pathway during pregnancy. Pacing and Clinical Electrophysiology, 22(1 Pt 1), 131–134.
Marchlinski, F., Callans, D., Gottlieb, C., Rodriguez, E., Coyne, R., & Kleinman, D. (1998). Magnetic electroanatomical mapping for ablation of focal atrial tachycardias. Pacing and Clinical Electrophsiology, 21(8), 1621–1635.
Chow, T., Galvin, J., & McGovern, B. (1998). Antiarrhythmic drug therapy in pregnancy and lactation. American Journal of Cardiology, 82(4A), 58I–62I.
Lieberman, B. A., Stirrat, G. M., Cohen, S. L., Beard, R. W., Pinker, G., D., & Belsey, E. (1978). The possible adverse effect of propranolol on the fetus in pregnancies complicated by severe hypertension. British Journal of Obstetrics and Gynaecology, 85(9), 678–683.
Lardoux, H., Gerard, J., Blazquez, G., Chouty, F., & Flouvat, B. (1983). Hypertension in pregnancy: Evaluation of two beta blockers atenolol and labetalol. European Heart Journal, 4(Suppl G), 35–40.
Montan, S., Ingemarsson, I., Marsal, K., & Sjoberg, N. O. (1992). Randomised controlled trial of atenolol and pindolol in human pregnancy: Effects on fetal haemodynamics. British Medical Journal, 304(6832), 946–949.
Butters L., Kennedy, S., & Rubin, P. C. (1990). Atenolol in essential hypertension during pregnancy. British Medical Journal, 301(6752), 587–589.
American Academy of Pediatrics Committee on Drugs (2001). The transfer of drugs and other chemicals into human milk. Pediatrics, 108(3), 776–789.
European Heart Rhythm Association, Heart Rhythm Society, Fuster, V., Ryden, L. E., Cannom, C. S., Crijns, H. J., et al. (2006). ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation—executive summary: A report of the American College of Cardiology/American Heart Association Task force on Practice Guidelines and the European Society of Cardioogy Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). Journal of the American College of Cardiology, 48(4), 854–906.
Drinkovic, N. (1981). Subcostal echocardiography to determine right ventricular pacing catheter position and control advancement of electrode catheters in intracardiac electrophysiologic studies. M mode and two dimensional studies. American Journal of Cardiology, 47(6), 1260–1265.
Jordaens, L. J., Vandenbogaerde, J. F., Van de Bruaene, P., & De Buyzere, M. (1990). Transesophageal echocardiography for insertion of a physiological pacemaker in early pregnancy. Pacing and Clinical Electrophysiology, 13(8), 955–957.
Dalvi, B. V., Chaudhuri, A., Kulkarni, H. L., & Kale, P. A. (1992). Therapeutic guidelines for congenital complete heart block presenting in pregnancy. Obstetrics and Gynecology, 79(5 Pt 2), 802–804.
Natale, A., Davidson, T., Geiger, M. J., & Newby, K. (1997). Implantable cardioverter-defibrillators and pregnancy: A safe combination? Circulation, 96(9), 2808–2812.
Wydra, D., Ciach, K., Matkowski, S., Sawicki, S., Emerich, J. (2003). [Cardiac arrest and implantation of a cardioverter-defibrillator in a pregnant woman]. Ginekologia Polska, 74(7), 545–548.
Abello, M., Peinado, R., Merino, J. L., Gnoatto, M., Mateos, M., Silvestre, J., et al. (2003). Cardioverter defibrillator implantation in a pregnant woman guided with transesophageal echocardiography. Pacing and Clinical Electrophysiology, 26(9), 1913–1914.
Curry, J. J., & Quintana, F. J. (1970). Myocardial infarction with ventricular fibrillation during pregnancy treated by direct current defibrillation with fetal survival. Chest, 58(1), 82–84.
Silversides, C. K., Harris, L., Haberer, K., Sermer, M., Colman, J. M., & Siu, S. C. (2006). Recurrence rates of arrhythmias during pregnancy in women with previous tachyarrhythmia and impact on fetal and neonatal outcomes. American Journal of Cardiology, 97(8), 1206–1212.
Wilbur, S. L., & Marchlinski, F. E. (1997). Adenosine as an antiarrhythmic agent. American Journal of Cardiology, 79(12A), 30–37.
Elkayam, U., & Goodwin, T. M. (1995). Adenosine therapy for supraventricular tachycardia during pregnancy. American Journal of Cardiology, 75(7), 521–523.
Page, R. L. (1995). Treatment of arrhythmias during pregnancy. American Heart Journal, 130(4), 871–876.
Widerhorn, J., Widerhorn, A. L., Rahimtoola, S. H., & Elkayam, U. (1992). WPW syndrome during pregnancy: Increased incidence of supraventricular arrhythmias. American Heart Journal, 123(3), 796–798.
Mendelson, C. L. (1956). Disorders of the heartbeat during pregnancy. American Journal of Obstetrics and Gynecology, 72(6), 1268–1301.
Tateno, S., Niwa, K., Nakazawa, M., Akagi, T., Shinohara, T., & Yasuda, T. (2003). Arrhythmia and conduction disturbances in patients with congenital heart disease during pregnancy: Multicenter study. Circulation Journal, 67(12), 992–997.
Reiffel, J. A. (2000). Drug choices in the treatment of atrial fibrillation. American Journal of Cardiology, 85(10A), 12D–19D.
Burkart, T. A., Kron, J., Miles, W. M., Conti, J.B., & Gonzalez, M.D. (2007). Successful termination of atrial flutter by ibutilide during pregnancy. Pacing and Clinical Electrophysiology, 30(2), 283–286.
Kockova, R., Kocka, V., Kiernan, T., & Fahy, G. J. (2007). Ibutilide-induced cardioversion of atrial fibrillation during pregnancy. Journal of Cardiovascular Electrophysiology, 18(5), 1–3.
Mackenzie, J. (1921). Heart disease and pregnancy. London: Henry Frowde and Hodder and Stoughton.
Chandra, N. C., Gates, E. A., & Thamer, M. (1991). Conservative treatment of paroxysmal ventricular tachycardia during pregnancy. Clinical Cardiology, 14(4), 347–350.
Briggs, G. G., Freeman, R. K., & Yaffe S. J. (Eds.). (1998). Drugs in pregnancy and lactation, 5th edition. Baltimore: Williams & Wilkins.
Brodsky, M., Doria, R., Allen, B., Sato, D., Thomas, G., & Sada, M. (1992). New-onset ventricular tachycardia during pregnancy. American Heart Journal, 123(4 Pt 1), 933–941.
Gemici, G., Tezcan, H., Fak, A. S., & Oktay, A. (2004). Peripartum cardiomyopathy presenting with repetitive monomorphic ventricular tachycardia. Pacing and Clinical Electrophysiology, 27(4), 557–558.
Connaughton, M., & Jenkins, B. S. (1994). Successful use of flecainide to treat new onset maternal ventricular tachycardia in pregnancy. British Heart Journal, 72(3), 297.
Strasburger, J. F., Cuneo, B.F., Michon, M. M., Gotteiner, N. L., Deal, B. J., McGregor, S. N., et al. (2004). Amiodarone therapy for drug-refractory fetal tachycardia. Circulation, 109(3), 375–379.
Koenig, C., Katz, M., Gertsch, M., Schaer, H. M., & Schneider, H. (1991). Pregnancy and delivery in a patient with Uhl anomaly. Obstetrics and Gynecology, 78(5 Pt 2), 932–934.
Lee, L. C., Bathgate, S. L., & Macri, C. J. (2006). Arrhythmogenic right ventricular dysplasia in pregnancy: A case report. Journal of Reproductive Medicine, 51(9), 725–728.
Rashba, E. J., Zareba, W., Moss, A. J., Hall, W. J., Robinson, J., Locati, E. H., et al. (1998). Influence of pregnancy on the risk for cardiac events in patients with hereditary long QT syndrome. LQTS Investigators. Circulation, 97(5), 451–456.
Bruner, J. P., Barry, M. J., & Elliott, J. P. (1984). Pregnancy in a patient with idiopathic long QT syndrome. American Journal of Obstetrics and Gynecology, 149(6), 690–691.
McCurdy, C. M., Jr., Rutherford, S. E., & Coddington, C. C. (1993). Syncope and sudden arrhythmic death complicating pregnancy. A case report of Romano-Ward syndrome. Journal of Reproductive Medicine, 38(3), 233–234.
Ganta, R., Roberts, C., Elwood, R. J., & Maddineni, V. R. (1995). Epidural anesthesia for cesarean section in a patient with Romano-Ward syndrome. Anesthesia and Analgesia, 81(2), 425–426.
Minakami, H., Nakayama, T., Ohno, T., Kuroki, S., & Sato, I. (1999) Effect of vaginal delivery on the Q-Tc interval in a patient with the long Q-T (Romano-Ward) syndrome. Journal of Obstetrics and Gynaecology Research, 25(4), 251–254.
Heradien, M. J., Goosen, A., Crotti, L., Durrheim, G., Corfield, V., Brink, P. A., et al. (2006). Does pregnancy increase cardiac risk for LQT1 patients with the KCNQ1-A341V mutation? Journal of the American College of Cardiology, 48(7), 1410–1415.
Moss, A. J., Zareba, W., Hall, W. J., Schwartz, P. J., Crampton, R. S., Benhorin, J., et al. (2000). Effectiveness and limitations of beta-blocker therapy in congenital long-QT syndrome. Circulation, 101(6), 616–623.
Priori, S. G., Napolitano, C., Schwartz, P. J., Grillo, M., Bloise, R., Ronchetti, E., et al. (2004). Association of long QT syndrome loci and cardiac events among patients treated with beta-blockers. Journal of the American Medical Association, 292(11), 1341–1344.
Kolibash, A. J., Ruiz, D. E., & Lewis, R. P. (1975). Idiopathic hypertrophic subaortic stenosis in pregnancy. Annals of Internal Medicine, 82(6), 791–794.
Shah, D. M., & Sunderji, S. G. (1985). Hypertrophic cardiomyopathy and pregnancy: Report of a maternal mortality and review of literature. Obstetrical & Gynecological Survey, 40(7), 444–448.
Maron, B. J., Bonow, R. O., Cannon, R. O., III, Leon, M. B., & Epstein, S. E. (1987). Hypertrophic cardiomyopathy. Interrelations of clinical manifestations, pathophysiology, and therapy (2). New England Journal of Medicine, 316(14), 844–852.
Autore, C., Conte, M. R., Piccininno, M., Bernabo, P., Bonfiglio, G., Bruzzi, P., et al. (2002). Risk associated with pregnancy in hypertrophic cardiomyopathy. Journal of the American College of Cardiology, 40(10), 1864–1869.
Thaman, R., Varnava, A., Hamid, M.S., Firoozi, S., Sachdev, B., Condon, M., et al. (2003). Pregnancy related complications in women with hypertrophic cardiomyopathy. Heart, 89(7), 752–756.
Kloeck, W., Cummins, R. O., Chamberlain, D., Bossaert, L., Callanan, V., Carli, P., et al. (1997). Special resuscitation situations: An advisory statement from the International Liaison Committee on Resuscitation. Circulation, 95(8), 2196–2210.
American Heart Association (2005). 2005 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 10.8: Cardiac arrest associated with pregnancy. Circulation, 112, IV-150–IV-153.
Kerr, M. G., Scott, D. B., & Samuel, E. (1964). Studies of the inferior vena cava in late pregnancy. British Medical Journal, 1(5382), 532–533.
Lee, R. V., Rodgers, B. D., White, L. M., & Harvey, R. C. (1986). Cardiopulmonary resuscitation of pregnant women. American Journal of Med, 81(2), 311–318.
Goodwin, A. P., & Pearce, A. J. (1992). The human wedge. A manoeuvre to relieve aortocaval compression during resuscitation in late pregnancy. Anaesthesia, 47(5), 433–434.
DeSilva, R. A., Graboys, T. B., Podrid, P. J., & Lown, B. (1980). Cardioversion and defibrillation. American Heart Journal, 100(6 part 1), 881–895.
Magee, L. A., Downar, E., Sermer, M., Boulton, B. C., Allen, L. C., & Koren, G. (1995). Pregnancy outcome after gestational exposure to amiodarone in Canada. American Journal of Obstetrics and Gynecology, 172(4 Pt 1), 1307–1311.
Ovadia M., Brito, M., Hoyer, G. L., & Marcus, F. I. (1994). American Journal of Cardiology, 73(4), 316–317.
Webster, W. S., Brown-Woodman, P. D., Snow, M. D., Danielsson, & B. R. (1996). Teratogenic potential of almokalant, dofetilide, and d-sotalol: Drugs with potassium channel blocking activity. Teratology, 53(3), 168–175.
Denniston, P. (1997). Mosby’s complete drug reference: Physicians Genrx, 7th Ed. St. Louis: Mosby-Yearbook.
Heaton, F. C., & Vaughan, R. (1982). Intrauterine supraventricular tachycardia: Cardioversion with maternal digoxin. Obstetrics and Gynecology, 60(6), 749–752.
Wladimiroff, J. W., & Stewart, P. A. (1985). Treatment of fetal cardiac arrhythmias. British Journal of Hospital Medicine, 34(3), 134–140.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Kron, J., Conti, J.B. Arrhythmias in the pregnant patient: Current concepts in evaluation and management. J Interv Card Electrophysiol 19, 95–107 (2007). https://doi.org/10.1007/s10840-007-9139-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10840-007-9139-4