Skip to main content

Advertisement

Log in

Arrhythmias in the pregnant patient: Current concepts in evaluation and management

  • INVITED STATE-OF-THE-ART REVIEW
  • Published:
Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Michaelsson, M., & Engle M. A. (1972). Congenital complete heart block: An international study of the natural history. Cardiovascular Clinics, 4(3), 85–101.

    PubMed  CAS  Google Scholar 

  2. Rotmensch, H. H., Elkayam, U., & Frishman, W. (1983). Antiarrhythmic drug therapy during pregnancy. Annals of Internal Medicine, 98(4), 487–497.

    PubMed  CAS  Google Scholar 

  3. Joglar, J. A., & Page, R. L. (1999). Treatment of cardiac arrhythmias during pregnancy: Safety considerations. Drug Safety, 20(1), 85–94.

    Article  PubMed  CAS  Google Scholar 

  4. Krauer, B., & Krauer F. (1977). Drug kinetics in pregnancy. Clinical Pharmacokinetics, 2(3), 167–181.

    PubMed  CAS  Google Scholar 

  5. 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.

    Article  CAS  Google Scholar 

  6. Cox, J. L., Gardner, & M. J. (1993). Treatment of cardiac arrhythmias during pregnancy. Progress in Cardiovascular Diseases, 36(2), 137–178.

    Article  PubMed  CAS  Google Scholar 

  7. 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.

    PubMed  CAS  Google Scholar 

  8. 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.

    PubMed  CAS  Google Scholar 

  9. 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.

    PubMed  CAS  Google Scholar 

  10. 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.

    Article  PubMed  CAS  Google Scholar 

  11. 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.

    Article  PubMed  CAS  Google Scholar 

  12. 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.

    Article  PubMed  CAS  Google Scholar 

  13. 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.

    Google Scholar 

  14. 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.

    Google Scholar 

  15. Schwartz, D. B., & Schamroth, L. (1979). The effect of pregnancy on the frontal plane QRS axis. Journal of Electrocardiology, 12(3), 279–281.

    Article  PubMed  CAS  Google Scholar 

  16. 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.

    PubMed  CAS  Google Scholar 

  17. 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.

    PubMed  CAS  Google Scholar 

  18. Grubb, B. P. (1998) Neurocardiogenic syncope. In: B. P. Grubb, & B. Olshansky (Eds.), Syncope: Mechanisms and management (pp. 73–106). Armonk, NY: Futura.

    Google Scholar 

  19. 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.

    Article  PubMed  CAS  Google Scholar 

  20. 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.

    PubMed  CAS  Google Scholar 

  21. Anderson, M. H. (1997). Rhythm disorders. In: C. Oakley (Ed.), Heart disease in pregnancy (pp. 248–281). London: BMJ Publishing Group.

    Google Scholar 

  22. Miller, R. W. (1988). Intrauterine radiation exposures and mental retardation. Health Physics, 55(2), 295–298.

    Article  PubMed  CAS  Google Scholar 

  23. Giles, D., Hewitt, D., Stewart, A., & Webb, J. (1956). Malignant disease in childhood and diagnostic irradiation in utero. Lancet, 271(6940), 447.

    PubMed  CAS  Google Scholar 

  24. Doll, R., & Wakeford, R. (1997). Risk of childhood cancer from fetal irradiation. British Journal of Radiology, 70(830), 130–139.

    PubMed  CAS  Google Scholar 

  25. 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.

    PubMed  CAS  Google Scholar 

  26. 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.

    Article  PubMed  CAS  Google Scholar 

  27. 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.

    Article  CAS  Google Scholar 

  28. Chow, T., Galvin, J., & McGovern, B. (1998). Antiarrhythmic drug therapy in pregnancy and lactation. American Journal of Cardiology, 82(4A), 58I–62I.

    Article  PubMed  CAS  Google Scholar 

  29. 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.

    PubMed  CAS  Google Scholar 

  30. 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.

    PubMed  Google Scholar 

  31. 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.

    PubMed  CAS  Google Scholar 

  32. Butters L., Kennedy, S., & Rubin, P. C. (1990). Atenolol in essential hypertension during pregnancy. British Medical Journal, 301(6752), 587–589.

    PubMed  CAS  Google Scholar 

  33. American Academy of Pediatrics Committee on Drugs (2001). The transfer of drugs and other chemicals into human milk. Pediatrics, 108(3), 776–789.

    Google Scholar 

  34. 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.

    Article  PubMed  Google Scholar 

  35. 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.

    Article  PubMed  CAS  Google Scholar 

  36. 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.

    Article  PubMed  CAS  Google Scholar 

  37. 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.

    PubMed  CAS  Google Scholar 

  38. Natale, A., Davidson, T., Geiger, M. J., & Newby, K. (1997). Implantable cardioverter-defibrillators and pregnancy: A safe combination? Circulation, 96(9), 2808–2812.

    PubMed  CAS  Google Scholar 

  39. 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.

    PubMed  Google Scholar 

  40. 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.

    Article  PubMed  Google Scholar 

  41. 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.

    PubMed  CAS  Google Scholar 

  42. 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.

    Article  PubMed  Google Scholar 

  43. Wilbur, S. L., & Marchlinski, F. E. (1997). Adenosine as an antiarrhythmic agent. American Journal of Cardiology, 79(12A), 30–37.

    Article  PubMed  CAS  Google Scholar 

  44. Elkayam, U., & Goodwin, T. M. (1995). Adenosine therapy for supraventricular tachycardia during pregnancy. American Journal of Cardiology, 75(7), 521–523.

    Article  PubMed  CAS  Google Scholar 

  45. Page, R. L. (1995). Treatment of arrhythmias during pregnancy. American Heart Journal, 130(4), 871–876.

    Article  PubMed  CAS  Google Scholar 

  46. 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.

    Article  PubMed  CAS  Google Scholar 

  47. Mendelson, C. L. (1956). Disorders of the heartbeat during pregnancy. American Journal of Obstetrics and Gynecology, 72(6), 1268–1301.

    PubMed  CAS  Google Scholar 

  48. 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.

    Article  PubMed  Google Scholar 

  49. Reiffel, J. A. (2000). Drug choices in the treatment of atrial fibrillation. American Journal of Cardiology, 85(10A), 12D–19D.

    Article  PubMed  CAS  Google Scholar 

  50. 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.

    Article  PubMed  Google Scholar 

  51. 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.

    Article  Google Scholar 

  52. Mackenzie, J. (1921). Heart disease and pregnancy. London: Henry Frowde and Hodder and Stoughton.

    Google Scholar 

  53. Chandra, N. C., Gates, E. A., & Thamer, M. (1991). Conservative treatment of paroxysmal ventricular tachycardia during pregnancy. Clinical Cardiology, 14(4), 347–350.

    PubMed  CAS  Google Scholar 

  54. Briggs, G. G., Freeman, R. K., & Yaffe S. J. (Eds.). (1998). Drugs in pregnancy and lactation, 5th edition. Baltimore: Williams & Wilkins.

    Google Scholar 

  55. 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.

    Article  PubMed  CAS  Google Scholar 

  56. 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.

    Article  PubMed  Google Scholar 

  57. 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.

    PubMed  CAS  Google Scholar 

  58. 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.

    Article  PubMed  CAS  Google Scholar 

  59. 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.

    PubMed  CAS  Google Scholar 

  60. 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.

    PubMed  Google Scholar 

  61. 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.

    PubMed  CAS  Google Scholar 

  62. 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.

    PubMed  CAS  Google Scholar 

  63. 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.

    PubMed  Google Scholar 

  64. 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.

    Article  PubMed  CAS  Google Scholar 

  65. 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.

    Article  PubMed  CAS  Google Scholar 

  66. 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.

    Article  PubMed  CAS  Google Scholar 

  67. 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.

    PubMed  CAS  Google Scholar 

  68. 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.

    Article  PubMed  CAS  Google Scholar 

  69. Kolibash, A. J., Ruiz, D. E., & Lewis, R. P. (1975). Idiopathic hypertrophic subaortic stenosis in pregnancy. Annals of Internal Medicine, 82(6), 791–794.

    PubMed  CAS  Google Scholar 

  70. 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.

    Article  CAS  Google Scholar 

  71. 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.

    Article  PubMed  CAS  Google Scholar 

  72. 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.

    Article  PubMed  Google Scholar 

  73. 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.

    Article  PubMed  CAS  Google Scholar 

  74. 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.

    PubMed  CAS  Google Scholar 

  75. 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.

    Article  Google Scholar 

  76. 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.

    Article  PubMed  CAS  Google Scholar 

  77. 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.

    Article  CAS  Google Scholar 

  78. 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.

    Article  PubMed  CAS  Google Scholar 

  79. DeSilva, R. A., Graboys, T. B., Podrid, P. J., & Lown, B. (1980). Cardioversion and defibrillation. American Heart Journal, 100(6 part 1), 881–895.

    Article  PubMed  CAS  Google Scholar 

  80. 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.

    Article  PubMed  CAS  Google Scholar 

  81. Ovadia M., Brito, M., Hoyer, G. L., & Marcus, F. I. (1994). American Journal of Cardiology, 73(4), 316–317.

    Article  PubMed  CAS  Google Scholar 

  82. 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.

    Article  PubMed  CAS  Google Scholar 

  83. Denniston, P. (1997). Mosby’s complete drug reference: Physicians Genrx, 7th Ed. St. Louis: Mosby-Yearbook.

    Google Scholar 

  84. Heaton, F. C., & Vaughan, R. (1982). Intrauterine supraventricular tachycardia: Cardioversion with maternal digoxin. Obstetrics and Gynecology, 60(6), 749–752.

    PubMed  CAS  Google Scholar 

  85. Wladimiroff, J. W., & Stewart, P. A. (1985). Treatment of fetal cardiac arrhythmias. British Journal of Hospital Medicine, 34(3), 134–140.

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Jamie B. Conti.

Rights and permissions

Reprints 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

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10840-007-9139-4

Keywords

Navigation