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Supraventricular arrhythmias during pregnancy

INTRODUCTION

Arrhythmias are the most common cardiac complication encountered during pregnancy in women with and without structural heart disease [1-3]. Arrhythmias may manifest for the first time during pregnancy, and in other cases, pregnancy can trigger exacerbations in women with pre-existing arrhythmias [1,4-6]. Women with established arrhythmias or structural heart disease are at highest risk of developing arrhythmias during pregnancy. In addition, there has been an increase in the number of women of childbearing age with congenital heart disease (due to surgical advances), and these women are at particularly high risk for arrhythmias (figure 1) [1,2,7-11]. Because of these associations, any woman who presents with an arrhythmia should have a clinical evaluation with a complete history and cardiac examination, an electrocardiogram, and a transthoracic echocardiogram to evaluate for evidence of structural heart disease.

In general, the approach to the treatment of arrhythmias in pregnancy is similar to that in the nonpregnant patient. However, due to the theoretical or known adverse effects of antiarrhythmic drugs on the fetus, antiarrhythmic drugs are often reserved for the treatment of arrhythmias associated with clinically significant symptoms or hemodynamic compromise [12-14]. Treatment recommendations are hampered by the lack of randomized trials and very little or no data on efficacy or safety of antiarrhythmic drugs during pregnancy. Choice of therapy, for the most part, is based on limited data from animal studies, case reports, and observational studies, as well as clinical experience.

The prevalence, clinical presentation, and management of supraventricular arrhythmias during pregnancy will be reviewed. Electrocardiographic characteristics of supraventricular arrhythmias, as well as issues relating to conduction disorders, ventricular arrhythmias, and cardiac arrest during pregnancy, are discussed separately. (See "ECG tutorial: Atrial and atrioventricular nodal (supraventricular) arrhythmias" and "Maternal conduction disorders and bradycardia during pregnancy" and "Ventricular arrhythmias during pregnancy".)

MECHANISM OF ARRHYTHMOGENESIS IN PREGNANCY

The exact mechanism of increased arrhythmia burden during pregnancy is unclear, but has been attributed to hemodynamic, hormonal, and autonomic changes related to pregnancy.

The hemodynamic changes of pregnancy have been well studied, and a number of these changes likely contributes to the development of arrhythmias during pregnancy [15,16]. (See "Maternal cardiovascular and hemodynamic adaptations to pregnancy".)

                           

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Literature review current through: Aug 2014. | This topic last updated: Mar 18, 2014.
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References
Top
  1. Siu SC, Sermer M, Colman JM, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation 2001; 104:515.
  2. Drenthen W, Pieper PG, Roos-Hesselink JW, et al. Outcome of pregnancy in women with congenital heart disease: a literature review. J Am Coll Cardiol 2007; 49:2303.
  3. Drenthen W, Boersma E, Balci A, et al. Predictors of pregnancy complications in women with congenital heart disease. Eur Heart J 2010; 31:2124.
  4. Lee SH, Chen SA, Wu TJ, et al. Effects of pregnancy on first onset and symptoms of paroxysmal supraventricular tachycardia. Am J Cardiol 1995; 76:675.
  5. Doig JC, McComb JM, Reid DS. Incessant atrial tachycardia accelerated by pregnancy. Br Heart J 1992; 67:266.
  6. Silversides CK, Harris L, Haberer K, et al. Recurrence rates of arrhythmias during pregnancy in women with previous tachyarrhythmia and impact on fetal and neonatal outcomes. Am J Cardiol 2006; 97:1206.
  7. Siu SC, Sermer M, Harrison DA, et al. Risk and predictors for pregnancy-related complications in women with heart disease. Circulation 1997; 96:2789.
  8. Drenthen W, Pieper PG, Ploeg M, et al. Risk of complications during pregnancy after Senning or Mustard (atrial) repair of complete transposition of the great arteries. Eur Heart J 2005; 26:2588.
  9. Drenthen W, Pieper PG, van der Tuuk K, et al. Cardiac complications relating to pregnancy and recurrence of disease in the offspring of women with atrioventricular septal defects. Eur Heart J 2005; 26:2581.
  10. Drenthen W, Pieper PG, Roos-Hesselink JW, et al. Pregnancy and delivery in women after Fontan palliation. Heart 2006; 92:1290.
  11. Blomström-Lundqvist C, Scheinman MM, Aliot EM, et al. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias). Circulation 2003; 108:1871.
  12. Joglar JA, Page RL. Treatment of cardiac arrhythmias during pregnancy: safety considerations. Drug Saf 1999; 20:85.
  13. Cox JL, Gardner MJ. Treatment of cardiac arrhythmias during pregnancy. Prog Cardiovasc Dis 1993; 36:137.
  14. European Society of Gynecology (ESG), Association for European Paediatric Cardiology (AEPC), German Society for Gender Medicine (DGesGM), et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J 2011; 32:3147.
  15. Silversides CK, Colman JM. Physiological changes in pregnancy. In: Heart disease in pregnancy, 2nd ed, Oakley C, Warnes CA (Eds), Blackwell Publishing, Malden 2007. p.6.
  16. Elkayam U, Gleicher N. Hemodynamics and cardiac function during normal pregnancy and puerperium. In: Cardiac problems in pregnancy, 3rd ed, Elkayam U, Gleicher N (Eds), Wiley-Liss, New York 1998. p.3.
  17. Katz R, Karliner JS, Resnik R. Effects of a natural volume overload state (pregnancy) on left ventricular performance in normal human subjects. Circulation 1978; 58:434.
  18. Rubler S, Damani PM, Pinto ER. Cardiac size and performance during pregnancy estimated with echocardiography. Am J Cardiol 1977; 40:534.
  19. Liebson PR, Mann LI, Evans MI, et al. Cardiac performance during pregnancy: serial evaluation using external systolic time intervals. Am J Obstet Gynecol 1975; 122:1.
  20. Campos O. Doppler Echocardiography During Pregnancy: Physiological and Abnormal Findings. Echocardiography 1996; 13:135.
  21. Franz MR, Cima R, Wang D, et al. Electrophysiological effects of myocardial stretch and mechanical determinants of stretch-activated arrhythmias. Circulation 1992; 86:968.
  22. Wang Y, Joyner RW, Wagner MB, et al. Stretch-activated channel activation promotes early afterdepolarizations in rat ventricular myocytes under oxidative stress. Am J Physiol Heart Circ Physiol 2009; 296:H1227.
  23. Ninio DM, Saint DA. The role of stretch-activated channels in atrial fibrillation and the impact of intracellular acidosis. Prog Biophys Mol Biol 2008; 97:401.
  24. Kamkin A, Kiseleva I, Isenberg G. Stretch-activated currents in ventricular myocytes: amplitude and arrhythmogenic effects increase with hypertrophy. Cardiovasc Res 2000; 48:409.
  25. Soliman EZ, Elsalam MA, Li Y. The relationship between high resting heart rate and ventricular arrhythmogenesis in patients referred to ambulatory 24 h electrocardiographic recording. Europace 2010; 12:261.
  26. Zuspan FP. Catecholamines. Their role in pregnancy and the development of pregnancy-induced hypertension. J Reprod Med 1979; 23:143.
  27. Natrajan PG, McGarrigle HH, Lawrence DM, Lachelin GC. Plasma noradrenaline and adrenaline levels in normal pregnancy and in pregnancy-induced hypertension. Br J Obstet Gynaecol 1982; 89:1041.
  28. Whittaker PG, Gerrard J, Lind T. Catecholamine responses to changes in posture during human pregnancy. Br J Obstet Gynaecol 1985; 92:586.
  29. Barron WM, Mujais SK, Zinaman M, et al. Plasma catecholamine responses to physiologic stimuli in normal human pregnancy. Am J Obstet Gynecol 1986; 154:80.
  30. Ramsay MM, Broughton Pipkin F, Rubin PC. Pressor, heart rate and plasma catecholamine responses to noradrenaline in pregnant and nonpregnant women. Br J Obstet Gynaecol 1993; 100:170.
  31. Roberts JM, Insel PA, Goldfien A. Regulation of myometrial adrenoreceptors and adrenergic response by sex steroids. Mol Pharmacol 1981; 20:52.
  32. Priori SG, Mantica M, Schwartz PJ. Delayed afterdepolarizations elicited in vivo by left stellate ganglion stimulation. Circulation 1988; 78:178.
  33. Shotan A, Ostrzega E, Mehra A, et al. Incidence of arrhythmias in normal pregnancy and relation to palpitations, dizziness, and syncope. Am J Cardiol 1997; 79:1061.
  34. Li JM, Nguyen C, Joglar JA, et al. Frequency and outcome of arrhythmias complicating admission during pregnancy: experience from a high-volume and ethnically-diverse obstetric service. Clin Cardiol 2008; 31:538.
  35. Tawam M, Levine J, Mendelson M, et al. Effect of pregnancy on paroxysmal supraventricular tachycardia. Am J Cardiol 1993; 72:838.
  36. Smith WM, Gallagher JJ, Kerr CR, et al. The electrophysiologic basis and management of symptomatic recurrent tachycardia in patients with Ebstein's anomaly of the tricuspid valve. Am J Cardiol 1982; 49:1223.
  37. MENDELSON CL. Disorders of the heartbeat during pregnancy. Am J Obstet Gynecol 1956; 72:1268.
  38. Gleicher N, Meller J, Sandler RZ, Sullum S. Wolff-Parkinson-White syndrome in pregnancy. Obstet Gynecol 1981; 58:748.
  39. Widerhorn J, Widerhorn AL, Rahimtoola SH, Elkayam U. WPW syndrome during pregnancy: increased incidence of supraventricular arrhythmias. Am Heart J 1992; 123:796.
  40. Kounis NG, Zavras GM, Papadaki PJ, et al. Pregnancy-induced increase of supraventricular arrhythmias in Wolff-Parkinson-White syndrome. Clin Cardiol 1995; 18:137.
  41. SZEKELY P, SNAITH L. Paroxysmal tachycardia in pregnancy. Br Heart J 1953; 15:195.
  42. Murphy JJ, Hutchon DJ. Incessant atrial tachycardia accelerated by pregnancy. Br Heart J 1992; 68:342.
  43. Treakle K, Kostic B, Hulkower S. Supraventricular tachycardia resistant to treatment in a pregnant woman. J Fam Pract 1992; 35:581.
  44. Schroeder JS, Harrison DC. Repeated cardioversion during pregnancy. Treatment of refractory paroxysmal atrial tachycardia during 3 successive pregnancies. Am J Cardiol 1971; 27:445.
  45. Hubbard WN, Jenkins BA, Ward DE. Persistent atrial tachycardia in pregnancy. Br Med J (Clin Res Ed) 1983; 287:327.
  46. Elkayam U, Goodwin TM. Adenosine therapy for supraventricular tachycardia during pregnancy. Am J Cardiol 1995; 75:521.
  47. Harrison JK, Greenfield RA, Wharton JM. Acute termination of supraventricular tachycardia by adenosine during pregnancy. Am Heart J 1992; 123:1386.
  48. Podolsky SM, Varon J. Adenosine use during pregnancy. Ann Emerg Med 1991; 20:1027.
  49. Mason BA, Ricci-Goodman J, Koos BJ. Adenosine in the treatment of maternal paroxysmal supraventricular tachycardia. Obstet Gynecol 1992; 80:478.
  50. Afridi I, Moise KJ Jr, Rokey R. Termination of supraventricular tachycardia with intravenous adenosine in a pregnant woman with Wolff-Parkinson-White syndrome. Obstet Gynecol 1992; 80:481.
  51. Leffler S, Johnson DR. Adenosine use in pregnancy: lack of effect on fetal heart rate. Am J Emerg Med 1992; 10:548.
  52. DiMarco JP, Miles W, Akhtar M, et al. Adenosine for paroxysmal supraventricular tachycardia: dose ranging and comparison with verapamil. Assessment in placebo-controlled, multicenter trials. The Adenosine for PSVT Study Group. Ann Intern Med 1990; 113:104.
  53. Wheeler CP, Yudilevich DL. Transport and metabolism of adenosine in the perfused guinea-pig placenta. J Physiol 1988; 405:511.
  54. Jaqueti J, Martinez-Hernández D, Hernández-Garcia R, et al. Adenosine deaminase in pregnancy serum. Clin Chem 1990; 36:2144.
  55. Mariani PJ. Pharmacotherapy of pregnancy--related SVT. Ann Emerg Med 1992; 21:229.
  56. Byerly WG, Hartmann A, Foster DE, Tannenbaum AK. Verapamil in the treatment of maternal paroxysmal supraventricular tachycardia. Ann Emerg Med 1991; 20:552.
  57. Briggs GC, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation, 8th ed, Lippincott Williams & Wilkins, Philadelphia 2008.
  58. Winniford MD, Fulton KL, Hillis LD. Long-term therapy of paroxysmal supraventricular tachycardia: a randomized, double-blind comparison of digoxin, propranolol and verapamil. Am J Cardiol 1984; 54:1138.
  59. Rubin PC. Beta blockers in pregnancy. Br J Obstet Gynaecol 1987; 94:292.
  60. Blake S, MacDonald D. The prevention of the maternal manifestations of pre-eclampsia by intensive antihypertensive treatment. Br J Obstet Gynaecol 1991; 98:244.
  61. Butters L, Kennedy S, Rubin PC. Atenolol in essential hypertension during pregnancy. BMJ 1990; 301:587.
  62. Magee, LA, Duley, L. Oral beta-blockers for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev 2000:CD002863.
  63. Lip GY, Beevers M, Churchill D, et al. Effect of atenolol on birth weight. Am J Cardiol 1997; 79:1436.
  64. Szumowski L, Szufladowicz E, Orczykowski M, et al. Ablation of severe drug-resistant tachyarrhythmia during pregnancy. J Cardiovasc Electrophysiol 2010; 21:877.
  65. Robards GJ, Saunders DM, Donnelly GL. Refractory supraventricular tachycardia complicating pregnancy. Med J Aust 1973; 2:278.
  66. Cruz FE, Cheriex EC, Smeets JL, et al. Reversibility of tachycardia-induced cardiomyopathy after cure of incessant supraventricular tachycardia. J Am Coll Cardiol 1990; 16:739.
  67. Haines DE, DiMarco JP. Sustained intraatrial reentrant tachycardia: clinical, electrocardiographic and electrophysiologic characteristics and long-term follow-up. J Am Coll Cardiol 1990; 15:1345.
  68. Pagad SV, Barmade AB, Toal SC, et al. 'Rescue' radiofrequency ablation for atrial tachycardia presenting as cardiomyopathy in pregnancy. Indian Heart J 2004; 56:245.
  69. Gowda RM, Punukollu G, Khan IA, et al. Lone atrial fibrillation during pregnancy. Int J Cardiol 2003; 88:123.
  70. Kuczkowski KM. New onset transient lone atrial fibrillation in a healthy parturient: déjà vu. Int J Cardiol 2004; 97:339.
  71. McCans JL, Wenger NK. Problems in management of the pregnant patient with rheumatic heart disease and valve prosthesis. South Med J 1976; 69:1007.
  72. Bryg RJ, Gordon PR, Kudesia VS, Bhatia RK. Effect of pregnancy on pressure gradient in mitral stenosis. Am J Cardiol 1989; 63:384.
  73. Autore C, Conte MR, Piccininno M, et al. Risk associated with pregnancy in hypertrophic cardiomyopathy. J Am Coll Cardiol 2002; 40:1864.
  74. Homans DC. Peripartum cardiomyopathy. N Engl J Med 1985; 312:1432.
  75. Walsh EP, Cecchin F. Arrhythmias in adult patients with congenital heart disease. Circulation 2007; 115:534.
  76. Tateno S, Niwa K, Nakazawa M, et al. Arrhythmia and conduction disturbances in patients with congenital heart disease during pregnancy: multicenter study. Circ J 2003; 67:992.
  77. Whittemore R, Hobbins JC, Engle MA. Pregnancy and its outcome in women with and without surgical treatment of congenital heart disease. Am J Cardiol 1982; 50:641.
  78. Balci A, Drenthen W, Mulder BJ, et al. Pregnancy in women with corrected tetralogy of Fallot: occurrence and predictors of adverse events. Am Heart J 2011; 161:307.
  79. Wessel HU, Benson DW Jr, Braunlin EA, et al. Exercise response before and after termination of atrial tachycardia after congenital heart disease surgery. Circulation 1989; 80:106.
  80. SZEKELY P, SNAITH L. Atrial fibrillation and pregnancy. Br Med J 1961; 1:1407.
  81. Forfar JC, Miller HC, Toft AD. Occult thyrotoxicosis: a correctable cause of "idiopathic" atrial fibrillation. Am J Cardiol 1979; 44:9.
  82. Fuster V, Rydén LE, Cannom DS, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2006; 114:e257.
  83. European Heart Rhythm Association, Heart Rhythm Society, Fuster V, et al. 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 Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). J Am Coll Cardiol 2006; 48:854.
  84. Page RL. Treatment of arrhythmias during pregnancy. Am Heart J 1995; 130:871.
  85. Tan HL, Lie KI. Treatment of tachyarrhythmias during pregnancy and lactation. Eur Heart J 2001; 22:458.
  86. Kockova R, Kocka V, Kiernan T, Fahy GJ. Ibutilide-induced cardioversion of atrial fibrillation during pregnancy. J Cardiovasc Electrophysiol 2007; 18:545.
  87. Burkart TA, Kron J, Miles WM, et al. Successful termination of atrial flutter by ibutilide during pregnancy. Pacing Clin Electrophysiol 2007; 30:283.
  88. Task Force on the Management of Cardiovascular Diseases During Pregnancy of the European Society of Cardiology. Expert consensus document on management of cardiovascular diseases during pregnancy. Eur Heart J 2003; 24:761.
  89. Mitani GM, Steinberg I, Lien EJ, et al. The pharmacokinetics of antiarrhythmic agents in pregnancy and lactation. Clin Pharmacokinet 1987; 12:253.
  90. Syme MR, Paxton JW, Keelan JA. Drug transfer and metabolism by the human placenta. Clin Pharmacokinet 2004; 43:487.
  91. Leung CY, Brodsky MA. Cardiac arrhythmias and pregnancy. In: Cardiac problems in pregnancy, 3rd ed, Elkayam U, Gleicher N (Eds), Wiley-Liss, New York 1998. p.155.
  92. Rotmensch HH, Rotmensch S, Elkayam U. Management of cardiac arrhythmias during pregnancy. Current concepts. Drugs 1987; 33:623.
  93. Dunlop W. Serial changes in renal haemodynamics during normal human pregnancy. Br J Obstet Gynaecol 1981; 88:1.
  94. Krauer B, Krauer F. Drug kinetics in pregnancy. Clin Pharmacokinet 1977; 2:167.
  95. Ueland K, McAnulty JH, Ueland FR, Metcalfe J. Special considerations in the use of cardiovascular drugs. Clin Obstet Gynecol 1981; 24:809.
  96. VOGEL JH, PRYOR R, BLOUNT SG Jr. DIRECT-CURRENT DEFIBRILLATION DURING PREGNANCY. JAMA 1965; 193:970.
  97. Lee RV, Rodgers BD, White LM, Harvey RC. Cardiopulmonary resuscitation of pregnant women. Am J Med 1986; 81:311.
  98. Russell RO Jr. Paroxysmal ventricular tachycardia associated with pregnancy. Ala J Med Sci 1969; 6:111.
  99. Wang YC, Chen CH, Su HY, Yu MH. The impact of maternal cardioversion on fetal haemodynamics. Eur J Obstet Gynecol Reprod Biol 2006; 126:268.
  100. DeSilva RA, Graboys TB, Podrid PJ, Lown B. Cardioversion and defibrillation. Am Heart J 1980; 100:881.
  101. Barnes EJ, Eben F, Patterson D. Direct current cardioversion during pregnancy should be performed with facilities available for fetal monitoring and emergency caesarean section. BJOG 2002; 109:1406.
  102. Spector P, Reynolds MR, Calkins H, et al. Meta-analysis of ablation of atrial flutter and supraventricular tachycardia. Am J Cardiol 2009; 104:671.
  103. Bongiorni MG, Di Cori A, Soldati E, et al. Radiofrequency catheter ablation of atrioventricular nodal reciprocating tachycardia using intracardiac echocardiography in pregnancy. Europace 2008; 10:1018.
  104. Risius T, Mortensen K, Meinertz T, Willems S. Cluster of multiple atrial tachycardias limited to pregnancy after radiofrequency ablation following senning operation. Int J Cardiol 2008; 123:e48.
  105. Kanjwal Y, Kosinski D, Kanj M, et al. Successful radiofrequency catheter ablation of left lateral accessory pathway using transseptal approach during pregnancy. J Interv Card Electrophysiol 2005; 13:239.
  106. Bombelli F, Lagona F, Salvati A, et al. Radiofrequency catheter ablation in drug refractory maternal supraventricular tachycardias in advanced pregnancy. Obstet Gynecol 2003; 102:1171.
  107. Domínguez A, Iturralde P, Hermosillo AG, et al. Successful radiofrequency ablation of an accessory pathway during pregnancy. Pacing Clin Electrophysiol 1999; 22:131.
  108. Berruezo A, Díez GR, Berne P, et al. Low exposure radiation with conventional guided radiofrequency catheter ablation in pregnant women. Pacing Clin Electrophysiol 2007; 30:1299.
  109. Damilakis J, Theocharopoulos N, Perisinakis K, et al. Conceptus radiation dose and risk from cardiac catheter ablation procedures. Circulation 2001; 104:893.
  110. Ferguson JD, Helms A, Mangrum JM, DiMarco JP. Ablation of incessant left atrial tachycardia without fluoroscopy in a pregnant woman. J Cardiovasc Electrophysiol 2011; 22:346.
  111. Szumowski L, Szufladowicz E, Orczykowski M, et al. Ablation of severe drug-resistant tachyarrhythmia during pregnancy. J Cardiovasc Electrophysiol 2010; 21:877.