Atrial fibrillation pregnancy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Varun Kumar, M.B.B.S. Anahita Deylamsalehi, M.D.[2]
Overview
Although physiologic changes during pregnancy cause some cardiovascular changes that may be arrhythmogenic, prevelance of atrial fibrillation is very low among pregnant women. Presence of atrial fibrillation during pregnancy has an identifiable underlying etiology such as mitral stenosis, congenital heart disease, or hyperthyroidism. Therefore in a pregnant patient with atrial fibrillation, conditions such as underlying congenital heart diseases, valvular heart diseases, electrolyte disturbance, hyperthyroidism and alcohol abuse should be evaluated. Atrial fibrillation during pregnancy has a wide range of presentation from a self limited and benign condition to sever and resistant arrhythmia with shock and fetal bradycardia. In the absence of heart failure digoxin, beta blocker or non-dihydropyridine CCB may be used to control the ventricular rate. Cardioversion is the treatment of choice in pregnanct patients with persistent atrial fibrillation. Synchronized electrical cardioversion is safe during all stages of pregnancy.
Atrial Fibrillation and Pregnancy
- Although physiologic changes during pregnancy cause some cardiovascular changes that may be arrhythmogenic, prevelance of atrial fibrillation is very low among pregnant women.[1]
- Based on one study done on pregnanct patients with history of rheumatic heart disease, 8% of them had atrial fibrillation at the onset of pregnancy, nevertheless rate of atrial fibrillation development after becoming pregnanct was only 2.5%. [1]
- Presence of atrial fibrillation during pregnancy has an identifiable underlying etiology such as mitral stenosis, congenital heart disease, or hyperthyroidism.[2][3][4][5]
- Therefore in a pregnant patient with atrial fibrillation, conditions such as underlying congenital heart diseases, valvular heart diseases, electrolyte disturbance, hyperthyroidism and alcohol abuse should be evaluated.[1][6][7]
- Usage of terbutaline as a tocolytic during pregnancy also could be related to atrial fibrillation development.[1][8]
- Atrial fibrillation during pregnancy has a wide range of presentation from a self limited and benign condition to sever and resistant arrhythmia with shock and fetal bradycardia.[1]
- Fetal growth surveillance is critical in pregnant patients with atrial fibrillation.[5][1]
- In the absence of heart failure digoxin, beta blocker or non-dihydropyridine CCB may be used to control the ventricular rate. Although intravenous administration of digoxin and non-dihydropyridine CCB is not recommended in patients with atrial fibrillation and a pre-excitation syndrome, since they might accelerate the ventricular response.[9][10][11][1][12]
- Among beta blockers, cardioselective agents such as metoprolol and atenolol are preferred. [1]
- Quinidine has been shown to be safe in pregnancy and remains the drug of choice for pharmacological cardioversion of atrial fbrillation in pregnancy.[13]
- Cardioversion is the treatment of choice in pregnanct patients with persistent atrial fibrillation. Synchronized electrical cardioversion is safe during all stages of pregnancy.[5][1]
- In cases of hemodynamic instability, direct-current cardioversion may be performed without fetal damage.[14]
- In severe and resistant cases that atrial fibrillation has been led to shock and consequent fetal bradycardia, urgent caesarean section under supervision of obstetric specialist and cardiologist might be warranted.[1]
2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)[15]
Pregnancy (DO NOT EDIT) [15]
| Class I |
| "1. Digoxin, beta blockers, or non dihydropyridine calcium channel antagonists are recommended to control the rate of ventricular response in pregnant patients with atrial fibrillation. (Level of Evidence: C)" |
| "2. Direct-current cardioversion is recommended in pregnant patients who become hemodynamically unstable due to atrial fibrillation. (Level of Evidence: C)" |
| "3. Protection against thromboembolism is recommended throughout pregnancy for all patients with atrial fibrillation (except those with lone atrial fibrillation and/or low thromboembolic risk). Therapy (anticoagulant or aspirin) should be chosen according to the stage of pregnancy. (Level of Evidence: C)" |
| Class IIb |
| "1. Administration of heparin may be considered during the first trimester and last month of pregnancy for patients with atrial fibrillation and risk factors for thromboembolism. Unfractionated heparin may be administered either by continuous intravenous infusion in a dose sufficient to prolong the activated partial thromboplastin time to 1.5 to 2 times the control value or by intermittent subcutaneous injection in a dose of 10 000 to 20 000 units every 12 h, adjusted to prolong the mid-interval (6 h after injection) activated partial thromboplastin time to 1.5 times control. (Level of Evidence: B)" |
| "2. Despite the limited data available, subcutaneous administration of low-molecular-weight heparin may be considered during the first trimester and last month of pregnancy for patients with atrial fibrillation (AF) and risk factors for thromboembolism. (Level of Evidence: B)" |
| "3. Administration of an oral anticoagulant may be considered during the second trimester for pregnant patients with atrial fibrillation (AF) at high thromboembolic risk. (Level of Evidence: C)" |
| "4. Administration of quinidine or procainamide may be considered to achieve pharmacological cardioversion in hemodynamically stable patients who develop atrial fibrillation (AF) during pregnancy. (Level of Evidence: C)" |
Sources
- 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation [16]
- ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter [17]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Cacciotti L, Passaseo I (2010). "Management of Atrial Fibrillation in Pregnancy". J Atr Fibrillation. 3 (3): 295. doi:10.4022/jafib.295. PMC 4955905. PMID 28496671.
- ↑ Whittemore R, Hobbins JC, Engle MA (1982) Pregnancy and its outcome in women with and without surgical treatment of congenital heart disease. Am J Cardiol 50 (3):641-51. PMID: 7113941
- ↑ Bryg RJ, Gordon PR, Kudesia VS, Bhatia RK (1989) Effect of pregnancy on pressure gradient in mitral stenosis. Am J Cardiol 63 (5):384-6. PMID: 2913749
- ↑ Forfar JC, Miller HC, Toft AD (1979) Occult thyrotoxicosis: a correctable cause of "idiopathic" atrial fibrillation. Am J Cardiol 44 (1):9-12. PMID: 110126
- ↑ 5.0 5.1 5.2 DiCarlo-Meacham LA, Dahlke LJ (2011). "Atrial fibrillation in pregnancy". Obstet Gynecol. 117 (2 Pt 2): 489–492. doi:10.1097/AOG.0b013e31820561ef. PMID 21252800.
- ↑ Hameed A, Karaalp IS, Tummala PP, Wani OR, Canetti M, Akhter MW; et al. (2001). "The effect of valvular heart disease on maternal and fetal outcome of pregnancy". J Am Coll Cardiol. 37 (3): 893–9. doi:10.1016/s0735-1097(00)01198-0. PMID 11693767.
- ↑ Autore C, Conte MR, Piccininno M, Bernabò P, Bonfiglio G, Bruzzi P; et al. (2002). "Risk associated with pregnancy in hypertrophic cardiomyopathy". J Am Coll Cardiol. 40 (10): 1864–9. doi:10.1016/s0735-1097(02)02495-6. PMID 12446072.
- ↑ Carson MP, Fisher AJ, Scorza WE (2002). "Atrial fibrillation in pregnancy associated with oral terbutaline". Obstet Gynecol. 100 (5 Pt 2): 1096–7. doi:10.1016/s0029-7844(02)02106-3. PMID 12423819.
- ↑ Page RL (1995) Treatment of arrhythmias during pregnancy. Am Heart J 130 (4):871-6. PMID: 7572599
- ↑ Chow T, Galvin J, McGovern B (1998) Antiarrhythmic drug therapy in pregnancy and lactation. Am J Cardiol 82 (4A):58I-62I. PMID: 9737655
- ↑ O'Nunain S, Garratt CJ, Linker NJ, Gill J, Ward DE, Camm AJ (1991) A comparison of intravenous propafenone and flecainide in the treatment of tachycardias associated with the Wolff-Parkinson-White syndrome. Pacing Clin Electrophysiol 14 (11 Pt 2):2028-34. PMID: 1721219
- ↑ European Heart Rhythm Association. Heart Rhythm Society. Fuster V, Rydén LE, Cannom DS, Crijns HJ; 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 Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation)". J Am Coll Cardiol. 48 (4): 854–906. doi:10.1016/j.jacc.2006.07.009. PMID 16904574.
- ↑ Vaughan Williams EM (1984) A classification of antiarrhythmic actions reassessed after a decade of new drugs. J Clin Pharmacol 24 (4):129-47. PMID: 6144698
- ↑ 14.0 14.1 Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) 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 114 (7):e257-354. DOI:10.1161/CIRCULATIONAHA.106.177292 PMID: 16908781
- ↑ 15.0 15.1 Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA; et al. (2011). "2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society". J Am Coll Cardiol. 57 (11): e101–98. doi:10.1016/j.jacc.2010.09.013. PMID 21392637.
- ↑ Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 123 (10):e269-367. DOI:10.1161/CIR.0b013e318214876d PMID: 21382897
- ↑ Estes NA, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS et al. (2008) ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation): developed in collaboration with the Heart Rhythm Society. Circulation 117 (8):1101-20. DOI:10.1161/CIRCULATIONAHA.107.187192 PMID: 18283199