Cardiac disease in pregnancy and arrhythmias: Difference between revisions

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Latest revision as of 20:47, 29 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Although underlying reasons remain unclear, if a woman has a prior history of arrhythmias, the risk of recurrent arrhythmias may increase during pregnancy.^[1] ^[2] ^[3] Unfortunately drugs that are effective in the management of arrhythmias such as amiodarone can present a hazard to the fetus during pregnancy.

Arrythmias

Supraventricular Tachycardia During Pregnancy

If there is hemodynamic compromise, the patient can be treated with DC cardioversion.
A rapid narrow complex rhythm suggestive of AV nodal re-entry tachycardia (AVNRT) can be treated emergently with IV adenosine which has a very short half life.
Lopressor is a mainstay of prevention of SVT in the setting of pregnancy. Atenolol and propranolol should be avoided given the risk of intrauterine growth retardation. Calcium channel blockade would be second line therapy. Sotalol and flecainide can be used in refractory cases. Ablation can be performed in refractory cases. Given the risk of fetal hypo/hyperthyroidism with amiodarone, this agent is not recommended.

Ventricular Tachycardia During Pregnancy

Acute VT

If there is hemodynamic compromise, DC cardioversion is recommended.
If the patient is hemodynamically stable with symptoms, then lidocaine, procainamide or as a last resort, amiodarone are recommended.

Recurrent VT

Ascertaining and directing the appropriate therapy to the underlying cause of the VT is critical such as right ventricular outflow tract tachycardia, Long QT Syndrome (treat with beta-blockers).
The following drugs are pregnancy category C drugs, and can be administered if the benefits outweigh the risks:

Amiodarone is a pregnancy category D drug. Amiodarone has been associated with fetal hypothyroidism and hyperthyroidism, fetal bradycardia, intrauterine growth retardation. The expert consensus is that amiodarone use should be restricted to the management of refractory maternal or fetal tachyarrhythmias. Given the long half life of amiodarone, if a woman intends to become pregnant, the drug should be discontinued several months before conception. Thyroid function tests in the neonate are recommended if the mother is administered amiodarone.

Anti-arrhythmic Drugs to Avoid During the Pregnancy

Amiodarone^[4]:

Propranolol and atenolol^[5] ^[6]:

Intrauterine growth restriction
Hypoglycemia in the newborn

Anti-arrhythmic Drugs to Avoid During Lactation

Amiodarone^[4]:

Secreted in breast milk

Acebutolol^[4]:

It becomes concentrated in breast milk. Infants receive much larger doses.
Neonatal bradycardia
Neonatal hypoglycemia

Related Chapters

Cardiac arrhythmias

References

↑ Tawam M, Levine J, Mendelson M, Goldberger J, Dyer A, Kadish A. Effect of pregnancy on paroxysmal supraventricular tachycardia. Am J Cardiol 1993; 72: 838-40.
↑ Brodsky M, Doria R, Allen B, Sato D, Thomas G, Sada M. New-onset ventricular tachycardia during pregnancy. Am Heart J 1992; 123: 933-41.
↑ Chow T, Galvin J, McGovern B. Antiarrhythmic drug therapy in pregnancy and lactation. Am J Cardiol 1998; 82 (4A): 58I - 62I.
↑ ^4.0 ^4.1 ^4.2 Onuigbo M, Alikhan M. Over-the-counter sympathomimetics: a risk factor for cardiac arrhythmias in pregnancy. South Med J 1998; 91: 1153-5.
↑ Eliahou HE, Silverberg DS, Reisin E, Romem I, Mashiach S, Serr DM. Propranolol for the treatment of hypertension in pregnancy. Br J Obstet Gynaecol 1978;85:431-6.
↑ Lydakis C, Lip GY, Beevers M, Beevers DG. Atenolol and fetal growth in pregnancies complicated by hypertension. Am J Hypertens 1999; 12:541-7.

Template:WikiDoc Sources CME Category::Cardiology

[1] Tawam M, Levine J, Mendelson M, Goldberger J, Dyer A, Kadish A. Effect of pregnancy on paroxysmal supraventricular tachycardia. Am J Cardiol 1993; 72: 838-40.

[2] Brodsky M, Doria R, Allen B, Sato D, Thomas G, Sada M. New-onset ventricular tachycardia during pregnancy. Am Heart J 1992; 123: 933-41.

[Chow-3] Chow T, Galvin J, McGovern B. Antiarrhythmic drug therapy in pregnancy and lactation. Am J Cardiol 1998; 82 (4A): 58I - 62I.

[Onuigbo-4] 4.0 ^4.1 ^4.2 Onuigbo M, Alikhan M. Over-the-counter sympathomimetics: a risk factor for cardiac arrhythmias in pregnancy. South Med J 1998; 91: 1153-5.

[5] Eliahou HE, Silverberg DS, Reisin E, Romem I, Mashiach S, Serr DM. Propranolol for the treatment of hypertension in pregnancy. Br J Obstet Gynaecol 1978;85:431-6.

[6] Lydakis C, Lip GY, Beevers M, Beevers DG. Atenolol and fetal growth in pregnancies complicated by hypertension. Am J Hypertens 1999; 12:541-7.

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@@ Line 1: / Line 1: @@
+__NOTOC__
 {{Cardiac disease in pregnancy}}
 {{CMG}}; {{AOEIC}} {{CZ}}
-==Arrhythmias in Pregnancy==
+==Overview==
-Although underlying reasons remain unclear, a significant increase of the incidence and severity of [[cardiac arrhythmias]] in pregnancy (particularly [[atrial arrhythmias|atrial]] and [[ventricular premature beat]]s without an existing heart disease) have been reported in numerous articles, and these [[arrhythmia]]s are usually benign. <ref> Tawam M, Levine J, Mendelson M, Goldberger J, Dyer A, Kadish A. Effect of pregnancy on paroxysmal supraventricular tachycardia. Am J Cardiol 1993; 72: 838-40.</ref> <ref>Brodsky M, Doria R, Allen B, Sato D, Thomas G, Sada M. New-onset ventricular tachycardia during pregnancy. Am Heart J 1992; 123: 933-41.</ref> <ref name="Chow">Chow T, Galvin J, McGovern B. Antiarrhythmic drug therapy in pregnancy and lactation. Am J Cardiol 1998; 82 (4A): 58I - 62I. </ref>
+Although underlying reasons remain unclear, if a woman has a prior history of [[arrhythmias]], the risk of recurrent arrhythmias may increase during pregnancy.<ref> Tawam M, Levine J, Mendelson M, Goldberger J, Dyer A, Kadish A. Effect of pregnancy on paroxysmal supraventricular tachycardia. Am J Cardiol 1993; 72: 838-40.</ref> <ref>Brodsky M, Doria R, Allen B, Sato D, Thomas G, Sada M. New-onset ventricular tachycardia during pregnancy. Am Heart J 1992; 123: 933-41.</ref> <ref name="Chow">Chow T, Galvin J, McGovern B. Antiarrhythmic drug therapy in pregnancy and lactation. Am J Cardiol 1998; 82 (4A): 58I - 62I. </ref>   Unfortunately drugs that are effective in the management of arrhythmias such as [[amiodarone]] can present a hazard to the fetus during pregnancy.
+==Arrythmias==
+===Supraventricular Tachycardia During Pregnancy===
+*If there is hemodynamic compromise, the patient can be treated with DC [[cardioversion]].
+*A rapid narrow complex rhythm suggestive of [[AV nodal re-entry tachycardia]] ([[AVNRT]]) can be treated emergently with IV [[adenosine]] which has a very short half life.
+*[[Lopressor]] is a mainstay of prevention of [[SVT]] in the setting of pregnancy. [[Atenolol]] and [[propranolol]] should be avoided given the risk of [[intrauterine growth retardation]].  [[Calcium channel blockade]] would be second line therapy.  [[Sotalol]] and [[flecainide]] can be used in refractory cases.  Ablation can be performed in refractory cases. Given the risk of fetal hypo/hyperthyroidism with amiodarone, this agent is not recommended.
-It is necessary to check if a pregnant woman takes any over the counter drug which causes palpitation or premature beats (e.g., [[pseudoephedrine]]). <ref name="Chow">Chow T, Galvin J, McGovern B. Antiarrhythmic drug therapy in pregnancy and lactation. Am J Cardiol 1998; 82 (4A): 58I - 62I. </ref>
+===Ventricular Tachycardia During Pregnancy===
+====Acute VT====
+*If there is hemodynamic compromise, DC [[cardioversion]] is recommended.
+*If the patient is hemodynamically stable with symptoms, then [[lidocaine]], [[procainamide]] or as a last resort, [[amiodarone]] are recommended.
+====Recurrent VT====
+*Ascertaining and directing the appropriate therapy to the underlying cause of the VT is critical such as [[right ventricular outflow tract tachycardia]], [[Long QT Syndrome]] (treat with [[beta-blockers]]).
+*The following drugs are pregnancy category C drugs, and can be administered if the benefits outweigh the risks:
+:*[[Quinidine]]
+:*[[Procainamide]]
+:*[[Disopyramide]]
+*[[Amiodarone]] is a [[pregnancy category]] D drug.  Amiodarone has been associated with fetal [[hypothyroidism]] and [[hyperthyroidism]], fetal bradycardia, [[intrauterine growth retardation]].  The expert consensus is that amiodarone use should be restricted to the management of refractory maternal or fetal tachyarrhythmias.   Given the long half life of amiodarone, if a woman intends to become pregnant, the drug should be discontinued several months before conception.   [[Thyroid function tests]] in the neonate are recommended if the mother is administered [[amiodarone]].
-==Anti-arrhythmic Drugs to Avoid During the Pregnancy==
+===Anti-arrhythmic Drugs to Avoid During the Pregnancy===
 * [[Amiodarone]]<ref name="Onuigbo"> Onuigbo M, Alikhan M. Over-the-counter sympathomimetics: a risk factor for cardiac arrhythmias in pregnancy. South Med J 1998; 91: 1153-5.</ref>:
@@ Line 18: / Line 34: @@
 :* [[Hypoglycemia]] in the newborn
-==Anti-arrhythmic Drugs to Avoid During Lactation==
+===Anti-arrhythmic Drugs to Avoid During Lactation===
 * [[Amiodarone]]<ref name="Onuigbo"> Onuigbo M, Alikhan M. Over-the-counter sympathomimetics: a risk factor for cardiac arrhythmias in pregnancy. South Med J 1998; 91: 1153-5.</ref>:
@@ Line 32: / Line 48: @@
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+[[Category:Obstetrics]]