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Management of Tachyarrhythmia During Pregnancy

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Management of Tachyarrhythmia During Pregnancy Turk Kardiyol Dern Ars 2017;45(2):189-196 doi: 10.5543/tkda.2016.78606 189 INVITED REVIEW Management of tachyarrhythmia during pregnancy Gebelik sırasında taşiaritmi tedavisi Emily Ann Enderlin, Khaldia Taufiq Khaled, M.D.,# Luke Oke, M.D.,* Mohammed Madmani, M.D.,† Hakan Paydak, M.D.* College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA #Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA *Department of Clinical Cardiac Electrophysiology, University of Arkansas for Medical Sciences, Lit †Department of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA Summary– Maternal tachyarrhythmia is a common compli- Özet– Annede taşiaritmi, hamile kadınlarda önceden var cation during pregnancy due to hormonal changes that en- olan aritmileri arttıran veya doğuştan kalp defektleri varlı- hance pre-existing arrhythmias or induce new arrhythmias ğında yeni aritmileri başlatan hormonal değişikliklere bağlı in the presence of congenital heart defects in pregnant fe- olarak sık görülen bir komplikasyondur. Gebelik sırasında males. Presence of tachyarrhythmia during pregnancy pos- taşiaritminin varlığı anne ve fetüs için risk oluşturmakta ve es risk to the mother and fetus, calling for proper treatment ilaçlarla uygun tedaviyi gerektirmektedir. Teratojenik yan et- with medications. Use of antiarrhythmic drugs in cases of kilerini de göz önüne alarak maternal taşiaritmide antiarit- maternal tachyarrhythmia must give due consideration of mik ilaçların kullanılması düşünülmelidir. Gebelik sırasında potential teratogenic side effects. Utilization of antiarrhyth- antiaritmik ilaçların kullanılması iyice incelenmiş olup bazı- mic drugs during pregnancy has been well studied; some ları minimal fötal hasara yol açacak bazıları hiç zararlı olma- result in minimal fetal harm or none at all. New techniques, such as cardiac ablation, have also been implemented with yacaktır. Kardiyak ablasyon gibi yeni teknikler de fetüs veya minimal or no radiation exposure to the fetus or mother. anneyi minimal (veya hiç) radyasyona maruz bırakmadan Pregnant women with tachyarrhythmia have been success- uygulanmıştır. Antiaritmik ilaçlarla giderek artan deneyim ve fully treated with little to no impact on the developing fetus yeni prosedürel tekniklerdeki ilerleme sayesinde gebe ka- as result of increasing experience with antiarrhythmic drugs dındaki taşiaritmiler başarıyla ve gelişmekte olan fetüse çok and progress of new procedural techniques. az (veya hiç) etkiyle tedavi edilmektedir. aking antiarrhythmic drugs during pregnancy can ing pregnancy that can affect absorption, bioavailabil- pose different risks to the fetus, depending on the ity, and elimination of anti-arrhythmic drugs, making Tclass of antiarrhythmic drug and which trimester the it difficult to maintain blood therapeutic drug levels.[1,2] mother is in. The greatest teratogenic risk to the fetus These changes include cardiac output and blood vol- is during first trimester of pregnancy, whereas second ume, decreased serum protein concentration, increased and third trimesters pose more risk for fetal growth, de- renal perfusion, enhanced liver metabolism, impair- velopment, and possible induction of arrhythmia in the ment of gastric secretion and motility, and hormonal fetus.[1,2] Teratogenic risk during first trimester alludes stimulation of liver enzymes.[1,2] Due to possible ad- to the fact that organogenesis occurs during this stage verse effects of drugs on the mother or fetus, there is a of pregnancy. Therefore, medical treatment of arrhyth- US Food and Drug Administration classification sys- mia is only advised in situations of severe symptoms or tem to define the level of risk of the drug if taken during increased risk of adverse consequences to the mother pregnancy. The aim of this review article is to describe or fetus.[1] There are many physiological changes dur- the classification system and several case studies along Received: September 12, 2016 Accepted: November 25, 2016 Correspondence: Dr. Emily Ann Enderlin. University of Arkansas, Division of Cardiovascular Medicine, 4301 West Markham Street Slot #532 Little Rock, Arkansas - United States. Tel: 479-970-4658 e-mail: [email protected] © 2017 Turkish Society of Cardiology 190 Turk Kardiyol Dern Ars with most common treatment strategies for managing consider severity of Abbreviations: different types of arrhythmia in pregnancy. the symptoms and AV Atrioventricular physiological effect of AVNRT AV nodal reentrant tachycardia Arrhythmias in Pregnancy the arrhythmia. If the DC Direct current IV Intravenous patient is asymptom- Premature atrial complexes and premature LVOT Left ventricular outflow tract atic or the symptoms PAC Premature atrial complex ventricular complexes are mild and there PVC Premature ventricular complex RVOT Right ventricular outflow tract Premature atrial complexes (PACs) and premature is no hemodynamic SVT Supraventricular tachycardia ventricular complexes (PVCs) are very common dur- compromise, then re- VT Ventricular tachycardia ing pregnancy. Oftentimes they are anxiety-provok- assurance alone is ad- WPW Wolff-Parkinson-White syndrome ing in patients who have not experienced them before. vised.[2] However, in healthy pregnant women with structur- Initial management in pregnant patients for acute ally normal hearts they are very benign. Pregnant conversion in the setting of SVT is vagal nerve stimu- women who are asymptomatic call for reassurance lation by way of carotid massage.[1,2,4,6,7] Various vagal that these complexes will cause no harm. It is impor- maneuvers can also be performed. Examples include tant to educate on stimulants, such as caffeine and al- exhibiting gag reflex, the Valsalva maneuver, immers- cohol, which increase frequency of PACs and PVCs. ing the patient’s face in ice-cold water, or coughing. In pregnant patients with severe symptoms or symp- If vagal nerve stimulation fails, proceed to medical toms interfering with their daily lives, beta blockers, management. In pregnant patients, first line medical such as metoprolol and propanolol, can be given for treatment in AVNRT should be intravenous (IV) ade- [3] symptomatic management. nosine (category C). It is effective in terminating par- Supraventricular tachycardia oxysmal SVT in approximately 84% to 90% of ma- ternal cases.[1,4–7] Standard dose of adenosine is rapid Supraventricular tachycardia (SVT) is defined as nar- IV administration of 6 mg, followed by 12 mg dose if row complex tachycardia with heart rate greater than the first dose fails to convert the patient to normal si- 100 bpm and mechanism of development at the level nus rhythm after 1 to 2 minutes.[4,8] Many studies have of the atrioventricular (AV) node. SVT is the most demonstrated variations of second dose, ranging be- common arrhythmia present in women of reproduc- tween 12 and 18 mg if the initial dose of 6 mg fails to tive age, with a prevalence of 24 per 100 000 hospi- convert the patient to normal sinus rhythm.[9–11] Sec- [4,5] tal admissions. Risk of developing SVT increases ond dose of adenosine has been safely administered in [4] during pregnancy, labor, and delivery. Furthermore, doses up to 24 mg IV during pregnancy.[10] Increasing exacerbation of previously diagnosed SVT occurs in dose to 15 mg in 1 study led to fetal bradycardia in approximately 20% of pregnant females.[2,5] Among 1 patient, which reverted back to normal within 10 subtypes of SVT, AV nodal reentrant tachycardia minutes of administering bolus.[9] Adenosine has been (AVNRT) and atrioventricular reciprocating tachycar- most studied during second and third trimesters, and dia are the most common forms, with atrial tachycar- is generally accepted as safe for use. Adenosine use dia being the least frequent cause of SVT in pregnant in first trimester is still not advised due to lack of suf- females.[4,5] It is important to diagnose and recognize ficient studies indicating safe administration and good SVT because it can pose harm to the mother and fe- outcome.[2] Beta blockers, such as IV propranolol (cat- tus, such as hemodynamic instability and fetal hypo- egory C) and IV metoprolol (category C), have been perfusion, resulting in emergent caesarean section extensively studied for use during pregnancy and are when the fetus is pre-term.[4] There is a relationship considered safe to use in the absence of adenosine. between gestational paroxysmal SVT and septal car- [1,2,5–8,10] Although digoxin (category C) is considered diac defects. Therefore, in pregnant women, it is very to be one of the safest drugs to use during pregnancy important to recognize and treat SVT. 10, there are few data showing effectiveness on con- verting the patient to normal sinus rhythm when used Atrioventricular nodal reentrant tachycardia and alone. Therefore, combined use with beta blocker is Wolff-Parkinson-White syndrome advised.[5] In pregnant patients with AVNRT, 10 mg When treating pregnant females with an SVT, always of IV verapamil (category C) over 3 minutes 11, or Management of tachyarrhythmia during pregnancy 191 5 mg of IV verapamil given over 5 minutes has been IL, USA) cardiac mapping system with no use of fluo- shown to successfully convert pregnant patients back roscopy.[15] Despite the fact there are new methods of to normal sinus rhythm.[12] However, verapamil is mapping and ablation that can be done with minimal considered third line agent in treatment of SVT dur- to no
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