Fetal Arrhythmias - kusm

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Fetal Arrhythmias - kusm
Fetal
Arrhythmias
Dawn Boender, PGY3
Overview
 Tachyarrhythmias
 Bradyarrhythmias
Fetal Arrhythmias
 1%
of fetuses
 75% extrasystoles
 15% tachyarrhythmias
 9% bradyarrhythmia
Tachyarrhythmias
Tachyarrhythmia
 Differential





Diagnosis
Premature Atrial Contractions
Supraventricular Tachycardia
Atrial Flutter
Sinus Tachycardia
Ventricular Tachycardia
Tachyarrhythmia
 Making
 Brief
the diagnosis
review…
Tachyarrhythmia
 Making

the diagnosis
M-mode
 Align
cursor through one atria and ventricle
 Visualizes relationship
 Distinguishes type of arrhythmias
Tachyarrhythmia
 Making

the diagnosis
Pulse wave doppler
 Cursor
placed between mitral and aortic
valve
 Flow disturbances (regurgitation)
Pulse wave doppler
Premature Atrial Contractions
 Most
common fetal arrhythmia
 18-24 wga
 Dx: Doppler inflow/outflow or left ventricle
or M-mode
 Aggrevating factors
 Spontaneous resolution
 1% progression to SVT
Premature Atrial Contractions
Premature Atrial Contractions
Premature Atrial Contractions
 Management





in pregnancy
No treatment needed
Evaluation with fetal echocardiogram
Doppler auscultation q1-4 weeks
F/u US
Resume routine care after 2-3 weeks
Supraventricular Tachycardia
 SVT
 Most
common sustained tachycardia
 FHR 240-280 bpm
 Accessory pathway vs autonomic
 Typically structurally normal

Congenital heart disease up to 5-10%
 Dx:
2D, Doppler, M-mode
 1:1 conduction
Supraventricular Tachycardia
Supraventricular Tachycardia
 Management




of Pregnancy
Controversial
D/C precipitating factors
Continuously monitor 8-24 hours
Treat if…
 Structurally
abnormal heart
 >33% present
 Hydrops


Controversial: delivery after 32-34wga
Consider vaginal delivery
Supraventricular Tachycardia
 Management

Digoxin
 Load




with 0.5mg IV q6-8h until:
<25% tachycardia or decreased hydrops
Therapeutic
Toxicity
 PO

of Pregnancy
administration BID-QID
Digoxin level, BMP, EKG, cardiologist consult
Second-line agents
Atrial Flutter
 Sustained
tachycardia
 FHR:


Atrial 300-500 bpm
Ventricular <100-300 bpm
 Often
2:1 or 3:1 conduction
 Structurally normal

Structural heart disease up to 20%
Atrial Flutter
Atrial Flutter
 Management

Digoxin
Sotalol

Propranolol

in Pregnancy
Sinus Tachycardia
 FHR
180-200
 1:1 conduction
 Causes:




Maternal pyrexia
Stimulants
Maternal thyrotoxicosis
Fetal systemic disease
 Anemia,
distress, infections
Ventricular Tachycardia
 FHR:
180-300 bpm
 Not well tolerated
 Structural abnormalities, tumors, long QT
 NOT a 1:1 ratio
Ventricular Tachycardia
Ventricular Tachycardia
 Management



in pregnancy
NO DIGOXIN
Oral propranolol, mexiletine, sotalol,
amiodarone
Umbilical vein - lidocaine
Tachyarrhythmia
Outcomes
 50%
relapse after birth
 Medical therapy
 Neurological outcomes
 Recurrence risk
Bradyarrhythmias
Bradyarrhythmias
 Differential






diagnosis
Sinus bradycardia
Atrial bradycardia
Blocked atrial bigeminy
Atrial flutter with high-degree block
Complete heart block
Transient responses
Sinus Bradycardia
 1:1
conduction ratio
 Fetal distress
 Long QT syndrome
 Risk for ventricular tachycardia
Atrial Bradycardia
 Accessory
atrial pacemaker
 Absent sinus node
 Associated with polysplenia
Atrial bigeminy
 Atria
alternates sinus beats with PACs
 PACs during refractory period (AV node)
 Ventricular rate


Regular
½ atrial rate
 Avoid
caffeine, decongestants, tobacco
Atrial Flutter
 Atrial
rate: 300-500 BPM
 High degree AV block
 Results in fetal bradycardia
 Constant arrhythmia
 Treatment: digoxin vs sotalol
Complete Heart Block (CHB)
 Most
common
 FHR: 40-70 bpm
 Atrial rate normal
 No conduction, resulting in ventricular
rate
 May find 1st or 2nd degree block
 Incidence: 1/20,000 live births
Complete Heart Block (CHB)
Complete Heart Block (CHB)
 Causes

Maternal anti-Ro (SSA) or anti-La (SSB)
antibodies
 Associated
with SLE, Sjogren’s syndrome,
connective tissue disorders
 Antibodies damage fetal AV node
 Suspected cofactor
 20-24wga
Complete Heart Block (CHB)
 Causes

Structural heart disease
 L-looped
ventricles
 AV septal defect
 Associated with polysplenia
 Poor survival outcome
Complete Heart Block (CHB)
 Management







in pregnancy
Rheumatologic evaluation
CPS, Fetal echo
Doppler of umbilical artery (limited)
Serial growth US
Cardiothoracic ratio
NST not helpful
FHR < 60, up to twice weekly US
Complete Heart Block (CHB)
 Management





in pregnancy
Dexamethasone
Betamimetic agents
IVIG
Plasmapheresis
In utero heart pacing: experimental
Complete Heart Block (CHB)
 Delivery


Cesarean
Consider if hemodynamic compromise
 Nonimmune
hydrops
 Ventricular rate <55bpm
 AV valve insufficiency

Pediatric cardiologist and surgeon
available
Outcomes

Up to 25% develop nonimmune hydrops


CHB with structural abnormality – poor outcome




14% survival
Early delivery for pacemaker


<20% survival
CHB with <55bpm


15% survival
20% survival
Neonatal lupus erythematous in 90% of SSA and
SSB
90% survival after neonatal period
Plaquenil – consider in future pregnancies
References






Bianci et al. (2010). Tachyarrhythmias in Fetology: Diagnosis and
Management of the Fetal Patient. McGraw Hill Medical. 313-319.
Bianci et al. (2010). Bradyarrhythmias in Fetology: Diagnosis and
Management of the Fetal Patient. McGraw Hill Medical. 313-319.
320-327.
Creasy & Resnik (2009). Fetal Cardiac Malformations and
Arrhythmias in Maternal Fetal Medicine Principles and Practice, 6th
edition. Saunders Elsevier. 336-341.
Simpson (2006). Fetal arrhythmias. Ultrasound Obstet Gynecol.
27:599-606.
Srinivasan, Strasburger (2008). Overview of fetal arrhythmias.
Current Opinions in Pediatrics. 20(5):522-531.
Strasburger, Cheulkar, Wichman (2007). Perinatal Arrhythmias:
Diagnosis and Management. Clinical Perinatology. 34(4):627.
Questions?

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