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Treatment of arrhythmias during
pregnancy.
Jan P. Amlie
Prevalens og incidens is not adequately
characterized during pregnancy.
Clinical Cardiol 2008 31 538-41
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ARRHYTHMIAS DURING
PREGNANCY
Evidence based medicine is almost
lacking
Pathophysiology:
Increased cathecholamines
Increased wall motion stress in the
atria and ventricles
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Arrhythmias during pregnancy
Sinus tachycardia is common.Commonly no treatment.
Sinus bradycardia is seldom
Other types of sinus arrhythmias.
These three arrhythmias caused hospitalization in 104
individuals in relation to 100 000 pregnancies
Corresponds to approximately10 per year in Oslo..
Department of Cardiology University of Minnesota.
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Supraventricular tachycardias
24/100 000 pregnancies.
2 per year in Oslo ?
Most common in the last trimester.
Spontaneous termination or after standard
medication.
Try vagus stimulation
Adenosine can be used
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Atrial tachycardia. Long RP tachycardia.
After surgery in the left or right atrium.
Spontanously most common in the right atrium.
Treatment: Flecainide evt Sotalol..
CARTO procedure (mapping) and ablation. Causal
treatment before pregnancy
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Supraventricular tachycardia
Nodal reentry tachycardia = Short RP tachycardia.
Verapamil i.v or orally
Adenosine i.v: Tell the patient that it hurts. Asystole
for a short periode of time
RF ablation of the slow conducting part of the AV
node
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AV
A
B
Rapid conduction B
Slow conduction A
ABLATION OF NODAL REENTRYTACHYCARDIA IN THE SLOW CONDUCTING
AREA
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ABLATION IN WPW SYNDROME
Is WPW syndrome present should ablation be
performed before pregnancy
WPW syndrome means preexcitation and
arrhythmias
Medium long RP tachycardia
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Atrial fibrillation
Seldom except in GUCH. (One per year in Oslo?)
Electroconversion can be performed.
Sotalol kan be used to inhibit recurrence
If atrial fibrillation occurs expect for 4-5 hours.
The starting time of atrial fibrillation can be very
difficult to decide from the medical history.
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Rate control in atrial fibrillation.
Cardiac failure and atrial fibrillation: digitoxin.
High resting heart rate: digitoxin.
High exercise heart rate: b-blockade.
Walking heart rate 120 if possible.
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ATRIAL FLUTTER
A
B
Reentry
circle in the
right atrium.
Reentry
circle in the
left atrium
Ablation of
Define the
the isthmus.. circle by
CARTO
mapping..
RFablation.
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A
B
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Treatment of atrial flutter.
RF ablation before pregnancy.
Left atrial flutter is very difficult to ablate during
pregnancy.
Do not use flecainide to patients with atrial flutter
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BRADYARRHYTMIAS
Sinus arrest.
Sino-atrialt block.
AV block grade II Mobitz type II with or without wide
QRS complexes
AV block grade III.
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SYNKOPE MED SINUS ARREST
.
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Long QT time syndromes
Prevalens in the litterature is 1/10 000 og 1/5 000.
In Norway 1/300 ?
12 Known gens
Defect IKs. KCNQ1 (LQT1) 45% and KCNE 1 (LQT5) 2-3%.
Alfa og beta subunit of the potassium channel
Defect IKr. KCNH2 (LQT2) and KCNE2(LQT6) gens codes
for alfasubunit (HERG) and betasubunit (MiRP) of IKr
respectively.
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LONG QT TIME SYNDROMES.
Less risk during pregnancy However I have seen an
arrhythmic storm in a patient with Jervell Lange
Nielsen . More than 8 ICD discharges.
Increased risk the first 6- 9 months after delivery.
Especially high risk the first two days after delivery.
.
J.Am Coll Cardiol 49 1092-8 2007
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LQT I and II
PROGNOSES
LQT 1 has better prognoses. Ventricular
tachycardia during exercise. Often well treated with
b-blockade.
LQT2 (HERG) are more prone to severe
arrhythmias in women with QTc more than 500 ms.
Less effect of b-blockade. Reacts on auditive
stimuli.
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VES and
Ventricular Tachycardias
VES Monofocale with left bundle branch block look
and inferior axis. Right ventricular outflow tract
VES.
Normal EKG og normal Ecco.
24 hours EKG should be performed to detect VTs..
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A
Inferior axis
B
Superior axis
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A
Inferior axis
B
Superior axis
Right Ventricular Outflow Tract VT
VT med left ventricular bundle branch look and
inferior axis
Sotalol, eventually propranolol or
metoprolol
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VES MED ANNEN KONFIGURASJON
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VES WITH OTHER CONFIGURATION.
Multifocale. Heart disease?.
Left bundle branch block look and superior axis.
From the right ventricle. EKG: neg T V1-V3.
Epsilonwave? Late potensials ? Right ventricular
dysplasia?
Right bundle branch look. Exit septum or left
ventricle.
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A
Inferiør akse
B
Superiør akse
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A
Inferiør akse
B
Superiør akse
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Personal Experience
SVT in fetus. Treat the mother with high doses of
digoxin. Flecainide also used..
Patient with GUCH and cardiac insufficiency (EF
20%) og ICD. Delivered a healthy child with sectio.
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Universitetssykehuset Rikshospitalet HF eies av Helse Sør-Øst RHF
og består av Rikshospitalet, Radiumhospitalet, Epilepsisenteret-SSE
og Spesialsykehuset for rehabilitering.
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