Prof.Dr. Sherif Eldegwi Solutions R&M www.rmsolutions.net

Arrhythmias in Pregnancy
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Prof.Dr. Sherif Eldegwi
Arrhythmia during pregnancy: introduction
• The most common cardiac complication in pregnant in
women with and without SHD
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Pregnant women with surgically
treated
RHDs
and CHDs
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are increasing in number
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Arrhythmias may manifest
for the first time during
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pregnancy or can be triggered in women with preexisting
arrhythmias or SHD who are at highest risk
Siu et al Circ 2001
Prevalence of arrhythmias during pregnancy in women with
congenital heart disease
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Data from: Drenthen, W, Pieper, PG, Roos-Hesselink, JW, et al. Outcome of pregnancy in
women with congenital heart disease: a literature review. J Am Coll Cardiol 2007; 49:2303.
Gender differences in arrhythmias
Women have:
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Higher intrinsic HR and shorter SNRT
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Longer QTc and more frequent
long QTc
syndrome
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higher incidence of drug
induced
TdP
but fewer SCD
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AVRT shows 2 : 1 female
.rmpredominance
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Sex hormones and hemodynamic adaption certainly play a
role
Wolbretteet al, ClinCard 2002
ECG changes in pregnancy ?
• Resting HR 10 b.p.m. this resulting in PR,
QRS and QT intervals, NO change in P wave,
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QRS complex and T wave tamplitude
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• Shift in the electrical
axis,
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commonly leftward
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heart due to thewenlargement of the gravid
uterus
• Common APCs and VPCs
Hemodynamic changes in normal pregnancy
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Normal pregnancy is characterized by an increase in cardiac output,
a reduction in systemic vascular resistance, and a
modest decline in mean blood pressure.
These changes are associated with a 10 to 15 beat/min increase in heart rate.
• Pregnancy alters the hormonal state:
↑estrogen
↑β-human chorionic gonadotropin
may have an effect on the genetic expression of cardiac ion channels
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Hemodynamic changes: Sol
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M theucardiac
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↑in the circulating volume that&doubles
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Rand an increase
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results in myocardial stretch
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Pregnancy increases
high plasma catecholamine and adrenergic receptor sensitivity
All of these changes can create arrhythmogenesis
Palpitations
• Most frequent reason for referral
• A source of significant anxiety
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• One study examined Holter data
of
104 pregnant women
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with palpitations:
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76% had no associated
arrhythmias
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24% arrhythmiaswwere found, but most were benign
Most cases, were attributed to sinus tachycardia
Ostrezegaet al, JACC 1992
Palpitations
Non-invasive work-up
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• Caution is advised with exercise
stress
testing, because of
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foetal bradycardia at maximal
exercise
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&Mfoetal
a low-level protocolRwith
monitoring
is advised
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When benign arrhythmias
.r are found, patients need:
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reassurance
should avoid stimulants, such as caffeine, smoking and
alcohol
Arrhythmia management during pregnancy
• Fortunately, most arrhythmias in this population are
and therapy mainly takes the form of reassurance
benign
• However, there are some Pts need drugs administration and
in few pregnant patients invasive procedures are
necessitated
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• The effects of drug administration
M utioand radiation exposure
&
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can lead to severe problems
for
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first half of pregnancy:
and
mental retardation
second half of pregnancy: increases the risk of childhood
malignancies
Supraventricular tachycardia
Conflicting data regarding SVT incidence during pregnancy:
Tawanet al, Am J Card 1993reported:
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a 34% increase in the risk of new
onset
SVT
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a 29% exacerbation of SVTSoduring
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On the other hand, Lee etwal,
.rmAm J Card 1995 found:
wwof SVT
a much lower prevalence
Pregnant AP Pt Show more pro-arrhythmic response than
AVNRT Pt
SVT Management during Pregnancy
• Vagal maneuvers should be tried first If tachycardia
persists, IV adenosine is the drug of choice
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• Safety of adenosine use :
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During the first trimester insufficient
data
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The second and third trimesters
M istsafe
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Foetal heart monitor
during
administration of the
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drug to detect possible
Management of SVT : Cont.
• If adenosine fails, IV propranolol or metoprolol may
be tried Verapamil should be avoided owing to possible
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prolonged hypotension
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M oruiftiohemodynamically
If not chemically converted,
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unstable, cardioversion
should be performed
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• Chronic medical therapy should be withheld unless
episodes of tachycardia become frequent, severe and
hemodynamically significan
Management of SVT : Cont.
• Women with known SVT should be advised to undergo a
curative catheter ablation prior to pregnancy due to :
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SVT episodes can become moreofrequent
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all drugs should be avoided
during
this
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If ablation is absolutely.rm
necessitated during pregnancy it
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should be performed
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shield over the abdomen and use of pulsed fluoroscopy
could help reduce radiation risk for the foetus
Prophylactic Drug treatment for SVT
The ACC/AHA/ESC Guidelines recommend:
First-line drugs digoxin or β-blocker
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Digoxin is relatively safe with careful
monitoring
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Propranolol or metoprolol
can
but Not during the first
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trimester
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Atenolol should not bewused (class D)
If these drugs fail, sotalol (class B), or flecainide if the patient
has no SHD
Blomstrom-Lundqvistet al, EurHeart J 2003
Atrial Fibrillation and Atrial Flutter
• Rarely seen during pregnancy
• Commonly occurs in pts with CHD , RHD and
hyperthyroidism
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Management
of
AF/Flutter
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Ventricular rate control
agents or digoxin
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Electrical cardioversion should
be considered within 48 h of
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onset of AF to avoidwthe
Coumadin is teratogenic and contraindicated during the first trimester
of pregnancy
Heparin is not absorbed by the placenta and is considered the drug of
choice
Ventricular Tachycardia and Pregnancy
• The commonest VT during pregnancy might be catecholaminesensitive or benign
RVOT tachycardia
• Rare cases of life-threatening VT associated with
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Peripartum cardiomyopathy
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HCM
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RHD
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CHD
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Right ventricular dysplasia
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MVP
SHD
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• Long QT syndrome
The general approach is to determine if the woman has SHD or long QT
syndrome, by doing an ECG & echo
Brodsky et al, Am Heart J 1992
Management of VT
• A morphology that is monomorphic, LBBB, and inferior axis would
be consistent with the diagnosis of RVOT tachycardia
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β-blocker is the drug of choice
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The finding of SHD would put the mother
at increased
risk of SCD
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Antiarrhythmic drug therapy andM
possibly an iICD
might be required
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Electrical cardioversion for.unstable
and lidocaine for more
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stable tachycardia
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Long QT Syndrome
A difficult management problem in the past
•Retrospective data revealed that there is a significant increase in the risk for cardiac events in
the postpartum period(the 40-week period post delivery), but not during pregnancy
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This delay might be related
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increased stress
of caring for an infant
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•During pregnancy, HR increases and might have a protective effect
•β-blocker therapy should be continued throughout pregnancy and postpartum
Rashbaet al, Circulation
1998
Implantable devices
• The presence of an ICD should not deter a woman from considering pregnancy, unless
her underlying SHD is a contraindication
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If a woman with an ICD delivers vaginally, theudevice’s
shockttherapy should be left
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activated
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The shock therapy should beRturned offso
during
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inappropriate shock secondary to electrocautery
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If it becomes necessary to implant an ICD or PM, the smallest sized generator should be
placed subpectorally
• leads with echo guidance or with a radiation shield
P.E. Vardas , 2004
Antiarrhythmic drug risk
The FDA has developed a drug classification
system to rate the level of foetal risk
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Antiarrhythmic drug risk
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None is category A
Prophylactic Drug treatment for VT
The ACC/AHA/ESC Guidelines recommend
• Sotalol should be considered if β-blocker therapy is not
adequate
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No data to the use of dofetilide
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Amiodarone is a risk class
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drug with known teratogenic
risk only when there are no other
therapy options
Blomstrom-Lundqvistet al, EurHeart J 2003
If drug therapy cannot be avoided…
• Frequent monitoring of the patient’s ECG and drug levels to reduce the risk of
toxicity
• plasma concentration can be altered due to:
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• increased renal
blood
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• increases in hepatic
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• changes&
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gastrointestinal
absorption
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Teratogenic risk is greatest in thew
first
8 weeks of gestation
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• begin AADs as late in
• use the
pregnancy as possible
lowest effective drug dose
• A low dose drug combination may be preferable to a higher dose of a single drug,
because side effects can be dose-related
The risk/benefit ratio
Must be considered in the decision regarding AAD
therapy:
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Benign arrhythmias, even when
symptomatic,
should not be
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treated
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Treatment should not be .denied
in malignant arrhythmias
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When possible, invasive procedures involving fluoroscopy
should be
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avoided until after delivery
Patients with Known arrhythmias should be urged to
undergo curative catheter ablation prior to pregnancy
Conclusions 1
• During pregnancy, significant changes occur in the hormonal
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and hemodynamic state of women
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Palpitations are frequently.rreported,
but are usually found to be
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associated with sinusw
tachycardia
more likely to occur
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• The incidence of paroxysmal SVT is increased during pregnancy,
whereas AF and VT
rare
Conclusions 2
• Women with long QT syndrome experience
significantly more cardiac events in the
postpartum period, making β-blocker
therapy
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most important during this
olutime et
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R&arrhythmias
Acute treatment of
for pregnant
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women is much the same
as that for non-pregnant
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patients
• Chronic drug therapy during pregnancy should be
reserved only for the frequent, hemodynamically
significant arrhythmias
Fetal arrhythmias are
defined by deviations
from normal (110150 BPM)
parameters. They are
typically detected
when auscultating
the fetal heart, while
monitoring the fetal
heart rate (FHR) with
external or internal
devices, or during an
antenatal ultrasound
examination
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Two-dimensional
ultrasound is used to
diagnose the specific
arrhythmia, evaluate
cardiac anatomy, evaluate
cardiac function, and look
for signs of hydrops fetalis.
The cardiac anatomy should
be carefully reviewed, as
arrhythmias can be
associated with congenital
heart disease. This risk is
about 10 percent in
patients with tachycardia
and about 50 percent in
patients with bradycardia
Management of fetal arrhythmias
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After Sumitera etal 2012
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