Management of rrhythmias During Pregnancy Management of Arrhythmias During Pregnancy – Key Points
Management of rrhythmias During Pregnancy
Management of Arrhythmias During Pregnancy – Key Points
Source: 2025 ESC Guidelines on CVD in pregnancy, supported by the November 2025 analysis on arrhythmias in pregnancy (J Multidiscip Healthc).
Keynotes:
1. Importance of the Consensus
• Provides the first unified, multidisciplinary approach (EP, OB, neonatology, genetics). • Summarizes limited evidence into clear, graded recommendations.
• Acts as a practical one-stop reference for managing maternal and fetal arrhythmias.
2. Most Common Presentation
• Palpitations are the most common cardiac symptom in pregnancy. • Only ~10% show a true arrhythmia on ECG/monitoring.
• Most detected rhythms are benign (sinus tachycardia, PACs).
3. Initial Diagnostic Workup
• Detailed history and physical exam.
• Resting 12-lead ECG.
• Targeted labs (thyroid, anemia, electrolytes).
• Holter/event monitor if symptoms are concerning.
4. Arrhythmias Requiring Intervention
• Most frequent: Supraventricular tachycardia (SVT).
• Ventricular tachycardia/fibrillation and high-grade AV block are rare.
5. Atrial Fibrillation (AF) Management
• Unstable AF: Cardioversion first line; safe in pregnancy.
• Stable AF: First-line = beta-blockers (IV for rapid control if needed).
Second-line: calcium-channel blockers or digoxin.
• Third-line: ibutilide or flecainide.
• Ablation/amiodarone = last resort (Class IIb).
• Anticoagulation guided by CHA2DS2-VASc; DOACs not recommended.
Anticoagulation in Pregnancy:
• LMWH = first-line.
• UFH when rapid reversal needed.
• Warfarin avoided; may be allowed only in specific mechanical valve cases (≤5 mg/day) in 2nd/3rd trimester.
• Switch to heparin near delivery (36–37 weeks).
6. Electrode Pad Placement
• VT/VF: sternal–apical (left-sided).
• AF/SVT: anterior–posterior.
• Avoid pads near abdomen/breast tissue.
7. Invasive Procedures
• Low/zero fluoroscopy with 3D mapping.
• Lead apron over abdomen not recommended. • Only in specialized centers.
8. Lactation Considerations
• Use caution: digoxin, propranolol, metoprolol, verapamil.
• Acceptable: carvedilol, esmolol, procainamide, diltiazem, flecainide, sotalol. • Avoid: amiodarone.
• DOACs not recommended in breastfeeding.
9. Genetic Arrhythmias (LQTS, Brugada, CPVT)
• Continue beta-blockers (caution with nadolol).
• Brugada: avoid fever/QT-prolonging drugs.
• CPVT: beta-blockers ± flecainide; avoid epinephrine; minimize ICD shocks.
10. Fetal Arrhythmias
• Managed with pediatric electrophysiology.
• Maternal systemic therapy usually adequate. • Fetal echo and monitoring recommended.
11. Syncope in Pregnancy
• Occurs in ~1%.
• Workup: exam, ECG, orthostatics, echo, monitoring.
• Loop recorder if recurrent.
• Vasovagal with normal workup needs no further testing.
12. Core Principle
• Shared decision-making (OB, EP, anesthesia, neonatology, pediatrics).