Management of Arrhythmias During Pregnancy – Key Points
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 and linked to pre-existing heart disease.
5. Atrial Fibrillation (AF) Management
• Unstable AF: Cardioversion first line; safe in pregnancy
• Stable AF: First-line therapy = beta-blockers
• In acute, stable Bp -AF during pregnancy, IV beta-blockers are the first-line option for rapid rate control. (with attention to fetal effects).
• Second-line: calcium-channel blockers or digoxin.
• Third-line: ibutilide or flecainide.
• Catheter ablation or amiodarone = last resort (Class IIb).
• Anticoagulation guided by CHA₂DS₂-VASc; DOACs not recommended in pregnancy.
Anticoagulation in Pregnancy:
• Anticoagulation guided by CHA₂DS₂-VASc
• DOACs not recommended in pregnancy
• Low-Molecular-Weight Heparin (LMWH), first-line and safest option in pregnancy.
• Unfractionated Heparin (UFH)
• Used when rapid reversal is needed (near delivery or procedures).
• Warfarin is avoided.
May be allowed (not preferred) in mechanical valve cases at ≤5 mg/day, and only in 2nd/3rd trimester.
• Switch to heparin near delivery.
(36–37 weeks):
6. VT/VF defibrillation: sternal-apical (left-sided).
• The sternal pad is typically placed on the right upper chest next to the sternum.
• However, it can also be placed on the left side of the sternum if anatomy, access, or pregnancy positioning makes it safer or easier -as long as it remains “upper chest”, parasternal, and not near the breast or abdomen.
• The apical pad goes on the left lateral chest below the nipple/axilla.
• This positioning creates a diagonal shock pathway across both ventricles.
• AF/SVT cardioversion: anterior–posterior.
• One pad on the front of the chest directly over the heart (anterior).
• The second pad on the back between the shoulder blades (posterior).
• This delivers a front-to-back shock targeting the atria.
• Avoid pads near the abdomen or breast tissue to ensure the electrical current travels through the heart, not surrounding structures.
7. Invasive Procedures
• Can be performed with low or zero fluoroscopy using 3D mapping.
• Lead apron over abdomen not recommended (increases scatter dose).
• Should be performed only in specialized centers.
8. Lactation Considerations (Postpartum)
• Use with caution: digoxin, propranolol, metoprolol, verapamil.
• Generally acceptable: carvedilol, esmolol, procainamide, diltiazem, flecainide, sotalol.
• Avoid if possible: amiodarone.
• DOACs not recommended during breastfeeding.
9. Genetic Arrhythmias (LQTS, Brugada, CPVT=Catecholaminergic Polymorphic Ventricular Tachycardia)
• Continue beta-blockers (caution with nadolol in breastfeeding).
• Brugada: avoid fever, avoid QT-prolonging drugs.
• CPVT: beta-blockers ± flecainide; avoid epinephrine; minimize ICD shocks.
• All require EP specialist involvement.
10. Fetal Arrhythmias
• Managed in collaboration with pediatric electrophysiology.
• Maternal systemic antiarrhythmics usually adequate; direct fetal administration rarely needed.
• Fetal echo and rhythm monitoring recommended.
• Ablation/procedures can be safe with radiation minimization techniques.
11. Syncope in Pregnancy
• Occurs in ~1% of pregnancies; first-trimester syncope linked to worse outcomes.
• Workup: history, exam, ECG, orthostatics, echo, monitoring.
• Loop recorder if recurrent.
• Vasovagal syncope with normal workup requires no further testing.
• Third trimester syncope often due to IVC compression, dehydration, autonomic shifts.
12. Core Principle
• Shared decision-making is central: mother + fetus + multidisciplinary team (OB, EP, anesthesia, neonatology, pediatrics).
https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Cardiovascular-Disease-in-Pregnancy
