Management of arrhythmias during pregnancy

Abstract

Pregnancy is a complex physiological state marked by various hormonal, cardiovascular, and hemodynamic changes, which can make pregnant women more susceptible to arrhythmias (1). Physiological changes in the cardiovascular system occur during pregnancy: heart rate increases by 10-25% and cardiac output by 45-50%. Also, pregnancy is associated with increased sympathetic and decreased parasympathetic activity. This, together with hormonal changes, can lead to a change in the structure and function of the myocardium and have a proarrhythmic effect (1-4). In addition, maternal age, prevalence of cardiovascular risk factors, e.g. obesity, and comorbidity, including congenital heart diseases, are increasing (6). The presence of arrhythmias during pregnancy varies across different populations, and more prevalent in the setting of structural heart disease (SHD). While most arrhythmias observed in pregnant patients are generally benign, such as sinus arrhythmia (60%), supraventricular tachycardia (SVT, 14%), and premature beats (19%), life-threatening arrhythmias like significant SVT or ventricular tachycardia (VT) are far less common (6). Vaidya et al. found a significant increase in hospitalizations due to atrial fibrillation (AF) by 111% and VT by 127% over 12 years (2). Of particular concern, AF is emerging as the most commonly diagnosed sustained arrhythmia during pregnancy (2). The presence of arrhythmias during pregnancy has significant implications for both the mother and the developing fetus. Maternal outcomes can involve palpitations, chest pain, syncope, heart failure, and an increased risk of thromboembolic events, preterm labor, and delivery. Poorly controlled arrhythmias may result in reduced blood flow to the placenta, potentially leading to fetal distress, growth restriction, or even fetal demise. Additionally, certain antiarrhythmic medications may pose risks to the developing fetus, necessitating careful consideration of maternal treatment choices to ensure fetal safety. Diagnosing arrhythmias during pregnancy presents challenges due to overlapping symptoms with normal pregnancy-related physiological changes. Noninvasive techniques like electrocardiography, echocardiography, and ambulatory monitoring play a vital role in diagnosing arrhythmias and evaluating their severity. The treatment options must carefully weigh the potential risks and benefits for both the mother and the fetus, depending on the presence of underlying structural heart disease, type and severity of the arrhythmia, and the stage of the pregnancy. Interventions may include adenosine, beta-blockers, and specific arrhythmic drugs with safety data during pregnancy, rarely, catheter ablation with minimal/ zero fluoroscopy can be used (3, 4). According to a survey, a significant number of cardiology professionals expressed discomfort when it comes to providing care for this patient population (5). In this editorial, we would like to give a brief understanding of 2023 HRS Consensus Statement on the Management of Arrhythmias during Pregnancy (6).