Isoproterenol and Lidocaine for Recurrent Torsades de Pointes in a 32-year-old Pregnant Woman

Guidelines recommend magnesium and defibrillation for Torsades de Pointes (TdP) treatment in pregnancy, both of which were unsuccessful at terminating our patient’s recurrent ventricular arrhythmias. Both lidocaine and isoproterenol carry potential risks to mother and fetus, but the risk of congenital abnormalities is significantly lower compared to other antiarrhythmics such as amiodarone. A 15-week pregnant 32-year-old female was admitted to an outside hospital for alcohol withdrawal and developed multiple episodes of ventricular tachycardia (VT) and TdP resulting in her prompt transfer to our hospital for escalation of care. On arrival she was awake, alert, and hemodynamically stable but quickly began experiencing recurrent episodes of TdP that developed into pulseless VT despite defibrillation, magnesium and calcium administration, and chest compressions. We initiated lidocaine and isoproterenol infusions, after which the patient stabilized. Isoproterenol and lidocaine were successfully discontinued after 2 days of treatment and the patient was discharged after 4 days of hospitalization with fetal heart sounds intact. While there are guideline recommendations for the management of TdP and ventricular arrhythmias, primary literature is lacking. This unique case demonstrates efficacy of isoproterenol pacing combined with the antiarrhythmic lidocaine for terminating a refractory and life-threatening ventricular arrhythmia.