Management of Arrhythmias During Pregnancy
Publication Date: May 19, 2023
Last Updated: December 12, 2024
Overarching Principles
General Electrophysiological Management
1. In pregnant patients with cardiac arrhythmias, treatment should be maintained during the pregnancy, delivery, and postpartum periods, preferably using drugs with the longest record of safe use and efficacy in pregnancy, at the lowest effective dose possible, and with periodic reevaluation for continued need for medications. (1, C-EO)
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2. In pregnant patients with cardiac arrhythmias, the use and management of antiarrhythmic drugs should be informed by precautions provided by regulatory drug agencies, awareness of potential drug interactions, and knowledge of potential risk to the fetus.
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Team-based Care and Shared Decision-making
1. For the ongoing management and treatment of pregnant patients with cardiac arrhythmias, a cardio-obstetrics team that includes a maternal-fetal medicine subspecialist, a cardiologist and/or electrophysiologist, a pediatric electrophysiologist when fetal arrhythmias are present, an anesthesiologist, and a neonatologist, should be engaged in open communication regarding optimal management strategies, including a birth plan.
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2. In pregnancies complicated by documented or potential cardiac arrhythmias, shared decision-making that includes discussion of the risks and benefits to both the mother and the fetus of antiarrhythmic drug therapy, specific procedures, and monitoring, as well as the risks of withholding such therapies, is recommended. (1, C-EO)
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3. In pregnant patients with complex cardiac arrhythmias, engagement with anesthesiologists and obstetricians to optimize care, including preparations to perform an emergency cesarean delivery if necessary, is recommended when performing invasive electrophysiology procedures. (1, C-EO)
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4. In pregnant patients with complex cardiac arrhythmias, consultation with a cardiac electrophysiologist, if available locally, or a cardiologist with expertise in arrhythmias is recommended (preferably with experience with pregnant patients); management at centers with expertise in women with cardiovascular disease is preferable.
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Genetic Testing
1. In pregnancies complicated by a documented or suspected family history of inherited arrhythmia syndromes (IAS) or arrhythmogenic cardiomyopathy (ACM), clinical cardiac evaluation and genetic counseling with consideration of genetic testing is recommended, ideally provided by an experienced cardiac genetics team.
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Procedural Considerations for Arrhythmia Management During Pregnancy
Cardioversion During Pregnancy
1. In pregnant patients with unstable SVT or VT, direct current synchronized cardioversion or defibrillation is recommended with energy dosing as in the nonpregnant patient.
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2. In pregnant patients with stable, symptomatic SVT or VT refractory or with contraindications to pharmacological therapy, elective synchronized cardioversion is recommended with fetal evaluation as indicated by the cardio-obstetrics team.
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3. In pregnant patients undergoing synchronized cardioversion or defibrillation, electrodes should be placed avoiding breast tissues to optimize current delivery to the heart. (1, C-LD)
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Radiation Exposure During Cardiac Procedures and Hemodynamic Concerns Related to Pregnancy
1. In pregnant patients with hemodynamically significant sustained cardiac arrhythmias refractory or with contraindications to pharmacological therapy who are candidates for catheter ablation, the benefit of controlling maternal tachycardia should be prioritized over the potential radiation risks to the fetus, especially if the procedure is done after the first trimester and radiation exposure is minimized to as low as reasonably achievable.
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2. In pregnant patients undergoing catheter ablation, the use of techniques and technology to minimize radiation exposure to as low as reasonably achievable during the procedure is recommended. (1, C-LD)
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3. In pregnant patients undergoing high-risk catheter ablation procedures, care by a cardio-obstetrics team prepared to manage potential complications, including urgent delivery if the fetus is close to term, is recommended.
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4. In pregnant patients undergoing cardiac procedures requiring fluoroscopy, placing a pelvic lead apron over the patient is not beneficial because it does not substantially reduce radiation exposure to the fetus. (3 - No Benefit, C-LD)
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Anesthesia Considerations
1. In pregnant patients with arrhythmias associated with hemodynamic instability requiring cardiac interventions, general anesthesia is recommended in preference to regional anesthesia for the sake of a secure airway and improved oxygenation during hemodynamic instability. (1, C-LD)
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2. In pregnant patients undergoing cardiac procedures to manage maternal arrhythmias later in gestation (beyond 26 weeks), left lateral tilt positioning is recommended as feasible to minimize aortocaval compression and optimize maternal hemodynamics around and during the time of the procedure.
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3. In pregnant patients undergoing cardiac procedures to manage maternal arrhythmias, medications used for anesthesia should be reviewed and modified, when possible, to prevent exacerbation of underlying maternal arrhythmogenic conditions. (1, C-LD)
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4. In pregnant patients with arrhythmias associated with hemodynamic instability requiring operative and/ or nonoperative cardiac interventions, intraprocedural monitoring of the viable fetus is recommended, in consultation with the cardio-obstetrics team, to manage potential complications including urgent delivery.
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Delivery and Lactation
1. In pregnant patients with cardiac arrhythmias, the route of delivery (vaginal or cesarean) should be determined by the birth plan and obstetrical factors in accordance with best clinical practice, along with continuation of antiarrhythmic drug therapy.
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2. Pregnant patients receiving antiarrhythmic drug therapy or at risk of cardiac arrhythmias should receive adequate pain control during labor, ideally with the use of neuraxial anesthesia (epidural), to avoid pain-induced catecholamine surges that may trigger preexisting arrhythmias. (1, C-LD)
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3. In breastfeeding patients, antiarrhythmic drug therapy should be used when clinically indicated, with a preference for agents with the best safety profile during lactation.
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4. In breastfeeding patients with life-threatening cardiac arrhythmias refractory or with contraindications to other treatment, the decision to treat with amiodarone should balance the severity of the arrhythmia against the potential risk for long-term toxicity with consideration of the risks and benefits of breast milk compared with alternatives such as infant formula or donated breast milk. (1, C-LD)
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Diagnosis of Pregnant Patients With Palpitations
1. Pregnant patients presenting with modest sinus tachycardia or extra systoles, with an otherwise normal initial evaluation and without suspicion of underlying cardiopulmonary disease, should be reassured without additional testing. (1, B-NR)
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2. Pregnant patients with suspected arrhythmic etiology of unexplained palpitations who have concerning symptoms or suspected electrical or SHD on initial evaluation should undergo ambulatory monitoring as clinically indicated, in consultation with a cardiologist or electrophysiologist with expertise in cardiovascular diseases in pregnancy. (1, B-NR)
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3. In pregnant patients presenting with palpitations, a detailed history, physical examination, resting 12-lead ECG, and targeted blood testing should be performed at initial evaluation. (1, C-EO)
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4. In pregnant patients with suspected arrhythmic etiology of palpitations unexplained after noninvasive cardiac evaluation, especially in the presence of syncope and/or electrical or SHD, consideration of an implantable cardiac monitor (ICM) is reasonable. (2a, C-LD)
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5. In pregnant patients with palpitations in the absence of a documented arrhythmia or other clinical evidence of potential arrhythmogenic substrate, electrophysiological study (EPS) solely as a first-line diagnostic test should not be performed. (3 - No Benefit, C-EO)
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Diagnosis and Management of Pregnant Patients With Syncope
Diagnosis and Approach to the Pregnant Patient With Syncope
1. In pregnant patients presenting with syncope, a detailed history, physical examination (including orthostatic vitals), resting 12-lead ECG, and targeted blood testing should be performed at initial evaluation. (1, B-NR)
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2. Pregnant patients with new onset of unexplained syncope, especially if it occurs in the first trimester or recurs during pregnancy, are at higher risk of adverse pregnancy outcomes and should receive enhanced evaluation, including echocardiogram, followed by close periodic monitoring. (1, B-NR)
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3. Pregnant patients with syncope suspected to be of cardiac origin, and/or due to suspected cardiovascular abnormalities after initial evaluation, should undergo additional cardiac testing, including imaging, as clinically indicated in consultation with a cardiologist or electrophysiologist with expertise in cardiovascular diseases in pregnancy. (1, B-NR)
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4. In pregnant patients with recurrent syncope unexplained after comprehensive noninvasive evaluation, including external monitor, insertion of an ICM is recommended. (1, C-LD)
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5. In pregnant patients presenting with clinical characteristics typical for reflex-mediated vasovagal syncope, a normal physical examination, and a normal resting 12-lead ECG at initial evaluation, further testing is not beneficial. (3 - No Benefit, B-NR)
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6. In pregnant patients with unexplained syncope but without evidence of cardiac disease or conduction system disease, diagnostic electrophysiological study is not indicated. (3 - No Benefit, C-LD)
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Management of Syncope and Orthostatic Hypotension in the Pregnant Patient
1. In pregnant patients with syncope, therapy should be provided as indicated in the nonpregnant patient. (1, B-NR)
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2. In pregnant patients with syncope presumed to be due to supine hypotensive syndrome, left lateral decubitus position and adequate hydration are recommended. (1, B-NR)
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Management of Specific Arrhythmias During Pregnancy
Management of Atrial Ectopy and SVT During Pregnancy
Management of Acute SVT During Pregnancy
1. In pregnant patients with acute onset of SVT, vagal maneuvers are recommended as a first-line therapy for tachycardia termination. (1, C-LD)
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2. In hemodynamically stable pregnant patients with acute onset of SVT, intravenous adenosine is recommended as the first line pharmacological therapy. (1, C-LD)
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3. In hemodynamically unstable pregnant patients with acute onset of SVT, synchronized direct current cardioversion is recommended, with energy dosing as in the nonpregnant patient. (1, C-LD)
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4. In hemodynamically stable pregnant patients with acute onset of SVT refractory or with contraindications to adenosine, intravenous beta-blockers, such as metoprolol or propranolol, are reasonable for termination of acute SVT. (2a, C-LD)
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5. In hemodynamically stable pregnant patients with acute onset of SVT refractory or with contraindications to adenosine or beta-blockers, intravenous calcium channel blockers, such as verapamil or diltiazem, or intravenous procainamide may be considered. (2b, C-LD)
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Management of Nonacute Atrial Ectopy and SVT During Pregnancy
1. In pregnant patients with premature atrial contractions (PACs) and intolerable symptoms, treatment with beta blockers is recommended, preferably with metoprolol or propranolol. (1, B-NR)
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2. In pregnant patients with PACs who are either asymptomatic or have tolerable symptoms, reassurance is recommended with no need for intervention. (1, C-LD)
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3. In pregnant patients with symptomatic SVT in the absence of preexcitation, metoprolol, propranolol, and/or digoxin should be used as first-line options and verapamil as the second-line option for the chronic oral prophylaxis of SVT. (1, C-LD)
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4. In pregnant patients with Wolff-Parkinson-White syndrome and poorly tolerated or frequent episodes of SVT, therapy with oral flecainide or propafenone is recommended for the pharmacological management of SVT. (1, C-LD)
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5. In pregnant patients with tachycardia-induced cardiomyopathy, aggressive treatment of the tachycardia with beta-blockers as a first-line option and early consultation with an electrophysiologist for escalation of pharmacological therapy and/or ablation are recommended. (1, C-LD)
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6. In pregnant patients with symptomatic recurrent SVT refractory or with contraindications to digoxin, beta-blockers, or calcium channel blockers, alternative antiarrhythmic drugs, including flecainide, propafenone, or sotalol, are reasonable. (2a, C-LD)
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7. In pregnant patients with recurrent SVT refractory or with contraindications to pharmacological therapies, catheter ablation is reasonable with attention to and techniques for eliminating or minimizing radiation exposure to as low as reasonably achievable. (2a, C-LD)
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8. In pregnant patients with poorly tolerated SVT refractory or with contraindications to other pharmacological and interventional therapies, therapy with amiodarone may be considered. (2b, C-LD)
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Management of Atrial Fibrillation and Atrial Flutter in Pregnancy
1. In pregnant patients with acute-onset AF or AFL, with accompanying hemodynamic compromise or preexcitation, direct current cardioversion is recommended, with energy dosing as in the nonpregnant patient. (1, C-LD)
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2. In hemodynamically stable pregnant patients with AF or AFL with rapid ventricular rates (RVR), intravenous beta-blockers are recommended as the first-line option and digoxin or nondihydropyridine calcium channel blockers, alone or in combination, are recommended as second-line options for initial rate control in the absence of preexcitation. (1, C-LD)
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3. In pregnant patients with AF or AFL with persistent symptoms or RVR refractory or with contraindications to beta-blockers or calcium channel blockers, elective direct current cardioversion is recommended with anticoagulation as in nonpregnant patients. (1, C-LD)
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4. In pregnant patients with AF or AFL and additional risk factors that place them at high risk for thromboembolism, anticoagulation is recommended as in the nonpregnant patient. (1, C-LD)
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5. In pregnant patients with AF or AFL with persistent symptoms or RVR refractory or with contraindications to beta-blockers or calcium channel blockers, pharmacological cardioversion with ibutilide, or flecainide in the absence of SHD, is reasonable, with the choice of drug dependent on the underlying maternal cardiac substrate. (2a, C-LD)
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6. In pregnant patients with AF or AFL with RVR, beta blockers, digoxin, or nondihydropyridine calcium channel blockers alone or in combination, are reasonable for rate control with the choice of drug dependent on the underlying maternal cardiac substrate. (2a, C-LD)
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7. In pregnant patients with AF or AFL with continued symptoms or RVR despite rate control therapy, flecainide in the absence of SHD or sotalol in the absence of severe left ventricular (LV) dysfunction are reasonable for rhythm control, with the choice of drug dependent on the underlying maternal cardiac substrate. (2a, C-LD)
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8. In pregnant patients with hemodynamically unstable typical AFL in whom pharmacological therapy is ineffective or contraindicated, catheter ablation is reasonable with attention to and techniques for eliminating or minimizing radiation exposure to as low as reasonably achievable. (2a, C-LD)
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9. In pregnant patients with recurrent hemodynamically unstable AF or atypical AFL in whom pharmacological therapy is ineffective or contraindicated, catheter ablation may be considered with attention to and techniques for eliminating or minimizing radiation exposure to as low as reasonably achievable. (2b, C-LD)
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10. In pregnant patients with AF or AFL with continued severe symptoms or RVR, amiodarone may be considered when alternative pharmacological therapy and/or catheter ablation are ineffective or contraindicated. (2b, C-LD)
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Management of Ventricular Arrhythmias in the Pregnancy Not Associated With Inherited Arrhythmia Syndromes
1. In pregnant patients with sustained VT and hemodynamic compromise, direct current cardioversion is recommended, with energy dosing as in the nonpregnant patient. (1, C-LD)
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2. In pregnant patients with idiopathic VT and hemodynamic stability, intravenous beta-blocker or adenosine for outflow tract VT and intravenous verapamil for fascicular VT are recommended as first-line options. (1, C-LD)
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3. In pregnant patients with hemodynamically stable VT, when pharmacological therapy is deemed necessary, intravenous procainamide is recommended for acute therapy. (1, C-LD)
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4. In pregnant patients with sustained VT refractory or with contraindications to beta-blockers and/or other antiarrhythmic drugs, synchronized cardioversion is recommended, with energy dosing as in the nonpregnant patient. (1, C-LD)
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5. In pregnant patients who meet indications for implantable cardioverter defibrillator (ICD) placement due to sustained ventricular arrhythmias or due to high risk for sudden cardiac death (SCD), device implantation is recommended with attention to and techniques for eliminating or minimizing radiation exposure to as low as reasonably achievable. (1, C-LD)
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6. In pregnant patients with ICDs prior to pregnancy, it is recommended to continue routine ICD care according to the underlying cardiac substrate. (1, C-LD)
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7. In women who are considering pregnancy and would otherwise meet indications for ICD, pacemaker, or cardiac resynchronization therapy (CRT) device placement, these procedures should be performed prior to pregnancy and according to the underlying cardiac substrate. (1, C-LD)
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8. In pregnant patients with chronic or recurrent VT, beta blockers, alone or in combination with other antiarrhythmic drugs, are recommended for arrhythmia suppression due to their overall safety profile in pregnancy. (1, C-LD)
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9. In pregnant patients with recurrent VT refractory or with contraindications to beta-blockers who require additional antiarrhythmic drug therapy, treatment with flecainide, sotalol, or mexiletine is recommended with the choice of drug based on the underlying cardiac substrate. (1, C-LD)
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10. In pregnant patients with recurrent symptomatic or hemodynamically unstable VT in whom pharmacological therapy is either ineffective or contraindicated, catheter ablation is reasonable with an experienced operator and with attention to and techniques for eliminating or minimizing radiation exposure to as low as reasonably achievable. (2a, C-LD)
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11. In pregnant patients with recurrent VT associated with hemodynamic impairment or ICD shocks, amiodarone is reasonable for arrhythmia suppression if alternative therapies, including ablation, are contraindicated or ineffective. (2a, C-LD)
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12. In pregnant patients who meet indications for sudden death prevention due to high-risk features or VT that may be of a reversible etiology, such as peripartum cardiomyopathy, a wearable cardioverter defibrillator may be reasonable. (2b, C-LD)
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Management of Pregnant Patients With Bradycardia and/or Heart Block
1. In pregnant patients who present with advanced heart block or conduction system disease, evaluation with transthoracic echocardiogram is recommended with cardiac magnetic resonance imaging reserved for select cases when myocardial and/or infiltrative processes are suspected and if done in the postpartum period. (1, C-LD)
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2. In pregnant patients with irreversible symptomatic bradycardia due to third-degree or second-degree Mobitz type II heart block or severe sinus node dysfunction, with syncope or presyncope that may place the mother and/or the fetus at risk, permanent pacemaker placement is recommended, with attention to and techniques for eliminating or minimizing radiation exposure to as low as reasonably achievable. (1, C-LD)
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3. In pregnant patients with symptomatic bradycardia refractory or with contraindications to pharmacological therapy, temporary ventricular pacing is recommended for those at risk of hemodynamic instability and/or syncope in the peripartum period. (1, C-LD)
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4. In pregnant and postpartum patients with asymptomatic sinus bradycardia or Mobitz type I AV block without evidence of SHD, reassurance is recommended with no need for intervention. (1, C-LD)
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5. In pregnant patients with hemodynamically stable and asymptomatic congenital heart block who were deemed potential candidates for permanent pacemaker placement prior to pregnancy, it is reasonable to defer the decision on device implantation until after delivery. (2a, B-NR)
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6. In pregnant patients with hemodynamically stable and asymptomatic congenital heart block with an acceptable ventricular rate, a narrow QRS complex, and normal ventricular function, prophylactic temporary pacemaker placement around the time of delivery is not recommended. (3 - No Benefit, B-NR)
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Advanced Cardiac Life Support for the Pregnant Patient
1. Obstetric caregivers should monitor high-risk pregnant patients for early warning signs of impending cardiovascular instability in order to activate cardiovascular life support teams in a timely manner. (1, B-NR)
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2. Basic life support (BLS) and advanced cardiac life support (ACLS) response in obstetric centers should include plans for immediate activation of a specialized obstetric-oriented code team with preparation for resuscitative hysterotomy and simultaneous activation of a neonatal code team. (1, C-LD)
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3. In the pregnant patient with cardiac arrest in the earlier parts of gestation, cardiopulmonary resuscitation (CPR) should be performed as in nonpregnant patients. (1, C-LD)
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4. In the pregnant patient undergoing CPR in the latter part of gestation when the uterine fundus is above the level of the maternal umbilicus, leftward and upward displacement of the uterus should be performed. (1, C-LD)
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5. Chest compressions of the pregnant patient should be done with the hands placed in the center of the lower half of the sternum as in the nonpregnant patient. (1, C-LD)
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6. In pregnant patients with a shockable rhythm, immediate defibrillation and medical management of arrhythmia should be provided as in nonpregnant patients, including standard defibrillation energy dose recommendations. (1, C-LD)
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7. In pregnant patients, defibrillator pad placement should be in the anterolateral position as in nonpregnant patients, but the lateral pad should be placed below and/or lateral to avoid breast tissue. (1, C-LD)
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8. In pregnant patients with in-hospital cardiac arrest when uterine evacuation is deemed necessary, resuscitative hysterotomy should be performed at the site of the arrest. (1, C-LD)
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9. In pregnant patients with cardiac arrest, resuscitation efforts and defibrillation of a shockable rhythm should be administered immediately, without delays for fetal assessment/monitoring or the removal of fetal monitoring devices. (1, C-EO)
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10. In pregnant patients undergoing CPR, ACLS medication should be given as in the nonpregnant patient without concern for fetal exposure or teratogenicity. (1, C-EO)
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11. In pregnant patients with cardiac arrest at >20 weeks’ gestational age or if uterine fundus is palpable above the umbilicus, it is reasonable to perform resuscitative hysterotomy early in resuscitative efforts, with to the goal of uterine evacuation ideally within 5 minutes of the onset of cardiac arrest, to maximize the chance of maternal survival. (2a, C-LD)
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12. In pregnant patients with cardiac arrest, resuscitative uterine evacuation with assisted vaginal delivery is reasonable as an alternative to resuscitative hysterotomy, if deemed feasible by the obstetric team. (2a, C-LD)
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Arrhythmia Management in the Pregnant Patient With Arrhythmogenic Structural Cardiac Substrates
Arrhythmia Management of the Pregnant Patient With Structural Heart Disease
1. Patients with SHD and a history of arrhythmias who are contemplating pregnancy should have preconception counseling. (1, C-LD)
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2. Pregnant patients who present with new complex SVT or VT should undergo an evaluation for SHD. (1, C-LD)
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3. Pregnant patients with preexisting SHD who develop new arrhythmias during pregnancy should have a clinical and echocardiographic evaluation to exclude changes in cardiac structure and/or function. (1, C-LD)
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Arrhythmia Management in the Pregnant Patient With Congenital Heart Disease
1. Patients with congenital heart disease (CHD) and arrhythmias who are considering pregnancy should receive preconception counseling, with input from an adult congenital cardiologist or electrophysiologist with expertise in adult CHD to determine maternal cardiac, obstetric, and fetal risks. (1, B-NR)
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2. Patients with Fontan circulation and refractory arrhythmias who are contemplating pregnancy should be advised that pregnancy is potentially harmful until the arrhythmias are addressed, due to the association with adverse maternal and fetal outcomes. (1, B-NR)
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3. In pregnant patients with CHD and intra-atrial reentrant tachycardia (IART), AF, or AFL, therapeutic anticoagulation regimen specific to pregnancy is recommended for stroke prevention. (1, C-LD)
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4. In pregnant patients with CHD and highly symptomatic or poorly tolerated acute onset IART, AF, or AFL, attempts to restore sinus rhythm (rhythm control) are recommended in preference to rate control only. (1, C-LD)
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5. In pregnant patients with complex CHD and hemodynamically unstable cardiac arrhythmias, urgent or emergency cardioversion is recommended as in the nonpregnant patient. (1, C-LD)
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6. In pregnant patients with CHD and recurrent VT, antiarrhythmic drug therapy should be tailored according to the underlying cardiac substrate and potential impact of the drug on the developing fetus, and preferably in conjunction with an electrophysiologist with expertise in CHD. (1, C-LD)
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7. In pregnant patients with CHD and recurrent IART, AF, or AFL, in whom a rhythm-control strategy is deemed necessary, it is reasonable to initiate antiarrhythmic drug therapy, alone or in combination with a beta-blocker, with the antiarrhythmic drug chosen according to the underlying cardiac substrate and potential impact of the drug on the developing fetus, and preferably in conjunction with an electrophysiologist with expertise in CHD. (2a, B-NR)
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8. In pregnant patients with CHD and recurrent atrial arrhythmias in whom pharmacological therapy is ineffective or contraindicated, ablation of arrhythmias deemed to involve a simple arrhythmic substrate is reasonable with attention to and techniques for eliminating or minimizing radiation exposure to as low as reasonably achievable, and preferably in conjunction with an electrophysiologist with expertise in CHD. (2a, C-LD)
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9. In pregnant patients with CHD and recurrent ventricular or atrial arrhythmias in whom other pharmacological or catheter ablation therapies are ineffective, contraindicated, or not preferred, amiodarone may be considered after a risks-versus-benefits discussion with the patient. (2b, C-LD)
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10. In pregnant patients with CHD and recurrent IART, AF, or AFL, in whom pharmacological therapy is ineffective or contraindicated, catheter ablation of arrhythmias deemed to involve a complex arrhythmic substrate may be considered, with attention to and techniques for eliminating or minimizing radiation exposure to as low as reasonably achievable, and preferably in conjunction with an electrophysiologist with expertise in CHD. (2b, C-LD)
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Arrhythmia Management in the Pregnant Patient With Valvular Heart Disease
1. In pregnant patients with mitral stenosis and acute onset of either AF or AFL of any duration, synchronized cardioversion is recommended, as long as the patient is adequately anticoagulated or atrial thrombus is excluded, and subsequent anticoagulation will be provided with the duration as in the nonpregnant patient. (1, C-LD)
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2. In pregnant patients with mitral stenosis and either AF or AFL, left atrial thrombosis, or prior embolism, therapeutic anticoagulation is recommended throughout pregnancy, unless there is contraindication. (1, C-LD)
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Arrhythmia Management of the Pregnant Patient With Arrhythmogenic Cardiomyopathy
1. Patients and/or their partners with ACM should be offered preconception counseling, including genetic counseling as indicated. (1, B-NR)
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2. Pregnant patients with ACM should be treated for documented or potential arrhythmias as in the nonpregnant patient, including continuation of beta-blockers and the use of antiarrhythmic drug– and device-based therapies as needed, favoring options with the best record of safety during pregnancy. (1, C-LD)
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3. In pregnant patients with ACM and high-risk features, the decision to implant an ICD should be made based on usual indications, regardless of pregnancy status, and ideally the procedure should be considered and performed prior to conception. (1, C-LD)
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4. In pregnant patients with ACM and recurrent VT or ICD shocks, it is reasonable to consider antiarrhythmic drug therapy, including sotalol or flecainide alone or in combination with a beta-blocker as first-line options. (2a, C-LD)
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Management of Fetal Arrhythmias
Fetal Atrial Tachyarrhythmias
1. Fetuses with intermittent AFL or intermittent SVT (defined as tachycardia <50% of the time) and no hydrops should be managed with observation, frequent fetal heart rate monitoring (auscultation), and serial biophysical testing, ideally under the guidance of a cardio-obstetrics team. (1, B-NR)
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2. Fetuses with incessant AFL or incessant SVT (defined as tachycardia >50% of the time) and/or hydrops should be referred to a cardio-obstetrics team, due to the potential for high fetal and maternal morbidity and fetal mortality. (1, B-NR)
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3. Fetuses with incessant SVT or AFL with or without hydrops who are not considered to be mature enough for delivery should be treated transplacentally with flecainide or sotalol, alone or in combination with digoxin, with frequent monitoring of fetal well-being and maternal drug toxicity, and with drug selection according to the specific arrhythmia mechanism. (1, B-NR)
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4. Fetuses with incessant AFL or incessant SVT complicated by hydrops who are close to term should be delivered. (1, C-LD)
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5. In pregnancies complicated by either fetal irregular heart rate or tachyarrhythmias, fetal echocardiography is recommended to further characterize the rhythm and to screen for structural or functional abnormalities. (1, C-LD)
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6. In pregnancies complicated by fetal PACs, serial auscultation of the fetal heart rate or serial biophysical testing (or, if these are unavailable, non-stress testing) is recommended to exclude development of fetal SVT until the arrhythmia resolves. (1, C-LD)
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7. In fetuses with incessant SVT complicated by hydrops or ventricular dysfunction refractory or with contraindications to first-line drug options, transplacental administration of oral amiodarone can be beneficial. (2a, C-LD)
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8. In immature fetuses with incessant SVT or incessant AFL complicated by hydrops that do not respond to treatment with transplacental drug therapy alone, direct fetal intramuscular injection of digoxin added to transplacental drug therapy can be effective. (2a, C-LD)
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9. In fetuses with incessant SVT or incessant AFL complicated by hydrops that do not respond to treatment with transplacental drug therapy, combination transplacental drugs, or direct injection of digoxin, direct umbilical intravenous injection or intraperitoneal injection of amiodarone may be effective as a last resort. (2b, C-LD)
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10. In fetuses with incessant SVT or incessant AFL, transplacental therapy with verapamil is potentially harmful. (3 - Harm, C-LD)
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Fetal Ventricular Arrhythmias Not Associated With Inherited Arrhythmia Syndromes
1. Fetuses with sustained VT with or without hydrops who are not considered to be mature enough for delivery should be treated transplacentally with either intravenous magnesium or oral propranolol, mexiletine, or lidocaine, alone or in combination, or with other antiarrhythmic agents according to the specific arrhythmia etiology, with frequent monitoring of fetal well-being and maternal drug toxicity. (1, B-NR)
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2. In fetuses with sustained VT, maternal hypomagnesia and other correctable causes should be treated aggressively. (1, C-LD)
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3. Fetuses with VT should be referred to a cardio-obstetrics team, if available, for evaluation and treatment secondary to the high fetal morbidity and mortality. (1, C-EO)
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4. Fetuses with sustained VT with or without hydrops who are close to term or at term should be delivered. (1, C-EO)
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5. In fetuses with VT complicated by hydrops or ventricular dysfunction refractory or with contraindications to first-line drug options and not secondary to IAS, transplacental administration of flecainide, sotalol, or amiodarone can be beneficial, with the choice of drug according to the underlying maternal and fetal substrate. (2a, B-NR)
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6. Fetuses with sustained VT suspected to be secondary to myocarditis or isoimmunization, depending on gestational age, may be treated with dexamethasone and/or intravenous immunoglobulin (IVIG). (2b, B-NR)
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Management of Fetal Bradycardia Conduction System Disorders
1. Pregnant patients with autoimmune and rheumatological disease should be evaluated for anti-Ro and anti-La antibodies in the first trimester of pregnancy or when care is initiated, even if previous titers were negative. (1, B-NR)
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2. In pregnancies complicated by third-degree fetal heart block, echocardiographic monitoring is recommended for surveillance of fetal hydrops and cardiomyopathy, since these conditions can lead to fetal compromise or the need for delivery. (1, B-NR)
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3. In pregnancies complicated by fetal bradycardia, fetal echocardiography is recommended to further characterize the rhythm and to screen for structural cardiac abnormalities. (1, C-LD)
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4. In pregnancies complicated by idiopathic fetal bradycardia, antenatal and postnatal evaluation of the neonate for IAS is recommended. (1, C-LD)
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5. In pregnancies complicated by fetal bradycardia, assessment of fetal well-being as appropriate for gestational age is recommended to exclude fetal compromise. (1, C-EO)
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6. In pregnant patients with positive anti-Ro and anti-La antibodies, periodic echocardiographic monitoring for the development of isoimmune heart block and isoimmune fetal cardiomyopathy is reasonable. (2a, C-LD)
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7. In anti-Ro-positive pregnancies complicated by fetal heart block, the utilization of fluorinated steroids may be reasonable after shared decision-making discussions as the benefit is uncertain. (2b, B-NR)
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8. In pregnancies complicated by fetal heart block secondary to maternal isoimmune disease with fetal cardiomyopathy or hydrops, maternal administration of combined therapy of fluorinated steroids and IVIG therapy may be considered after shared decision-making discussions. (2b, C-LD)
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9. In pregnancies complicated by fetal bradycardia with a fetal heart rate <55 bpm, the benefit of antenatal maternal administration of beta-adrenergic medications is uncertain, as it has not been shown to improve fetal outcomes and could potentially lead to maternal complications. (3 - No Benefit, C-LD)
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Inherited Arrhythmia Syndromes
Management and Risk Stratification of Inherited Arrhythmia Syndromes During Pregnancy
General Management Considerations for Inherited Arrhythmia Syndromes in Pregnancy
1. For pregnancies in families with IAS, genetic testing of the proband is recommended, if not previously performed, for antenatal risk stratification and for optimal management of the fetus and, if affected, the pregnant patient. (1, B-NR)
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2. Pregnancies in families with IAS should be evaluated and, preferably, managed by a specialized cardio-obstetrics team with expertise in IAS. (1, B-NR)
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3. In a pregnant patient with an IAS and presumed cardiac syncope or documented VT, referral to an electrophysiologist is recommended for consideration of additional therapeutic interventions, including escalation of pharmacological therapy and possible ICD implantation. (1, B-NR)
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4. For women and their partners with a documented IAS or who are at risk of an IAS, preconception genetic counseling is recommended, ideally by a trained genetic counselor with expertise in IAS. (1, C-LD)
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5. A pregnant patient who survives cardiac arrest due to an IAS should undergo ICD implantation, if indicated, as in the nonpregnant patient. (1, C-LD)
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6. In pregnant patients with IAS, arrhythmia management should include a review of medications and anesthetic agents for safety, the correction of electrolyte abnormalities, and discussion of situational precipitants. (1, C-EO)
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7. Pregnant patients with IAS should have a delivery plan formulated by a cardio-obstetrics team in conjunction with an electrophysiologist or a cardiologist with expertise in arrhythmias during pregnancy, which may include continuous ECG monitoring in accordance with the level of risk and delivery at a facility capable of ACLS for pregnancy. (1, C-EO)
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Management of Long QT Syndrome in Pregnancy
1. For pregnancies in families with IAS, genetic testing of the proband is recommended, if not previously performed, for antenatal risk stratification and for optimal management of the fetus and, if affected, the pregnant patient. (1, B-NR)
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2. In pregnant patients with LQTS2, therapy with a beta blocker, particularly nadolol or propranolol, is recommended particularly during the postpartum period, which represents a high-risk period for cardiac events. (1, B-NR)
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3. In pregnant patients with LQTS who experience cardiac arrest in pregnancy or in whom cardiac syncope or ventricular arrhythmias occur despite beta-blocker use, intensification of therapy including ICD implantation, if indicated, is recommended as in the nonpregnant patient. (1, C-LD)
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4. In pregnancies in which either of the parents carry a diagnosis of LQTS, fetal echocardiography is recommended to detect channelopathy-related rhythm abnormalities. (1, C-LD)
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5. In pregnant patients with LQTS who are genotype-positive but phenotype-negative, it is reasonable to treat with a beta blocker, particularly nadolol or propranolol, after a shared decision-making discussion with the affected woman. (2a, B-NR)
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Management of Brugada Syndrome in Pregnancy
1. Pregnant and postpartum patients with BrS should be provided with care as in the nonpregnant patient, including continuing therapies for sudden death prevention and avoidance of contraindicated drugs throughout pregnancy and lactation. (1, C-LD)
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2. In pregnant and postpartum breastfeeding patients with BrS, education about the prompt treatment of fever, such as in cases of mastitis, with antipyretics is recommended, as fever is a potential precipitant for sudden death. (1, C-LD)
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Management of Catecholaminergic Polymorphic Ventricular Tachycardia in Pregnancy
1. In pregnant patients with CPVT, pharmacological therapy as in the nonpregnant patient should be continued throughout pregnancy and the postpartum period, including during delivery and breastfeeding. (1, C-LD)
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2. In pregnant patients with CPVT, with symptoms ongoing despite beta-blocker therapy, such as recurrent syncope, VT, or cardiac arrest, intensification of therapy with either the addition of flecainide and/or a left cardiac sympathetic denervation, and/or an ICD is recommended as in the nonpregnant patient. (1, C-LD)
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3. In pregnant patients with CPVT who are genotype-positive and phenotype-negative, use of beta-blockers during pregnancy and postpartum is reasonable. (2a, C-LD)
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Management of Short QT Syndrome in Pregnancy
1. In pregnant patients with SQTS, arrhythmia-specific treatment should be administered as in the nonpregnant patient and continued throughout pregnancy and the postpartum period. (1, C-EO)
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Management of Inherited Arrhythmia Syndromes in the Fetus, Specifically Long QT Syndrome
1. In pregnancies complicated by suspected or documented IAS related fetal arrhythmias, complete fetal echocardiography is recommended to better evaluate heart anatomy, ventricular function, and arrhythmia mechanisms. (1, B-NR)
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2. Fetuses with arrhythmias potentially suggestive of IAS should be referred to a cardio-obstetrics team with expertise in IAS management. (1, B-NR)
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3. In pregnancies complicated by suspected or documented IAS, the fetal heart rate should be assessed initially as a baseline and at each prenatal visit and compared against gestation specific normative values. (1, B-NR)
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4. In fetuses with TdP, a maternal intravenous loading dose of magnesium sulfate followed by continuous infusion should be administered as first-line therapy at all stages of pregnancy before considering urgent delivery. (1, B-NR)
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5. In pregnancies complicated by suspected or documented maternal or fetal IAS, limiting medications that could potentially lengthen the QTc or trigger arrhythmias in the fetus is recommended. (1, C-LD)
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6. In pregnancies complicated by suspected or documented fetal IAS, fMCG can be beneficial, if available, to identify affected fetuses and IAS-related repolarization abnormalities, and to better assess the severity of the IAS-related arrhythmias. (2a, B-NR)
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7. In fetuses with TdP despite magnesium administration, maternal treatment with lidocaine or with a beta-blocker (preferably propranolol) is reasonable at all stages of pregnancy before considering urgent delivery. (2a, B-NR)
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8. In fetuses with prenatal and postnatal persistent bradycardia, it is reasonable to obtain a postnatal ECG and referral to a pediatric cardiologist or electrophysiologist for further clinical evaluation and genetic testing as indicated to exclude IAS. (2a, C-LD)
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9. In fetuses manifesting arrhythmias associated with exposure to QT-prolonging medications, evaluation for maternal nutritional deficiency or concealed maternal or fetal diseases associated with QT prolongation is reasonable. (2a, C-LD)
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10. In fetuses with TdP or polymorphic VT associated with potential or documented LQTS, sotalol, procainamide, and amiodarone should not be administered because they can further lengthen QTc and exacerbate arrhythmias. (3 - Harm, C-LD)
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Recommendation Grading
Disclaimer
The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.
Overview
Title
Management of Arrhythmias During Pregnancy
Authoring Organization
Heart Rhythm Society
Publication Month/Year
May 19, 2023
Last Updated Month/Year
November 20, 2024
Supplemental Implementation Tools
Document Type
Guideline
Country of Publication
US
Document Objectives
This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses.
Inclusion Criteria
Female, Adolescent, Adult
Health Care Settings
Ambulatory, Hospital, Outpatient
Intended Users
Nurse, nurse midwife, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Assessment and screening, Treatment, Management, Prevention
Diseases/Conditions (MeSH)
D011247 - Pregnancy, D011248 - Pregnancy Complications, D011249 - Pregnancy Complications, Cardiovascular
Keywords
ventricular arrhythmias, pregnancy, arrhythmias, Syncope, pregnancy complication
Source Citation
José A. Joglar, Suraj Kapa, Elizabeth V. Saarel, Anne M. Dubin, Bulent Gorenek, Afshan B. Hameed, Sissy Lara de Melo, Miguel A. Leal, Blandine Mondésert, Luis D. Pacheco, Melissa R. Robinson, Andrea Sarkozy, Candice K. Silversides, Danna Spears, Sindhu K. Srinivas, Janette F. Strasburger, Usha B. Tedrow, Jennifer M. Wright, Carolyn M. Zelop, Dominica Zentner, 2023 HRS expert consensus statement on the management of arrhythmias during pregnancy, Heart Rhythm, Volume 20, Issue 10, 2023, Pages e175-e264, ISSN 1547-5271, https://doi.org/10.1016/j.hrthm.2023.05.017