How are palpitations (irregular heartbeats) managed in pregnancy?

Management of Palpitations in Pregnancy

Palpitations in pregnancy should be managed with a stepwise approach based on the type of arrhythmia, hemodynamic stability, and presence of structural heart disease, with vagal maneuvers and adenosine as first-line treatments for supraventricular tachycardias, and immediate electrical cardioversion for any hemodynamically unstable arrhythmia. 1

Initial Assessment

When a pregnant woman presents with palpitations, the following should be evaluated:

• Determine if the palpitations represent benign premature beats or sustained arrhythmia
• Assess for hemodynamic stability
• Investigate for underlying structural heart disease
• Evaluate for symptoms of presyncope, especially in patients with family history of sudden death 1

Most palpitations in pregnancy (especially isolated ectopic beats) are benign and do not require treatment 2. However, new-onset ventricular tachycardia is concerning and requires investigation for underlying structural heart disease 1.

Management Algorithm

For Hemodynamically Unstable Arrhythmias:

• Immediate electrical cardioversion is recommended regardless of the type of tachycardia 1

For Hemodynamically Stable Supraventricular Tachycardia (SVT):

1. First-line treatment: Vagal maneuvers followed by IV adenosine 1
2. Second-line treatment: IV metoprolol if adenosine fails 1
3. For long-term management:
   • Oral digoxin or selective β-blocker (metoprolol/propranolol) 1
   • If first-line agents fail: sotalol or flecainide 1
   • Last options: propafenone or procainamide 1

For Atrial Flutter/Fibrillation:

• Electrical cardioversion for hemodynamic instability
• For stable patients: rate control with β-blockers or digoxin
• Anticoagulation with LMWH or vitamin K antagonists is recommended 1
• Cardioversion may be considered for persistent atrial fibrillation 1

For Focal Atrial Tachycardia:

• Rate control with β-blockers and/or digitalis to prevent tachycardia-induced cardiomyopathy
• For symptomatic patients: flecainide, propafenone, or sotalol 1

Medication Safety in Pregnancy

Safe First-Line Options:

• Adenosine: Safe in all trimesters 3
• Metoprolol/Propranolol: Safe for long-term management 1
• Digoxin: Safe for rate control 1, 4

Second-Line Options (use if benefits outweigh risks):

• Sotalol: Category B drug 1
• Flecainide/Propafenone: Category C drugs 1
• Verapamil: May be considered for rate control if other AV nodal-blocking agents fail 1, 5

Avoid or Use with Extreme Caution:

• Amiodarone: Should only be used when other therapy has failed due to fetotoxic effects 1
• Atenolol: Should not be used for any arrhythmia in pregnancy 1

Special Considerations

• Structural Heart Disease: Patients with congenital or structural heart disease are at higher risk (15%) of developing arrhythmias during pregnancy 1
• Hypertrophic Cardiomyopathy: Delivery should be performed with β-blocker protection 1
• Dilated Cardiomyopathy: Women should be informed about risk of deterioration during pregnancy 1
• Family History of Sudden Death: Close surveillance with prompt investigation is recommended if palpitations occur 1

Interventional Management

• Catheter ablation should be considered only in special cases if necessary during pregnancy, particularly for drug-resistant and poorly tolerated tachycardias 1
• If indicated during pregnancy, ICD implantation is recommended to protect the mother's life 1

Common Pitfalls to Avoid

1. Dismissing all palpitations as benign without proper evaluation
2. Failing to investigate new-onset ventricular tachycardia for underlying structural heart disease
3. Using atenolol for arrhythmia management in pregnancy
4. Delaying electrical cardioversion in hemodynamically unstable patients
5. Using AV nodal blocking agents in patients with manifest pre-excitation on ECG 1
6. Overusing amiodarone when safer alternatives are available

By following this systematic approach to managing palpitations in pregnancy, clinicians can effectively treat arrhythmias while minimizing risks to both mother and fetus.