Is discharge with Tylenol (acetaminophen) appropriate for a 20-week pregnant surrogate patient with resolved symptoms of tachycardia, dizziness, and shortness of breath?

Management of Tachycardia and Associated Symptoms in a Pregnant Patient

Discharging the patient with Tylenol and instructions to go to the ER if symptoms recur was not appropriate management for this pregnant patient with tachycardia, dizziness, and shortness of breath. This patient requires more thorough cardiac evaluation and monitoring. 1, 2

Assessment of Presenting Symptoms

• The patient's symptoms of sudden tachycardia (HR 119), dizziness, shortness of breath, and abnormal blood pressure (129/49) strongly suggest a possible cardiac arrhythmia that warrants immediate and thorough evaluation 1
• These symptoms during pregnancy require investigation to rule out underlying structural heart disease, as pregnancy can exacerbate underlying arrhythmias or precipitate new ones 1, 2
• The combination of tachycardia with an abnormal blood pressure reading suggests hemodynamic changes that require prompt assessment 1

Recommended Management Approach

Immediate Actions Required:

• A 12-lead ECG should have been performed to evaluate for any underlying conduction abnormalities or evidence of structural heart disease 2
• Continuous cardiac monitoring should have been initiated to identify the type of arrhythmia 1
• Referral to the emergency department for further evaluation was indicated given the constellation of symptoms 2

Diagnostic Workup:

• Holter monitor for detection of intermittent arrhythmias 2
• Echocardiogram to rule out structural heart disease and evaluate for peripartum cardiomyopathy 2
• Laboratory tests to rule out other causes of tachycardia (thyroid function, electrolytes, complete blood count) 1

Treatment Considerations

• For supraventricular tachycardia (SVT), which is common in pregnancy (20-44%), first-line treatments include vagal maneuvers, adenosine if vagal maneuvers fail, and IV metoprolol if adenosine fails 3
• If ventricular tachycardia is suspected and the patient is hemodynamically unstable, immediate electrical cardioversion is recommended 3
• For stable patients with recurrent symptoms, cardioselective beta-blockers (particularly metoprolol) are the first-line prophylactic treatment during pregnancy 3, 2
• Tylenol (acetaminophen) is safe in pregnancy but does not address the underlying cardiac issue 4

Pitfalls and Caveats

• A normal fetal heart rate (140 in this case) does not rule out the need for maternal cardiac evaluation 2
• Pregnant patients can develop hypoxemia rapidly due to decreased functional residual capacity and increased oxygen demand, making prompt evaluation of shortness of breath essential 1
• Anxiety about pregnancy (especially in a surrogate) may exacerbate symptoms but should not lead to dismissal of potentially serious cardiac symptoms 2
• Discharge against medical advice in cases of potentially serious symptoms carries significant risk and should be avoided 5

When to Escalate Care

• Immediate ER referral is required for:
  • Recurrent episodes of dizziness and tachycardia
  • Development or worsening of shortness of breath
  • Syncope or near-syncope
  • Persistent abdominal cramping (which could indicate preterm labor)
  • Any signs of hemodynamic instability 2

Follow-up Plan

• Close follow-up within 24-48 hours is essential to reassess symptoms and cardiac status 2
• If arrhythmia is documented, cardiology consultation should be obtained 1, 2
• Regular monitoring of both maternal cardiac symptoms and fetal well-being throughout pregnancy 2

In conclusion, while the patient's symptoms resolved in the office and fetal heart rate was reassuring, the episode of tachycardia with associated symptoms warranted more thorough evaluation than simply providing Tylenol and discharge instructions. A more appropriate approach would have included ECG, consideration of cardiac monitoring, and possible referral to the emergency department for complete evaluation.