What questions should be asked in the history taking of a 33-week pregnant patient presenting with palpitations?

Key Questions for History Taking in a 33-Week Pregnant Patient with Palpitations

When assessing a pregnant patient at 33 weeks with palpitations, a structured approach focusing on cardiac symptoms, pregnancy-specific factors, and underlying conditions is essential for proper diagnosis and management.

Characteristics of Palpitations

• Ask about the onset and termination pattern - sudden onset and termination suggests paroxysmal supraventricular tachycardia (PSVT), while gradual onset and termination is more consistent with sinus tachycardia 1
• Determine if palpitations are regular or irregular - irregular palpitations may indicate premature beats, atrial fibrillation, or multifocal atrial tachycardia 1
• Inquire about frequency, duration, and number of episodes 1
• Ask about precipitating factors or triggers (caffeine, alcohol, smoking, medications) 2
• Determine if the palpitations started during pregnancy or existed before 3

Associated Symptoms

• Ask about associated symptoms such as:
  • Lightheadedness, dizziness, or syncope (suggests hemodynamic compromise) 4
  • Chest discomfort or pain 1
  • Dyspnea (shortness of breath) 1
  • Fatigue 1
  • Polyuria (may occur with AVNRT or AVRT) 1

Medical and Obstetric History

• Inquire about pre-existing cardiac conditions:
  • History of structural heart disease (valvular disease, cardiomyopathy) 1, 2
  • Previous arrhythmias or palpitations before pregnancy 3
  • Family history of sudden cardiac death or inherited arrhythmias 1
• Ask about obstetric history:
  • Previous pregnancies and any cardiac complications during those pregnancies 5
  • Current pregnancy complications 4
• Inquire about thyroid disease history (hyperthyroidism can cause or exacerbate arrhythmias in pregnancy) 1

Medication and Substance Use

• Current medication use, including over-the-counter medications 2
• Caffeine, alcohol, and tobacco use 2
• Use of stimulants or recreational drugs 2

Risk Assessment for Arrhythmias

• Ask about symptoms suggesting hemodynamic compromise that would require urgent intervention:
  • Severe shortness of breath 4
  • Chest pain 4
  • Syncope or pre-syncope 4
• Inquire about previous episodes of similar symptoms and their resolution (spontaneous or requiring intervention) 5
• Ask about effectiveness of any maneuvers attempted to terminate the palpitations (Valsalva, etc.) 1

Impact on Daily Life

• Effect of palpitations on daily activities 5
• Sleep disturbances related to palpitations 5
• Anxiety or psychological impact of symptoms 5

Red Flags Requiring Urgent Attention

• Assess for signs of hemodynamic instability that would require immediate cardioversion, including hypotension, altered mental status, or severe dyspnea 1
• Ask about syncope associated with palpitations, which may suggest more serious arrhythmias 1
• Inquire about persistent tachycardia (weeks to months), which could lead to tachycardia-mediated cardiomyopathy 1

Remember that while palpitations are common during pregnancy and often benign, they may represent the first manifestation of underlying cardiac disease exacerbated by the hemodynamic changes of pregnancy 2. A thorough history is essential for appropriate risk stratification and management.