From the Guidelines
Treatment of tachycardia during pregnancy should prioritize vagal maneuvers as the first-line approach, followed by adenosine if necessary, to minimize risks to both mother and fetus. According to the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1, vagal maneuvers are recommended for acute treatment in pregnant patients with SVT. This approach includes techniques such as the Valsalva maneuver and carotid sinus massage, which can be performed quickly and are considered safe.
If vagal maneuvers are unsuccessful, adenosine is recommended as the next line of treatment 1. Adenosine has a short half-life and is unlikely to reach the fetal circulation, making it a relatively safe option for pregnant patients. The initial dose for adenosine is 6-mg rapid bolus IV, which can be increased up to 12 mg if necessary.
For patients with hemodynamically unstable SVT, synchronized cardioversion is recommended when pharmacological therapy is ineffective or contraindicated 1. This procedure should be performed with caution, ensuring that the energy source and trajectory are directed away from the uterus, and fetal monitoring should be conducted during and after the procedure if possible.
Other treatment options, such as beta-blockers (e.g., metoprolol or propranolol) and verapamil, may be considered in specific situations but are not the first line of treatment due to potential side effects and risks to the fetus 1. The choice of antiarrhythmic medication must carefully balance the need to control maternal symptoms against potential fetal effects, and medication doses may need to be adjusted as pregnancy progresses.
Key considerations in the treatment of tachycardia during pregnancy include:
- Identifying and addressing underlying causes of tachycardia
- Using non-pharmacological approaches whenever possible
- Selecting medications that are safe for use during pregnancy
- Monitoring fetal well-being during treatment
- Adjusting medication doses as necessary to minimize risks to both mother and fetus.
From the Research
Treatment of Tachycardia in Pregnancy
- The treatment of tachycardia in pregnancy requires careful consideration to ensure the safety of both the mother and the fetus 2, 3, 4, 5, 6.
- For acute therapy, electrical cardioversion with 50-100 J is indicated in all unstable patients 4, 5, 6.
- In stable supraventricular tachycardia, initial therapy includes vagal maneuvers to terminate tachycardias 3, 4, 5, 6.
- If vagal maneuvers fail, intravenous adenosine is the first choice drug and may safely terminate the arrhythmia 2, 3, 4, 5, 6.
Management of Specific Arrhythmias
- For paroxysmal supraventricular tachycardia, vagal stimulation maneuvers should be tried first, followed by adenosine or a cardioselective beta-blocker if necessary 3.
- In pregnant women with atrial fibrillation, the goal of treatment is conversion to sinus rhythm or to control ventricular rate by a cardioselective beta-adrenergic blocker drug or digoxin 3.
- Ventricular arrhythmias may occur in pregnant women with cardiomyopathy, congenital heart disease, valvular heart disease, or mitral valve prolapse, and can be treated with intravenous lidocaine or procainamide, or electrical cardioversion 3.
Considerations for Pregnancy
- The treatment of cardiac arrhythmias in pregnant women requires important modifications of the standard practice of arrhythmia management to protect the patient and fetus through delivery 4, 5, 6.
- The goal of therapy is to protect the patient and fetus through delivery, after which chronic or definitive therapy can be administered 4, 5, 6.
- No drug therapy is usually needed for the management of supraventricular or ventricular premature beats, but potential stimulants, such as smoking, caffeine, and alcohol, should be eliminated 3.