In a 20‑year‑old woman at 20 weeks gestation with Wolff‑Parkinson‑White syndrome presenting with supraventricular tachycardia, is sotalol safe and what are the recommended treatment options?

Management of SVT in a 20-Year-Old Pregnant Woman with WPW at 20 Weeks Gestation

Sotalol is no longer recommended for SVT during pregnancy according to the most recent 2020 ESC guidelines, which specifically removed it from the recommended treatment options. 1

Acute Management of SVT Episode

For immediate termination of the current SVT episode, use the following sequence:

• Vagal maneuvers should be attempted first (Class I recommendation) 1
• Adenosine 6 mg IV is the drug of choice for acute conversion (Class I recommendation), with rapid bolus followed by saline flush; can repeat with 12 mg if needed 1
• Synchronized DC cardioversion is indicated if the patient becomes hemodynamically unstable or if adenosine fails (Class I recommendation) 1
• Intravenous metoprolol or propranolol can be used if adenosine is ineffective (Class IIa recommendation) 1

Critical pitfall: Avoid verapamil in WPW patients with pre-excited atrial fibrillation, as AV nodal blocking agents can increase ventricular rate and risk of ventricular fibrillation in this specific scenario 1

Prophylactic/Ongoing Management Options

Since she is at 20 weeks (second trimester, past organogenesis), the following medications are appropriate for preventing recurrent SVT in WPW:

First-Line Options for WPW in Pregnancy:

• Flecainide or propafenone are the preferred agents for WPW syndrome during pregnancy (Class IIa recommendation) 1
• These drugs are specifically recommended for women with WPW syndrome but without ischemic or structural heart disease 1
• Must be combined with an AV nodal-blocking agent (beta-blocker or digoxin) to prevent rapid ventricular response if atrial fibrillation develops 1

Alternative Options:

• Propranolol or metoprolol (beta-1 selective preferred) can be used (Class I-IIa recommendation) 1, 2
• Beta-blockers should be used at the lowest effective dose with close fetal monitoring for growth restriction and bradycardia 2, 3
• Serial ultrasounds for fetal growth and surveillance for fetal bradycardia are essential throughout pregnancy 2, 3

Why Sotalol Is NOT Recommended

The evidence against sotalol in this scenario is compelling:

• The 2020 ESC guidelines explicitly removed sotalol from recommended treatments for SVT during pregnancy, including for prophylaxis of AVRT (the mechanism in WPW) 1
• While older 2003 guidelines listed sotalol as Class IIa for prophylactic therapy 1, and it is FDA Pregnancy Category B 4, the most recent expert consensus has downgraded its use
• The 2016 ACC/AHA/HRS guidelines list sotalol as an option (Class IIa) but this predates the 2020 ESC update that specifically removed it 1
• Research shows sotalol has lower conversion rates and higher mortality in fetal SVT compared to atrial flutter, with 3 of 4 deaths occurring in SVT patients 5

Definitive Management Consideration

• Catheter ablation may be reasonable for highly symptomatic, recurrent, drug-refractory SVT with efforts to minimize radiation exposure (Class IIb recommendation) 1
• This should be considered if medications fail or are poorly tolerated, as ablation can provide curative treatment 1
• Use echocardiographic guidance and minimize fluoroscopy time if performed during pregnancy 1

Monitoring Requirements

• Serial fetal ultrasounds for growth assessment (increased risk of intrauterine growth restriction with beta-blockers) 2, 3
• Fetal echocardiography and heart rate monitoring, particularly during second and third trimesters 2, 3
• Maternal ECG monitoring for QTc prolongation if using any antiarrhythmic agents 1
• Dose adjustments may be needed due to pregnancy-related changes in drug absorption, bioavailability, and elimination 1

Bottom line: For this 20-year-old with WPW at 20 weeks, treat acute SVT with adenosine, then use flecainide or propafenone (with AV nodal blockade) for prophylaxis rather than sotalol, based on the most recent 2020 guidelines.