Atrial Fibrillation in a Structurally Normal Heart during Pregnancy: A Review of Cases From a Registry and From the Literature

Arrhythmias and Pregnancy: Management of Preexisting and New-Onset Maternal Arrhythmias

Arrhythmias are the most common cardiovascular complication of pregnancy in women with and without structural heart disease. Appropriate maternal diagnosis and management is of utmost importance to optimize maternal and fetal outcomes. A multidisciplinary care approach with cardiology, maternal fetal medicine, anesthesia, and pediatrics is important for preconceptional, pregnancy, and delivery planning.

Management of tachyarrhythmias in pregnancy - A review

The most common arrhythmias detected during pregnancy include sinus tachycardia, sinus bradycardia, and sinus arrhythmia, identified in 0.1% of pregnancies. Isolated premature atrial or ventricular arrhythmias are observed in 0.03% of pregnancies. Arrhythmias may become more frequent during pregnancy or may manifest for the first time.

New-onset lone maternal atrial fibrillation: A case report

RATIONALE

Atrial fibrillation (AF) is encountered rarely in pregnancy. Management of maternal AF is challenging as it poses a threat to both maternal and fetal well-being.

PATIENT CONCERNS

We report a case of a 35 weeks pregnant woman who presented in emergency with sudden-onset palpitations and mild shortness of breath with no personal/family history of cardiac diseases.

DIAGNOSES

Patient's pulse was irregularly irregular with an average rate of 179 beats per minute. The obstetric examination was normal.

DIAGNOSIS

High-sensitive cardiac troponin T (hs-cTnT) was elevated. The 12 lead electrocardiogram (ECG) confirmed AF. The obstetric ultrasound, electronic fetal heart rate (EFHR) trace, and maternal echocardiography were normal.

INTERVENTIONS

The patient was admitted under joint cardiology and obstetric care and monitored with continuous telemetry. She was commenced on a therapeutic dose of low-molecular weight heparin (LMWH) and intravenous fluid. She received a single 200 Joule synchronized direct current (DC) shock under general anesthesia in operation theater, which reverted the rhythm back to normal. EFHR monitoring was normal pre- and post-DC cardioversion. We acknowledge the unwise use of therapeutic dose of LMWH before DC cardioversion (DCCV) because of a potential need for emergency cesarean delivery for maternal and/or fetal compromise.

OUTCOME

The patient remained well and in sinus rhythm after cardioversion. She was discharged home the following day on Flecainide (anti-arrhythmic) and therapeutic dose of low molecular weight heparin (LMWH) and followed up in outpatient clinics frequently. She had a baby at term and received prophylactic LMWH for 10 days post-cesarean. She was discharged from cardiology clinic when she was 10 weeks postnatal, and Flecainide was discontinued.

LESSONS

We are reporting this case because of the rarity of the condition and successful use of DCCV for treating maternal AF. High-sensitive cardiac troponin T (hs-cTnT) level is a useful laboratory indicator to gauge the severity of AF in pregnancy. We emphasize to make the arrangements for EFHR monitoring and potential cesarean delivery and advocate cautious use of thromboprophylaxis while planning for electrical cardioversion (ECV) for maternal AF.

Management of New-Onset Atrial Fibrillation in Pregnancy: When Should Early Delivery Be Considered?

BACKGROUND

The hemodynamic and physiological changes of pregnancy may predispose women to cardiac arrhythmias such as atrial fibrillation (AF). Nevertheless, new-onset AF in pregnancy remains rare, and treatment is challenging. Current recommendations are to treat pregnant women with AF as non-pregnant adults, by using pharmacological or synchronized electrical cardioversion, without mention of gestational age or possibility of delivery.

CASE

A 23-year-old nulliparous woman developed new-onset symptomatic AF at 36² weeks gestation, but presented to our hospital was delivered at 36⁴ weeks gestation. Beta-blockers were administered for heart rate control. After 48 hours, the decision was made to proceed with delivery rather than cardioversion. The patient's arrhythmia resolved spontaneously postpartum without further treatment.

CONCLUSION

In pregnant patients near or at term, delivery should be considered in the management of new-onset AF after consultation with cardiology, anaesthesiology, and maternal-fetal medicine.

Incidence of atrial fibrillation in pregnancy and clinical significance: A meta-analysis

PURPOSE

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia worldwide, and is associated with increased morbidity and mortality. However, the incidence and maternal/fetal outcomes of AF in pregnancy remain unclear. This study's aims were to investigate the pooled incidence of AF in pregnant women and to assess maternal/fetal outcomes of AF in pregnancy.

MATERIAL AND METHODS

A literature search for studies that reported incidence of AF in pregnancy, was conducted using MEDLINE, EMBASE and Cochrane Database from inception through May 2018. Pooled incidence with 95%CI were calculated using a random-effect model. The protocol for this meta-analysis is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42018095955).

RESULTS

We identified 7 cohort studies including 301,638 pregnancies. The pooled estimated incidence of AF in pregnancy among women with no known heart disease, and those with structural heart disease was 0.3% (95%CI: 0.01%-40.6%) and 2.2% (95%CI: 0.96%-5.01%), respectively. Among women with known AF, the pooled estimated incidence of recurrent AF in pregnancy was 39.2% (95%CI: 16.9%-67.2%). The pooled estimated incidence of pre-eclampsia and congestive heart failure among pregnant patients with AF was 4.1% (95%CI: 2.1%-7.8%) and 9.6% (95%CI: 5.7%-15.9%), respectively. The pooled estimated incidence of fetal events including premature birth, small for gestational age, respiratory distress syndrome, intraventricular hemorrhage, death was 26.6% (95%CI: 20.4%-34.0%).

CONCLUSION

The overall estimated incidence of AF and recurrent AF during pregnancy is as high as 2.2% and 39.2%, respectively. AF during pregnancy may result in poor maternal and fetal outcomes.

Atrial Fibrillation as a Rare Complication of the Use of Nifedipine as a Tocolytic Agent: A Case Report and Review of the Literature

Calcium channel blockers are commonly used tocolytic agents on Labor and Delivery units worldwide as part of the management of preterm labor. Despite their overall reassuring safety profile, rare cardiovascular complications have been reported. In this report, we describe the case of threatened preterm labor managed with nifedipine with subsequent development of atrial fibrillation. This type of cardiac arrhythmia may have considerable consequences for both the mother and the fetus. The aim of this case report and comprehensive review of the literature is to raise awareness.

Atrial fibrillation with a structurally normal heart in pregnancy: An international survey on current practice

BACKGROUND

Little evidence exists for the optimal management of atrial fibrillation with a structurally normal heart in pregnancy.

METHODS

A survey was sent to members of two associations to obtain input on optimal management of atrial fibrillation in pregnancy. The survey presented four cases with respect to (1) baseline investigations; (2) rate versus rhythm control; (3) chemical versus electrical cardioversion; and (4) anticoagulation.

RESULTS

Sixty-one responders from 11 countries participated. High agreement was noted for baseline investigations. A quarter (25%) of participants chose elective cardioversion even with a reversible precipitant. Electrical cardioversion was preferred over chemical (p < 0.05). Anticoagulation strategies were heterogeneous except in the presence of a left atrial appendage thrombus.

DISCUSSION

This study revealed that there was little consensus in current practice in pregnancy beyond basic investigations. An adaptation of established guidelines to the pregnant population would require a meeting of Cardiologists with input from colleagues in Obstetric Medicine.