Maternal arrhythmia management during pregnancy in patients with structural heart disease

Trends and Immediate Outcomes of Syncope During Pregnancy: A Narrative Review

Pregnancy-related syncope presents special difficulties due to the rapid physiological changes that occur throughout gestation. This narrative review provides a thorough summary of the patterns and pregnancy outcomes secondary to syncope during pregnancy. There is an increase in syncope burden during pregnancy, and hence it is critical that medical professionals understand the significance of syncope during pregnancy. Syncope can have a negative impact on the health of the mother as well as the fetus. Therefore, this review summarizes data from studies on syncope in pregnancy. It includes observational studies, case reports, and review articles. Early detection and proper management are very important because pregnant women who experience cardiac syncope are at risk of unfavorable neonatal and maternal outcomes. The review reveals diverse trends in syncope incidence during pregnancy, emphasizing the need for a nuanced understanding of temporal variations. Risks of injury, uteroplacental insufficiency, psychological effects, interruptions in prenatal treatment, possible aggravation of pre-existing diseases, and lifestyle changes are examples of immediate maternal repercussions. Pregnancy-related syncope is a complex condition that affects the health of the mother and the fetus. The study stresses the need for careful clinical treatment due to the rapid results and the diversity in incidence patterns. The unique component of a possible relationship to the brain health of offspring justifies further investigation in this area.

Diagnosis and management of arrhythmias in pregnancy

Arrhythmias are the most common cardiac complications occurring in pregnancy. Although the majority of palpitations in pregnancy may be explained by atrial or ventricular premature complexes, the full spectrum of arrhythmias can occur. In this article, we establish a systematic approach to the evaluation and management of arrhythmias in pregnancy. Haemodynamically unstable arrhythmias warrant urgent cardioversion. For mild cases of benign arrhythmia, treatment is usually not needed. Symptomatic but haemodynamically stable arrhythmic patients should first undergo a thorough evaluation to establish the type of arrhythmia and the presence or absence of structural heart disease. This will ultimately determine the necessity for treatment given the potential risks of anti-arrhythmic pharmacotherapy in pregnancy. We will discuss the main catalogue of anti-arrhythmic medications, which have some established evidence of safety in pregnancy. Based on our appraisal, we provide a treatment algorithm for the tachyarrhythmic pregnant patient.

Arrhythmic risk during pregnancy in patients with congenital heart disease

Arrhythmias play a significant role in the morbidity and mortality of patients with adult congenital heart disease (CHD). Pregnancy-associated physiological changes in hormonal status, hemodynamics, and myocardial structure further enhance arrhythmic risk in CHD patients, leading to increased adverse maternal and foetal events and making arrhythmias one of the most common complications during pregnancy. Nearly all CHD patients are affected by asymptomatic rhythm disturbances during the ante-, peri-, or post-partum periods, and almost one tenth of patients develop sustained, symptomatic arrhythmias requiring treatment. The majority of arrhythmias originate from the atrium, mostly in the form of supraventricular tachycardia or atrial fibrillation. Patients with CHD often tolerate these even more poorly during pregnancy than before pregnancy. Sustained ventricular tachycardia or ventricular fibrillation are rare, but potentially life-threatening for mother and foetus. Risk stratification models developed specifically for arrhythmias during pregnancy in CHD patients are lacking, but direct or indirect signs of heart failure, previous history of arrhythmia, and complex CHD may be associated with higher arrhythmic risk in these patients. Rigorous individual assessment before, and careful monitoring during pregnancy in a multidisciplinary team is crucial to ensure the best possible pregnancy outcome for patients with CHD.

Antiarrhythmic drugs-safety and efficacy during pregnancy

When deciding on antiarrhythmic drug (AAD) treatment, a thorough knowledge of the physiological adaptation processes that occur during pregnancy and their effect on metabolism and the efficacy of AAD is mandatory. Beyond the desired effects of AAD therapy, side effects can occur in pregnant women. Furthermore, potential harm to fetal development-depending on gestational age-needs to be considered. A thorough evaluation of potential risks opposed to expected benefits for mother and fetus should be carried out before initiation of AAD treatment. Regular maternal echocardiography and fetal sonographic examination during pregnancy under AAD treatment are advisable. If possible, serum concentrations of AAD should be measured on a regular basis. Due to electrolyte and volume imbalances after delivery, maternal monitoring is recommended for approximately 48 h under AAD therapy. Current guidelines are based on almost historic analyses, where AAD were often prescribed for other indications than rhythm disorders. In clinical practice, AAD predominantly used during pregnancy are intravenous adenosine for acute treatment of atrioventricular nodal dependent tachycardias, whereas betablockers, sotalol, and flecainide can be orally administered for long-term therapy.

Management of Pregnancy in Patients With Complex Congenital Heart Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association

Today, most female children born with congenital heart disease will reach childbearing age. For many women with complex congenital heart disease, carrying a pregnancy carries a moderate to high risk for both the mother and her fetus. Many such women, however, do not have access to adult congenital heart disease tertiary centers with experienced reproductive programs. Therefore, it is important that all practitioners who will be managing these women have current information not only on preconception counseling and diagnostic evaluation to determine maternal and fetal risk but also on how to manage them once they are pregnant and when to refer them to a regional center with expertise in pregnancy management.

Cardiac arrhythmias in pregnancy

As more women with repaired congenital heart disease survive to their reproductive years and many other women are delaying pregnancy until later in life, a rising concern is the risk of cardiac arrhythmias during pregnancy. Naturally occurring cardiovascular changes during pregnancy increase the likelihood that a recurrence of a previously experienced cardiac arrhythmia or a de novo arrhythmia will occur. Arrhythmias should be thoroughly investigated to determine if there is a reversible etiology, and risks/benefits of treatment options should be fully explored. We discuss the approach to working up and treating various arrhythmias during pregnancy with attention to fetal and maternal risks as well as treatment of fetal arrhythmias. Acute management in stable patients includes close monitoring and intravenous pharmacologic therapy, while DC cardioversion should be used to terminate arrhythmias in hemodynamically unstable patients. Long-term management may require continued oral antiarrhythmic therapy, with particular attention to fetal safety, to prevent complications associated with arrhythmias.

Management of pregnancy in women with palliated and unpalliated congenital heart defects

Medical advancements have made it possible for more women with congenital heart defects (CHDs) to carry successful pregnancies. Most CHD surgeries or interventions are palliative with persistent residua and sequelae exacerbated by the physiologic stresses of pregnancy. Preconception assessment, a tailored multidisciplinary approach during pregnancy, and a planned, elective delivery followed by careful postpartum monitoring may improve outcomes. Teratogenic medications should be stopped and changed to safer alternatives. Major hemodynamic changes in pregnancy, labor, and delivery may aggravate the underlying cardiovascular defects. Interventions or surgeries, when anticipated, should be performed before pregnancy. Antibiotic prophylaxis is indicated for nearly all palliated and unpalliated defects.

Congenital heart disease and pregnancy: maternal and fetal risks

Women with congenital heart disease (CHD) now comprise most patients with heart disease seen during pregnancy, accounting for 80% of all patients. In general, pregnancy is well tolerated in patients with CHD. For some women with particularly high-risk lesions and poor functional class, however, pregnancy poses significant risk for cardiovascular complications, including premature death. As result, preconception counseling and risk stratification are mandatory and should be done in all women of childbearing age with CHD.

Repaired tetralogy of Fallot in the adult

The majority of persons living with tetralogy of Fallot are now adults and may face a number of long-term cardiac problems that necessitate reoperation. These problems include pulmonary regurgitation, tricuspid regurgitation, ventricular tachycardia, atrial flutter and/or fibrillation, pulmonary artery branch stenoses, right ventricular aneurysms, right ventricular outflow tract obstruction, residual ventricular septal defects, and coronary artery disease. Management approaches to these potential problems are discussed. Issues related to genetics, pregnancy, infective endocarditis, insurability, and employment are also reviewed with specific reference to the individual with repaired tetralogy of Fallot.