Episode Transcript
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My name is doctor Annabelle SantosVolgman.
I'm a cardiologist.
And thank you for joining usfor this session
on management of arrhythmiasduring pregnancy.
This project was supported
by funding from Merckthrough its Merck for mothers program.
As I said,I'm Doctor Annabelle Santos Volgman,
I'm the McMullen-Eybel Endowed Chairfor Excellence in Clinical Cardiology
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and professor of medicineat Rush College of Medicine,
and I am the co-founder of the RushHeart Center for Women.
The recommendations and opinionspresented by our guest speakers
may not represent the official positionof the American Heart Association.
The materials are for educational purposesonly and do not constitute
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an endorsement or instruction by the AHAor the American Stroke Association.
The AHA/ASA does not endorse any productor device.
These are my disclosures.
In this episode, we will exploreand summarize the epidemiology of a rhythm
as seen during pregnancyand during the postpartum period.
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We will review the guidelinedirected treatment for a rhythm during
pregnancy, incorporating the safetyof medications and invasive treatments,
as well as recommendations for the careduring the postpartum period.
The learning objectivesfor this session is one.
Discuss the epidemiology of arrhythmias
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seen during pregnancy and postpartum.
Two. Identify the treatment of a withmales during pregnancy and postpartum.
Three.
Evaluate the safety of medicationsand invasive treatments
of arrhythmiasduring pregnancy and postpartum.
The most commonly rhythmabnormalities in pregnant women
are usually PVCs and packs.
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When women present with palpitationsduring pregnancy,
50 to 60% of these
are due to these PVCs and pieces
that are benign,and they generally resolve spontaneously.
In the United States, the nationwidehospital discharges of pregnant women
between the age of 18 to 50 years old
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have increased from 2000 to 2012.
The frequencyper 100,000 pregnancy related
hospitalizations have a resonanceare shown in this figure.
As you can see, there are slightdifferences in the different age groups,
and you can see that, the age group of 41
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to 50 have the highest frequency
of pregnancy related hospitalizationsfor every three years.
So it's this
age groupthat we really need to be aware of,
that they will have, a lot morearrhythmias than the younger group.
But all of them,unfortunately, have risen over the last,
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decade between 2000 and 2012.
I'm going to start the presentationwith an illustration of
what are the problems that we deal within pregnant women.
This is a 35 yearold female with twin pregnancies
who complained of palpitationsthat she felt randomly and frequently.
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Her vital signs were normal,but her pulse was irregular.
The ECG was normal except for three PVCs,
and her labs were normal.
We checked her electrolytes, CBC,TSH, and vitamin D.
Her echocardiogram was normal,
but her Holter showed frequent PVCs.
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Initially,we treated her with oral magnesium,
and when she still had palpitations,we started her, beta blockers,
which really markedly decreased hersymptoms.
This slide shows the most commonarrhythmias among hospitalized patients.
As you can see,
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atrial fibrillation and supraventricular
tachycardiahave the highest frequency for 100,000
pregnancyrelated hospitalizations of arrhythmias.
These are increasing,as you saw previously in the slide
over the last, decade.
And we need to know how to treat,these common
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arrhythmias as well as all the other,arrhythmias.
As you know, pregnancy induced changesincrease susceptibility to arrhythmias.
These changesinclude increased resting heart rate
and because there's increasedblood volume.
This leads to
dilation of the cardiac chambers,which can contribute to the activation
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of stretch sensitive ion channelswith subsequent membrane depolarization,
slowed conduction,and changes in refractory nerves,
and these also lead to increasesin the length of these reentrant pathways,
all of which can increasethe risk of atrial fibrillation.
SVT v2 and VF placental
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origin hormonescan also be arrhythmia, genic,
including estradiol, progesterone,and free cortisol.
It's very important to also think
of the fetal safety of medicationswhen we treat arrhythmias.
Every patient who is pregnantwho has arrhythmias should have a multi
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disciplinary cardio obstetrics team,
including, of course, an obstetrician,
a maternal fetal medicine physician
and a cardiologist,as well as an electrophysiologist.
If the cardiologist is requiringmore expertise
from an electrophysiologist,of course we need nursing always
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and if needed,an anesthesiologist during delivery
and if needed, a neonatologist
if there is any during the deliveryand birth.
In terms of general electrophysiological
management of patients with arrhythmias,
the Heart Rhythm Society expertconsensus made some recommendations.
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This is a
class one recommendationthat patients with cardiac arrhythmias
should continue treatment duringpregnancy, delivery, and postpartum.
We should use medications with the longest
safety and efficacy record in pregnancy
at the lowest effective dose,and with periodic reevaluation.
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The use of antiarrhythmic drugsshould be informed by regulatory guidance.
Potential drug interactionsand risk to the fetus.
We should also know that
the changes in metabolismand intravascular volume during pregnancy
can alter the pharmacokineticsof antiarrhythmic drugs.
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Some of these medications may need
close monitoring of drug levelsor physiologic effects
that include serial EKGs,especially looking for q.t prolongation,
which are severalantiarrhythmic drugs can cause.
It is essential to talk to our patients
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about all of the risksand benefits of everything that we do
in patients with a regimens,so shared decision making is essential
when treatingpregnant patients with arrhythmias.
However, we
should also make sure that we treat thethe mother first.
And fetal growthrestrictions should not limit
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the use of beta blockerswhen clinically appropriate.
There's also, a table in the heartrhythm.
The 2023 Heart Rhythm ExpertConsensus Statement
on the Management of Arrhythmiasduring Pregnancy.
That is very helpful.
As you can see,not all beta blockers are equal.
Atenolol is really at a higher risk
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than most of the beta blockersand should not be used.
There are many other safe options,including
propranolol and metoprolol,
so we should use those beta blockers.
Natal during breastfeeding should be used
with caution and mixed gelatin and otherantiarrhythmic drugs that are not anti
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beta blockersshould also be used with caution.
But kundan and circle all have the bestsafety profile in pregnancy.
The heart rhythms
at society expert consensusalso have a class one recommendation
for cardioversion during pregnancy,
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including patients with unstable
supraventricular tachycardiaor ventricular tachycardia
used to current synchronized
cardioversion, for atrial fibrillation.
But defibrillationis also recommended for arrhythmias
that are such as ventricular fibrillation
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and use the same energy dosesfor non-pregnant patients.
For pregnant patients with stablebut symptomatic supraventricular
tachycardia or ventricular tachycardiathat are refractory
to pharmacological treatmentor contraindication to such treatment,
we should also considerelective synchronized cardioversion,
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or with fetal evaluation
as advised by the cardio obstetrics team.
During synchronized cardioversionor defibrillation, electrodes should be
positioned to avoid breast tissuefor optimal current delivery to the heart,
and these includethe sternal apical position
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and the antero posterior position.
Please remember to use these positionsin pregnant women
to avoid breast tissueand the fetus when, defibrillator ING
or converting these patients with lifethreatening arrhythmias.
The Heart Rhythm Society consensus
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also discusses radiation exposureduring cardiac procedures,
such as ablations for patientsthat need them.
There's a class one recommendationfor pregnant
patientswith significant arrhythmias unresponsive
to or unsuitablefor pharmacological therapy,
where we need to do catheter ablations,and we should prioritize
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this over the potential radiationrisk to the fetus.
A lot of times during
catheter ablation,they don't even need radiation.
They can do it without, radiation.
So especially during the first trimester
and with radiation exposure,
we we need to use the lowest possible
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radiation exposureor not use radiation exposure at all.
As I said,
techniques to minimize radiationexposure should be recommended.
And the Electrophysiologist are very wellaware of these recommendations.
Pregnant patients undergoing high riskcatheter
ablation should be managedby a cardio obstetrics team
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ready to handle complications,including urgent delivery.
If the fetus is near term.
Another recommendation is to placea pelvic
LED apron during fluoroscopy,which offers some benefit,
but it does not substantially reducefetal radiation exposure.
The Heart Rhythm Society also has
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recommendations for anesthesia.
The class one recommendation forthis is in patients with arrhythmias,
with hemodynamic instabilitythat require cardiac interventions,
general anesthesia is preferred overregional anesthesia
to optimize oxygenation
for patients beyond 26 weeks.
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Undergoing cardiac procedures of loftlateral tilt positioning is recommended
to avoid, to reduce, or avoid aorta
cable compressionand improve maternal hemodynamics.
Medications used during anesthesia
should be reviewed and adjustedto avoid exacerbation of revenues
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through the prolongationof acute interval.
Fetal monitoring duringcardiac procedures is also recommended,
with a cardio obstetrics teamprepared for complications,
including urgent delivery.
They also have a table,for the medications
that may prolong the acute interval.
And the list is substantial.
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And I'm not going to read all of these,but these include,
antihypertensive agents,antibiotics and induction agents.
And, the anesthesiologistsand electrophysiologist should be aware
of all these medications, risk.
And they also recommendthat pregnant patients can enter at next
or at risk for arrhythmias.
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Should receive neuro neuraxialor epidural anesthesia during labor
to prevent paininduced catecholamines, surges
that may trigger these arrhythmiasin terms of breastfeeding,
there are recommendations,during breastfeeding.
But there aresome that have minimal risk,
such as digoxin, propranolol,which are prolonged for optimal.
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There are some favorable safety profilebut limited data
which include Kavita Lal Asma la prochaine
amide, Jill Tyson Fleck and Soto all
but please, pleaseavoid, if possible, amiodarone
and it is not recommendeddue to lack of data to use.
Jornada roan or IV utilized.
Another statement about antiarrhythmicdrugs during lactation
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is that safety in lactation is determinedby its concentrate in the breast.
Milk needle with low protein bindingcan be heavily excreted into the breast.
Milk can accumulate in infants,so this should be avoided.
As a beta blocker, decision should always
be made based on the underlyingclinical pathology.
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And pleaseremember that amiodarone is a last
resort in pregnant and breastfeeding womenwith life threatening arrhythmias
due to concernsabout fetal and neonatal toxicity.
So back to our case.
After,
our patient, had safe
deliveries of her twin boys,she continued to have frequent PVCs.
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She wanted to breastfeed and askedif that was safe for the babies.
We referred ourselvesto the discussion of medications
during lactation,which is, called the Drugs and Lactation
Database, or lack that she ended upusing beta blockers and magnesium.
Since then, I took care
of this patient many years ago,and the twin boys
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have graduated from collegeand the mom is doing very well.
So key takeaways from this talkis that arrhythmia care in pregnancy
requires a multidisciplinary careand always shared decision making.
Hemodynamics.
Significant arrhythmias require,the most effective therapy available,
including a cardioversionentered MC drugs, catheter ablation
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with fetal monitoringand measures to minimize radiation.
Thank you for listening to
this session and for more information,please visit this website.
For all of cardiovascular health andmaternal health in the professional Heart.
BaileyAmerican Heart Association. Thank you.