123. Cardio-Obstetrics: Pregnancy and Arrhythmia with Dr. Andrea Russo

CardioNerd (Amit Goyal), cardioobstetrics series co-chair Dr. Natalie Stokes, Cardionerds Duke University CardioNerds Ambassador and episode lead fellow, Dr. Kelly Arps, join Dr. Andrea Russo, Director of Electrophysiology and Arrhythmia Services at Cooper Medical School of Rowan University and immediate past president Heart Rhythm Society, for a discussion about pregnancy and arrhythmia. Stay tuned for a message from Dr. Sharonne Hayes about WomenHeart. Audio editing by Gurleen Kaur. Claim free CME for enjoying this episode! Dr. Russo's disclosures: Johnson and Johnson, Medtronic, Inc., Boston Scientific Corporation, Kestra, Medilynx, Up-to-Date, and ABIM. Abstract • Pearls Notes • References • Guest Profiles • Production Team CardioNerds Cardio-Obstetrics Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Episode Abstract Pregnant patients may have exacerbation of underlying arrhythmic syndromes or unmasking of previously undiagnosed arrhythmic syndromes. Management of atrial and ventricular tachyarrhythmias should proceed with increased urgency in pregnant patients due to risk of adverse hemodynamic events in the mother and fetus. Cardioversion of atrial and ventricular arrhythmias is safe in pregnancy. Preferred antiarrhythmic agents in pregnant patients include metoprolol, propranolol, verapamil, flecainide, propafenone, sotalol, procainamide, and lidocaine. Management of arrhythmias in pregnancy should include collaboration with obstetrics and maternal-fetal medicine teams. Pearls Pre-conception counseling is a shared decision making process; include obstetrics and maternal-fetal medicine colleagues in challenging cases. Have a high sense of urgency for acute arrhythmias in pregnancy due to risk of impaired fetal perfusion. Goals of acute arrhythmic management should include rapid treatment while avoiding hypotension. In scenarios when beta blockers are indicated, metoprolol and propranolol are first choice. Avoid atenolol as this drug has the highest risk of fetal bradycardia and intra-uterine growth retardation in the class. Lidocaine or procainamide should be first line for ventricular arrhythmias in pregnancy. Amiodarone is potentially teratogenic and should not be used in pregnant patients unless all other options have been exhausted. Show notes 1. What are the expected electrophysiologic changes associated with pregnancy? Increase in resting heart rate which peaks in third trimesterPR shorteningECG axis shift leftward and upwardNon-specific ST and T wave changes These changes, along with increased cardiac output and volume with increased stretch in all chambers, increase the risk of re-entrant arrhythmias in those who are predisposed. ↑ atrial volume -> ↑ stretch -> ↑ ectopy -> ↑ risk for re-entrant arrhythmias 2. What is the approach to pre-conception counseling for patients with known arrhythmias or arrhythmic syndromes? Anticipate frequency and potential severity of adverse arrhythmic outcomes during pregnancy and post-partum periodConsider available options for rhythm control and anticoagulation therapy, as appropriate, during the pre-conception, pregnancy, and post-partum periodsConsider catheter ablation prior to pregnancy, particularly for curable arrhythmias such as Wolff-Parkinson-White (WPW) and AVNRT Offer genetic counseling about hereditary risk to fetus for inherited arrhythmias such as Brugada syndrome and Long QT syndrome 3. What is the management of SVT in pregnancy? Consider the increased risk of tachyarrhythmias in pregnancy: Typically benign arrhythmias can lead to more rapid decompensation in mother due to increased baseline cardiac output. Typically benign arrhythmias can lead to rapid danger to the fetus due to maternal hypotension and shortened diastolic filling time, both of which contribute to impaired fetal perfusion. Treatment algorithm is identical to that of non-pregnant patients Attempt vagal maneuversAdenosine is safeCardioversion is safe: monitor the fetus during and after cardioversionIn stable arrhythmias, choose nodal blocking agents with the best safety profile: metoprolol, propranolol, and verapamil. Evaluation of the pregnant patient with new onset SVT Have a high index of suspicion for underlying structural heart disease such as peripartum cardiomyopathy in a pregnant women with new diagnosis of SVT – presence of structural heart disease significantly increases the risk of maternal morbidity and mortality. Pregnancy can be the first presentation of inherited arrhythmia syndromes that commonly present in young adults such as WPW, Brugada Syndrome, Catecholaminergic Polymorphic VT (CPVT), Long QT Syndrome (LQTS), Arrhythmogenic Right Ventricular Cardiomyopathy / Dysplasia (ARVC/D), and Hypertrophic Cardiomyopathy (HCM). 4. What are some special considerations for acute management of VT in pregnancy? Cardioversion is safe. First line pharmacologic therapy: lidocaine or procainamide Lidocaine has been associated fetal bradycardia but has been used safely without reported teratogenic effectBrugada syndrome: consider quinidine in Brugada syndromeFascicular VT: use verapamilOnly use amiodarone if absolutely necessary, and after the first trimester 5. What is the approach to chronic arrhythmia management in pregnancy? Preferred rate control agents: MetoprololPropranololDigoxinVerapamil AVOID: atenolol (increased risk of fetal bradycardia and intrauterine growth restriction; note that this risk is present with all beta blockers*) Preferred rhythm control agents: Flecainide (if no structural heart disease)Propafenone (if no structural heart disease)SotalolLidocaineProcainamideQuinidine AVOID: amiodarone; use only in a patient with refractory unstable arrhythmias after the first trimester (due to fetal thyroid and neurodevelopmental issues) AVOID: dronedarone; Category X in pregnancy Catheter ablation in the pregnant patient Best delayed until late in pregnancy or after deliveryMaternal-fetal medicine colleagues should be involved in procedural planningMinimize fluoroscopic timeShield the pelvis during fluoroscopy and use electroanatomic mapping *Surveillance for pregnant patients on beta blockers: Serial growth ultrasounds in the third trimesterAntenatal testing of for bradycardia and hypoglycemiaPostnatal monitoring for: BradycardiaApneaGrowth retardation 6. What is the approach to antiarrhythmic therapy in the breastfeeding patient? All antiarrhythmic drugs are passed into breast milk Preferred rate control agents: metoprolol, propranolol (watch for fetal bradycardia)Rhythm control agents: weigh risks and benefits; read dosing adjustments on prescribing instructions carefully AVOID: atenololAVOID amiodaroneAVOID: dronedarone 7. What is the approach to anticoagulation in pregnancy and breastfeeding? Use the CHAD2S2-VASc score to estimate stroke risk for pregnant patients with AF and AL Risk of stroke with AF and AFL in pregnancy are uncertain, as women of childbearing age were minimally represented in large studies evaluating prophylactic antithrombotic drug treatment. Pregnancy Low molecular weight heparin is preferred in the first trimester and around the time of delivery.Warfarin should be avoided during the first trimester (especially at doses >5 mg daily), but may be used in the second and beginning of the third trimester.Avoid DOACs Breastfeeding Use warfarin or LMWH AVOID: DOACs may be excreted in breast milk and should not be used during breast feeding. 8. What is the approach to specific arrhythmic syndromes? AVNRT: recommend catheter ablation prior to conception if prior diagnosis. Manage acute events if they occur during pregnancy. WPW: recommend catheter ablation prior to conception if prior diagnosis. Use procainamide for acute arrhythmic events and avoid nodal blocking agents. LQTS:recommend beta blockers (metoprolol or propranolol) through pregnancy and at least through the post -partum period CPVT: recommend beta blockers (metoprolol or propranolol) through pregnancy and at least through the post-partum period 9. What is the approach to management of cardiac arrest in the pregnant patient? ACLS should be performed per ACLS guidelines, including chest compressions and defibrillation. Positioning: aim to avoid IVC compression and impaired venous return to the heart in the supine pregnant patient. Patients with a pulse: left lateral decubitusNo pulse: Manually displace the uterus to the leftAll patients: place IVs above the diaphragm Be prepared for difficult airway in mother due to airway edema Call OB and neonatal teams immediately to determine need for emergency C-section if no ROSC within the first several minutes. References Lindley KJ, Judge N. Arrhythmias in Pregnancy. Clin Obstet Gynecol. 2020;63(4):878-892. doi:10.1097/GRF.0000000000000567 Vaidya VR, Arora S, Patel N, et al. Burden of Arrhythmia in Pregnancy. Circulation. 2017;135(6):619-621. doi:10.1161/CIRCULATIONAHA.116.026681 Seth R, Moss AJ, McNitt S, et al. Long QT syndrome and pregnancy. J Am Coll Cardiol. 2007;49(10):1092-1098. doi:10.1016/j.jacc.2006.09.054 Hodes AR, Tichnell C, Te Riele AS, et al. Pregnancy course and outcomes in women with arrhythmogenic right ventricular cardiomyopathy. Heart. 2016;102(4):303-312. doi:10.1136/heartjnl-2015-308624 European Society of Gynecology (ESG); Association for European Paediatric Cardiology (AEPC); German Society for Gender Medicine (DGesGM), et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC).