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12599 2019;21:263–70
The Obstetrician & Gynaecologist
Review
http://onlinetog.org
Please cite this paper as: Roberts A, Mechery J, Mechery A, Clarke B, Vause S. Management of palpitations and cardiac arrhythmias in pregnancy. The Obstetrician
& Gynaecologist 2019;21:263–70. https://doi.org/10.1111/tog.12599
left axis deviation, within the normal range, in part due to the
Table 1. Differential diagnosis of palpitations in pregnancy
rotation of the heart from the gravid uterus.5 Inverted or
flattened T waves in leads III, V1–V3 and a Q wave in leads Aetiology Diagnosis
II, III and aVF, are also commonly seen.9
Atrial and ventricular ectopic beats are also more frequent; Physiological/ Relative sinus tachycardia of pregnancy
benign Exercise or stress-induced sinus tachycardia
50–60% of pregnant women will have ectopic beats on Occasional ectopic beats
continuous ECG recordings.2
Arrhythmias Supraventricular tachycardia/extrasystoles
Atrial fibrillation/flutter
Ventricular tachycardia/extrasystoles
Arrhythmogenesis Bradyarrhythmias: sinus bradycardia,
The generation of arrhythmias in pregnancy may be related to atrioventricular heart block
Awareness of a fast, regular heartbeat, particularly when lying down Fast and irregular heart beat
Occasional ‘thumping sensation’ suggestive of occasional ectopic beats Palpitations waking from sleep or at work
Pre-vasovagal symptoms preceding the palpitations Dizziness following the onset of palpitations
Shortness of breath, chest pain, syncope
Associated headache, sweating or abdominal
pain and/or hypertension (consider phaeochromocytoma)
Personal history of pre-existing cardiac disease
Family history of cardiac disease, e.g. long QT syndrome,
cardiomyopathy, sudden death
Audible heart murmur Isolated sinus tachycardia at time of symptoms on ambulatory ECG
Concerning features on history, e.g. shortness of breath Infrequent ectopic beats in the absence of other signs of structural heart disease/
inherited arrhythmia
Known structural heart disease
ECG = electrocardiogram.
Adenosine Benefits outweigh risk of fetal toxicity in large doses Safe (short half-life)
Flecainide Likely safe, insufficient data to suggest any fetal issue Present in breastmilk, not known to
Also used to treat fetal supraventricular tachycardia be harmful
Women should remain on beta blocker therapy throughout Box 3. General principles of the management of pre-existing
arrhythmias
– and most importantly – after pregnancy. Care should be
taken to avoid electrolyte disturbances or drugs that prolong Preconception
the QT interval. Hyperemesis can be a particularly high-risk Condition-specific advice on risk in pregnancy
situation, when frequent vomiting means that anti-arrhythmic Review of medication and changes advised if appropriate
medication may not be tolerated and electrolyte disturbances Optimisation of condition prior to conceiving; consider referral for
accessory pathway ablation
may occur. The charity Cardiac Risk in the Young has
published a list of drugs to avoid in LQTS.33 This list Antenatal
includes several drugs commonly prescribed in pregnancy, Review of medication
for example, the anti-emetics prochloperazine and Growth scans if on beta-blockers
Anaesthetic review and planning
ondansetron, and the antibiotics trimethoprim and Planning for birth
erythromycin. LQTS has been associated with sudden infant
Intrapartum
death, with one study detecting an LQTS gene variant in almost
10% of cases.34 Mothers with LQTS should therefore be offered Vaginal birth usually recommended
Consider place of birth if risk of arrhythmia high; co-located unit
a review by the neonatal team prior to discharge and a referral with appropriate facilities
to genetics for their baby.5 Consider continuous cardiac monitoring in those at high risk
Care plan to include advice on management of acute arrhythmia
and ensure drugs/facilities available in advance, and drugs to be
Bradyarrhythmias avoided
pregnancy. Whenever possible, women should be counselled 5 Cordina R, McGuire M. Maternal cardiac arrhythmias during pregnancy and
lactation. Obstet Med 2010;3:8–16.
regarding the pros and cons of a particular treatment choice. 6 Carruth JE, Mivis SB, Brogan DR, Wenger NK. The electrocardiogram in
The UK Teratology Information Service is a useful source of normal pregnancy. Am Heart J 1981;102:1075–8.
further information.37 Table 5 details drugs referred to in 7 Emmanuel Y, Thorne SA. Heart disease in pregnancy. Best Pract Res Clin
Obstet Gynaecol 2015;29:579–97.
this article.16,38 8 Samways J, Vause S, Kontopantelis E, Eddleston J, Ingleby S, Roberts A, et al.
Maternal heart rate during the first 48 h postpartum: a retrospective cross
sectional study. Euro J Obstet Gynecol Repro Biol 2016;206:41–7.
Management of pregnancy in pre-existing 9 Sunitha M, Chandrasekharappa S, Brid S. Electrocardiographic Qrs axis, Q
arrhythmia wave and T-wave changes in 2nd and 3rd trimester of normal pregnancy. J
Clin Diagn Res 2014;8:17–21.
Ideally, women with a pre-existing cardiac arrhythmia should 10 Greenwood JP, Scott EM, Stoker JB, Walker JJ, Mary DA. Sympathetic neural
mechanisms in normal and hypertensive pregnancy in humans. Circulation
be managed by a multidisciplinary team, which should include 2001;104:2200–4.
an obstetrician with an interest in maternal medicine, a 11 Roberts JM, Insel PA, Goldfien A. Regulation of myometrial adrenoreceptors
cardiologist and an anaesthetist. Care will vary depending on and adrenergic response by sex steroids. Mol Pharmacol 1981;20:52–8.
12 Brugada P, G€ ursoy S, Brugada J, Andries E. Investigation of palpitations.
the condition and any associated underlying cardiac disease. Lancet 1993;15(341):1254–8.
Box 3 summarises the general principles of management. 13 Raviele A, Giada F, Bergfeldt L, Blanc JJ, Blomstrom-Lundqvist C, Mont L,
et al. Management of patients with palpitations: a position paper from the
European Heart Rhythm Association. Europace 2011;13:920–34.
14 Thavendiranathan P, Bagai A, Khoo C, Dorian P, Choudhry NK. Does this
Conclusion patient with palpitations have a cardiac arrhythmia? JAMA
2009;302:2135–43.
Palpitations are a common complaint in pregnancy. Many
15 Neuberger F, Nelson-Piercy C. Acute presentation of the pregnant patient.
women who report palpitations are experiencing an awareness Clin Med 2015;15:372–6.
of the physiological cardiovascular changes in pregnancy, but 16 Adamson DL, Nelson-Piercy C. Managing palpitations and arrhythmias
during pregnancy. Heart 2007;93:1630–6.
some will have serious arrhythmias. Women with pre-existing
17 Mahendru AA, Everett TR, Wilkinson IB, Lees CC, McEniery CM. A
heart disease are most at risk; the clinician should be vigilant for longitudinal study of maternal cardiovascular function from preconception
undiagnosed underlying cardiac disease. The majority of anti- to the postpartum period. J Hypertens 2014;32:849–56.
18 Stein PK, Hagley MT, Cole PL, Domitrovich PP, Kleiger RE, Rottman JN.
arrhythmic treatments are safe in pregnancy and prompt,
Changes in 24-hour heart rate variability during normal pregnancy. Am J
effective treatment of pathological arrhythmias should be Obstet Gynecol 1999;180:978–85.
instigated without delay. Care in pregnancy should be 19 Li JM, Nguyen C, Joglar JA, Hamdan MH, Page RL. Frequency and outcome
of arrhythmias complicating admission during pregnancy: experience from a
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Disclosure of interests 20 Lee SH, Chen SA, Wu TJ, Chiang CE, Cheng CC, Tai CT, et al. Effects of
pregnancy on first onset and symptoms of paroxysmal supraventricular
Sarah Vause is an RCOG Council Member (North West tachycardia. Am J Cardiol 1995;76:675–8.
Fellows Representative) and MPTS Tribunal Member. The 21 Tawam M, Levine J, Mendelson M, Goldberger J, Dyer A, Kadish A. Effect of
other authors have no conflicts of interest. pregnancy on paroxysmal supraventricular tachycardia. Am J Cardiol
1993;72:838–40.
22 Di Biase L, Walsh EL. Wolff-Parkinson-White syndrome: anatomy,
Contribution to authorship epidemiology, clinical manifestations, and diagnosis. In: Levy S, Knight BP,
AR researched and wrote the article. JM conceived the idea Downey BC, eds. UpToDate. Waltham, MA: Wolters Kluwer; 2018 [https://
www.uptodate.com/contents/wolff-parkinson-white-syndrome-anatomy-
for the article. BC provided the ECG images. JM, AM, BC epidemiology-clinical-manifestations-and-diagnosis].
and SV drafted and revised the manuscript. All authors read 23 Miller JM. Therapy of Wolff-Parkinson-White syndrome and concealed
and approved the final version of the manuscript. bypass tracts: Part I. J Cardiovasc Electrophysiol 1996;7:85–93.
24 Silversides C, Harris L, Yap S-C. Supraventricular arrhythmias during
pregnancy. In: Calkins H, Estes NAM, III, Downey BC, eds. UpToDate.
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