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DOI: 10.1111/tog.

12599 2019;21:263–70
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Management of palpitations and cardiac arrhythmias


in pregnancy
Anna Roberts MBChB MRCOG,a,* Joseph Mechery MBBS MD DFFP FRCOG,b Anthony Mechery MBBS MD DM MRCP,
c

Bernard Clarke MRCP MD FRCP FRCOG,d Sarah Vause MD FRCOGe


a
Consultant Obstetrician, St Mary’s Hospital, Manchester University Hospitals NHS Foundation NHS Trust, Manchester M13 9WL, UK
b
Consultant Obstetrician and Gynaecologist, Ysbyty Glan Clwyd, Betsi Cadwaladr University Health Board, Rhyl LL18 5UJ, UK
c
Fellow in Interventional Cardiology, Queen Elizabeth University Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham
B15 2GW, UK
d
Professor and Consultant Cardiologist, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation NHS Trust, Manchester
M13 9WL, UK
e
Consultant in Fetal and Maternal Medicine, St Mary’s Hospital, Manchester University Hospitals NHS Foundation NHS Trust, Manchester
M13 9WL, UK
*Correspondence: Anna Roberts. Email: anna.roberts@mft.nhs.uk

Accepted on 19 December 2018. Published online 22 August 2019.

Key content Learning objectives


 Palpitations are common in pregnancy; while they are frequently  To identify which women presenting with palpitations require
benign, some will represent a significant arrhythmia. further investigation.
 Pregnant women presenting with palpitations require a careful  To understand normal changes in the electrocardiogram in
assessment to determine whether their symptoms can be attributed pregnancy and be able to identify common arrhythmias.
to normal physiology or require further investigation  To understand the principles of management of common cardiac
for pathology. arrhythmias during pregnancy.
 Management of pre-existing arrhythmias in pregnancy requires a  To know the risks and benefits of common anti-arrhythmic drugs
multidisciplinary team approach. in pregnancy and breastfeeding.
 Most anti-arrhythmic treatments are safe in pregnancy, and
Keywords: arrhythmias / long QT syndrome / palpitations /
prompt, effective treatment of pathological arrhythmias should be
pregnancy
instigated without delay.

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

Introduction Physiological changes


Palpitations are a common complaint in pregnancy. Only a Cardiac output increases by approximately 50% during
few women presenting with palpitations will have significant pregnancy.5 This is largely due to an increase in stroke
cardiac arrhythmias, which are the most frequent cardiac volume as a result of reduced vascular resistance and an
complication in pregnancy.1 increase in blood volume. The heart rate rises by 10–20 beats
Palpitations are usually benign: around 50% of pregnant per minute, mainly during the third trimester, and accounts
women who are investigated for palpitations are found to for further enhancement in cardiac output.6
have ectopic beats or non-sustained arrhythmias.2 Those with Intrapartum, the cardiac output rises further, with stroke
pre-existing cardiac disease (congenital, structural or prior volume and a further rise in heart rate implicated.7
arrhythmias) are at highest risk of arrhythmias.3 In one Postpartum, changes in heart rate are less well defined. One
cohort of 1802 women with congenital heart disease, the study found the upper threshold of normal to be around
prevalence of arrhythmias was 4.7%.1 In another cohort of 110 beats per minute within the first 48 hours postpartum.8
women who had experienced a sustained tachyarrhythmia
prior to pregnancy, 43% had a recurrence during pregnancy
Electrocardiogram changes
or in the first month postpartum.4 Arrhythmias may also
occur de novo during pregnancy, although descriptions of A resting 12-lead electrocardiogram (ECG) in pregnancy will
prevalence vary widely. demonstrate an increase in heart rate. There may be a slight

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Management of palpitations in pregnancy

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

a combination of haemodynamic, autonomic and hormonal Systemic causes Hyperthyroidism


factors. An increase in atrial and ventricular stretch that is Anaemia
Sepsis
secondary to an increased blood volume may contribute. Hypovolaemia
Higher levels of estrogen may increase alpha-adrenergic Pulmonary embolus
receptors, resulting in an enhanced adrenergic response.10,11 Hypoglycaemia
Phaeochromocytoma
Postural orthostatic tachycardia syndrome (POTS)
Management of palpitations Psychosomatic Anxiety
Panic disorder
Definitions and descriptions
Drugs Caffeine
Palpitations are defined as an unpleasant awareness of the
Nicotine
heartbeat.12 The sensation of the heart beating may be Alcohol
forceful, irregular or fast. Under normal conditions, the Cocaine, heroin, amphetamines
heartbeat is not usually perceived.13 However, during exercise Sympathomimetic drugs, e.g. salbutamol inhalers
Vasodilators, anticholinergics
or at times of emotional stress, it is normal for the individual
Recent withdrawal of beta blockers
to become aware of their heart beating. Ingestion of
substances such as coffee and nicotine, which increase
adrenergic tone, can also have this effect, inducing a
symptomatic sinus tachycardia.12,13 In these circumstances, associated with syncope or pre-syncope should always
palpitations are considered physiological rather than prompt further investigation.
pathological. During pregnancy, women may experience the Other salient features to elicit from the history are shown
sensation of a ‘pounding heartbeat’, originating from a in Table 2.13
heightened awareness of the physiological increase in heart
rate and accompanying increased stroke volume.5 Atrial and
Examination
ventricular ectopic beats are often experienced as a ‘missed’
or ‘skipping’ heartbeat. Many women presenting with Basic observations – including a manual palpation of the
palpitations will be experiencing an awareness of these pulse, blood pressure, respiratory rate, oxygen saturation and
benign, physiological changes rather than a pathological temperature – are essential, both in the acute and non-acute
arrhythmia. Table 1 summarises the differential diagnoses of presentation. Cardiovascular examination, including
palpitations in pregnancy. auscultation of the heart, will elicit any abnormal heart
It is essential to take a thorough, careful history when sounds that raise the possibility of underlying heart disease.
making an initial assessment to delineate physiology from Although a flow murmur is a common finding in pregnancy,
pathology. It is imperative to ask what the woman means by in the context of a presentation with cardiac symptoms,
‘palpitations’. Despite a clear definition in the doctor’s mind, further investigation for structural heart disease is
in colloquial terms, palpitations may mean many things – mandatory. Respiratory examination is also useful to
something to be especially mindful of if English is not the determine any features suggestive of pulmonary oedema or
patient’s first language. The woman should be asked to lung pathology; for example, infection.
describe the exact sensation, as well as the frequency and
duration: is it fast, regular or irregular? Classically, women
Investigation
with physiological symptoms will describe an awareness of a
fast heartbeat, often at rest and particularly when lying down. Determining who is at risk of arrhythmia
Patients may also describe a ‘thumping’ sensation or a A systematic review of seven studies, which aimed to
compensatory pause from ectopic beats. Palpitations determine the accuracy of features in the history for

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Roberts et al.

Women with congenital heart disease are particularly at


Table 2. Salient features to elicit with a history of palpitations
risk of a pathological arrhythmia, especially those who have
History Comments previously had cardiac surgery.15,16 It should also be borne in
mind that underlying cardiac conditions can present for the
Frequency and duration Sudden onset and offset may raise the first time in pregnancy. Table 3 summarises the clinical
Onset and offset suspicion of arrhythmia
features that might raise suspicion of an arrhythmia.
Circumstances At rest or on exertion Women with a very clear history of an awareness of a
Provoking and relieving Vagal manoeuvres, rest physiological rise in heart rate (in the absence of a significant
factors tachycardia on examination) or the occasional ectopic beat
Associated symptoms? Pre-syncope, syncope may not require further investigation. If this is not clear from
What is their chronology? Shortness of breath; ask about the history, or if symptoms are severe or persistent, baseline
orthopnoea and paroxysmal investigations should be performed,15 including a full blood
nocturnal dyspnoea count to exclude anaemia, thyroid function tests to exclude
Chest pain
Dizziness
thyrotoxicosis and a 12-lead ECG.
Symptoms suggestive of Sepsis
systemic disorders Thyrotoxicosis
12-lead electrocardiogram
Although pregnant women often report palpitations to their
Did the symptoms pre-date Pre-existing symptoms may raise
pregnancy? suspicion of underlying arrhythmia
obstetrician, the obstetrician is usually not present during a
symptomatic episode of palpitations when the 12-lead ECG is
Prescription or illicit drug use Including caffeine intake
the gold standard for diagnosis.13 Occasionally, if women
Personal history of heart – have been seen in an emergency department, a copy of an
disease
ECG taken at the time may be available.
Family history of heart Raises suspicion of underlying heart An abnormal baseline ECG may indicate underlying
disease or sudden cardiac disease, inherited cardiomyopathy or
death channelopathies
pathology and is therefore an essential part of arrhythmia
assessment. For example, the ECG of a woman with Wolff-
Parkinson-White syndrome may show a delta wave; high
voltages in the precordial leads with Q wave and ST changes
predicting the diagnosis of arrhythmias, found that only a
may be seen in hypertrophic cardiomyopathy, or a corrected
known history of cardiac disease (likelihood ratio [LR] 2.03,
QT interval of more than 460 ms in long QT
95% confidence interval [CI] 1.33–3.11) and palpitations
syndrome (LQTS).13,16 Any variant other than those already
affected by sleeping (LR 2.29, 95% CI 1.33–3.94) or while at
described as normal changes in pregnancy should prompt a
work (LR 2.17, 95% CI 1.25–5.78) increase the likelihood of a
second opinion from a medical or cardiology colleague.
cardiac arrhythmia. Arrhythmias may be less likely when
there is a prior history of panic disorder (LR 0.26, 95% CI
0.07–1.01) or when the duration of a palpitation episode is Ambulatory electrocardiogram monitoring
less than 5 minutes (LR 0.38, 95% CI 0.22–0.63).14 This If there are concerning features in the history or examination,
review was of the general adult population and did not or if the history is not consistent with physiological symptoms,
specifically include pregnant women. then ambulatory ECG monitoring is indicated. While this

Table 3. Features raising suspicion of an arrhythmia

Reassuring features Features requiring further attention

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

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Management of palpitations in pregnancy

Box 1. Interpreting the results of a Holter monitor


Tachyarrhythmias
Sinus tachycardia
 If symptoms correspond with a sinus tachycardia and all other Small physiological studies (including up to 55 women) have
investigations are normal (in the absence of suspicion of systemic
pathology, e.g. pulmonary embolus or sepsis), reassure that this is defined average heart rate in the third trimester as between 80
physiological and do not perform any further investigations. and 87 beats per minute (standard deviation 10 and 8,
 Infrequent atrial or ventricular ectopic beats, couplets and triplets respectively).17,18. Once systemic disorders have been
without other suspicion of an underlying structural heart disease on
excluded, it is often difficult to determine when a sinus
clinical examination or an inherited arrhythmia do not require
further investigation.17 tachycardia represents an exaggerated physiological response
 If there is significant arrhythmia and the patient is symptomatic, to pregnancy or pathology. Most are benign and do not
seek urgent advice from Cardiology. require treatment, but inappropriate sinus tachycardia and
postural orthostatic hypotension (POTS) should be
increases the likelihood of capturing an episode of palpitations, considered as alternative diagnoses.
symptoms are often infrequent and unpredictable, meaning
that this investigation has very variable sensitivity.13,16 A Atrial and ventricular premature beats
Holter monitor, the most used monitor in pregnant women Atrial and ventricular premature beats or ectopic beats are
presenting with palpitations, is an external recorder very common in pregnancy. One Holter monitor study
connected to the woman by skin electrodes. It is commonly detected atrial or ventricular beats in more than 50%
used for periods of 24–72 hours (Box 1). In a systematic review of of pregnant women. Rates of both were similar in
diagnostic yield, a 24-hour Holter monitor diagnosed a clinically those experiencing palpitations and those who were
significant arrhythmia in 3–24% of women.14 Women should be asymptomatic.2 Women should be reassured that ectopic
asked to record any symptoms and correlating activity on the beats are benign and treatment is not usually required.
diary card accompanying the monitor, to aid interpretation.
Various alternative devices for ambulatory monitoring may Supraventricular tachycardia
be of particular use when symptoms occur less frequently. An Supraventricular tachycardia (SVT) is the most common
event recorder is a portable device that can be held to the non-benign arrhythmia in pregnancy, with a frequency of
chest during a palpitation and records a one-lead ECG 24 in 100 000.19 Reports of first onset of SVT in pregnancy
reading. More invasive systems include implantable loop range from 3.8%20 to 34% of women presenting with SVT
recorders, pacemakers and internal cardiac defibrillators, in pregnancy.21
which can automatically detect arrhythmic events.13 Most commonly, paroxysmal supraventricular tachycardia
(PSVT) is caused by an atrioventricular nodal re-entrant
Echocardiogram tachycardia (AVNRT).20 In this arrhythmia, a re-entry circuit
An echocardiogram will exclude structural heart disease and is occurs via the atrioventricular (AV) node and surrounding
an important investigation in the assessment of palpitations in perinodal atrial tissue.5 Another common cause of PSVT is
many women. In women for whom the clinician believes the presence of an overt or concealed accessory pathway,
symptoms are physiological rather than pathological, an which allows conduction to bypass the AV node. Accessory
echocardiogram may not be required. Table 4 summarises tissue conducts electrical impulses faster than the AV node,
the types of patients who might need an echocardiogram. hence the PR interval on an ECG is usually shortened where

Table 4. Who needs an echocardiogram?

Features suggesting need for echocardiogram Echocardiogram may not be indicated

Diagnosed arrhythmia Symptoms consistent with physiological changes in pregnancy

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

Previous chemotherapy with cardiotoxic agents

Family history of inherited arrhythmia, e.g. long QT syndrome,


sudden cardiac death

ECG = electrocardiogram.

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Roberts et al.

an accessory pathway is present.22 In Wolff-Parkinson-White


syndrome, an accessory pathway is present that allows Box 2. Cardiac disease associated with ventricular tachycardia31
conduction between the atria and the ventricles in both
Cardiac disease
directions (anterograde and retrograde). This is manifested  Hypertrophic cardiomyopathy
on the resting ECG as a delta wave.23  Peripartum cardiomyopathy
SVT classically presents as a palpitation with abrupt onset  Arrhythmogenic right ventricular cardiomyopathy
 Congenital heart disease, including previous cardiac surgery
and offset. Associated symptoms, for example syncope or
 Valvular disease
chest pain and related haemodynamic compromise, are  Myocardial infarction
variable, in part influenced by whether structural heart
Inherited channelopathies
disease is also present.24  Long QT syndrome
Vagal manoeuvres such as the Valsalva manoeuvre are the
first-line treatment for SVT. If these measures fail,
intravenous adenosine should be used. This successfully
terminates 90% of SVT in pregnancy25 and is safe to use in a Ventricular tachycardia
monitored clinical environment. Alternative measures include In ventricular tachycardia (VT), the ventricular muscle
verapamil, metoprolol or direct current cardioversion, depolarises with a high frequency, resulting in a wide and
particularly if there is haemodynamic compromise.16,26 Beta abnormal QRS complex.29 VT is often associated with
blockers are commonly used for prophylaxis in women with structural heart disease or primary electrical disease
known PSVT. Catheter ablation of an accessory pathway is (Box 2). In a woman presenting with VT, these conditions
not usually recommended in pregnancy.27 must be carefully excluded. Idiopathic VT in healthy women
most commonly originates from the right ventricular outflow
Atrial fibrillation and flutter tract (RVOT). This usually presents with short runs of non-
Atrial fibrillation and flutter are uncommon in pregnancy sustained VT with a left bundle branch block pattern and is
and usually associated with cardiac pathology such as mitral treated with beta blockade or verapamil.16,27
stenosis, or metabolic and electrolyte abnormalities.16 New Ventricular arrhythmias in women with cardiac disease
episodes in pregnancy should prompt investigation and carry a potential risk of sudden death and require immediate
treatment of an underlying cause. treatment.16,30 When there is haemodynamic instability,
In atrial fibrillation, atrial muscle fibres contract electrical cardioversion is preferable. There is no evidence
independently in an irregular manner, resulting in the of harm to the fetus with electrical cardioversion.30 If the
absence of P waves and irregular ventricular contraction. In woman is haemodynamically stable, pharmacological
atrial flutter, the atria beat regularly at a rate of 300 beats per cardioversion can be attempted, for example with sotalol or
minute with a ventricular rate of 150 beats per minute (in 1:2 flecanide. The drug of choice is dependent on the
conduction), resulting in a characteristic ‘saw tooth’ underlying pathology.27
appearance on the ECG.28 Prophylaxis against VT in women at high risk includes
In addition to the haemodynamic consequences, most beta blockers, amiodarone (Table 5) or an implantable
apparent in the presence of mitral stenosis, the presence of cardioverter defibrillator device (ICD). ICDs are also
atrial fibrillation or flutter increases the risk of systemic sometimes inserted for secondary prevention in those who
embolism in an already pro-thrombotic state of are known to be at high risk of life-threatening arrhythmias.
pregnancy.16,25 Women with persistent atrial fibrillation
should be anticoagulated.28 This is usually done with low Long QT syndrome
molecular weight heparin and requires a multidisciplinary LQTS is characterised by a prolonged QT interval on the
approach involving cardiologists, haematologists and ECG, secondary to a disorder of ventricular myocardial
obstetricians, with careful planning around delivery. repolarisation. This can lead to ventricular arrhythmias,
If haemodynamic compromise is present, the first-line typically torsade de pointes and a risk of sudden death. In
treatment for an acute episode is direct current cardioversion. inherited LQTS, gene defects code for cardiac ion channels.
Pharmacological methods aim to cardiovert or rate control, Numerous genes have been identified, with KCNQ1, KCNH2
and are usually considered in stable women. Preferred drugs and SCN5A mutations being most commonly associated.31
in the acute setting for those who have a structurally normal Events appear to be less common during pregnancy, but
heart include intravenous flecainide or butilide. AV nodal- there is a significant increase in the risk of cardiac events in
blocking drugs are used as rate control in prophylaxis for the postpartum period, particularly in women with type 2
paroxysmal episodes, or in those where cardioversion cannot LQTS.32 This may be compounded by the disturbed routines
be achieved. The European Society for Cardiology and sleep deprivation associated with caring for a newborn
recommends beta blockers as a first-line agent.27 baby, when women may forget to take their medication.

ª 2019 Royal College of Obstetricians and Gynaecologists 267


Management of palpitations in pregnancy

Table 5. Antiarrhythmic drugs in pregnancy (BNF)16,38

Drug Safety/complications Breastfeeding

Adenosine Benefits outweigh risk of fetal toxicity in large doses Safe (short half-life)

Amiodarone Suitable for short-term use in emergencies Avoid long-term use


Prolonged use: fetal thyroid abnormalities, growth restriction and prematurity; risk may Risk neonatal hypothyroidism
outweigh benefit

Beta Commonly used, benefits generally outweigh risks Safe


blockers Possible relationship with growth restriction in fetus but many confounding factors, e.g.
hypoglycaemia, hyperbilirubinaemia

Digoxin Safe unless toxic doses Safe

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

Lidocaine Safe unless toxic doses Safe

Verapamil Safe Safe


Rapid injection may cause maternal hypotension and associated fetal distress

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

Bradyarrhythmias are rare in pregnancy and are usually Postnatal


tolerated well. In women with a structurally normal heart,  Period of inpatient monitoring
 Some conditions high risk of postnatal event, e.g. long QT syndrome
first-degree heart block is benign and second-degree heart
 Plans for medication and breastfeeding
block of the Wenkebach type is usually not associated with  Ensure plans for continuing cardiological care/investigations
symptomatic bradycardia.5 Complete heart block can be arranged
congenital or acquired, usually in the context of previous
surgery for congenital heart disease. New diagnoses of
congenital heart block can occur in pregnancy because it is
Anti-arrhythmic drugs in pregnancy
often not diagnosed until adult life.35 If women are
asymptomatic, pregnancy and birth is usually well tolerated.36 A careful analysis of the risks and benefits of the
In symptomatic women, pacing is recommended. This can pharmacological treatment of arrhythmias is important.
be temporary to cover delivery, or permanent, which is safe Most anti-arrhythmic drugs, with the notable exception of
to perform in pregnancy.27 long-term amiodarone, have an acceptable safety profile in

268 ª 2019 Royal College of Obstetricians and Gynaecologists


Roberts et al.

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.
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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
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Maternal heart rate during the first 48 h postpartum: a retrospective cross
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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
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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
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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.
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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
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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://
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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.
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