Antiarrhythmic drug therapy in pregnancy and lactation

doi:10.1016/S0002-9149(98)00473-1

The American Journal of Cardiology

Volume 82, Issue 4, Supplement 1, 20 August 1998, Pages 58I-62I

https://doi.org/10.1016/S0002-9149(98)00473-1 Get rights and content

Abstract

Antiarrhythmic agents commonly used in clinical practice are reviewed with respect to their potential for teratogenic or other adverse fetal effects. Although most experience with antiarrhythmic drug therapy during pregnancy has accrued with digoxin, quinidine, and propranolol, other antiarrhythmic agents may also be used in the pregnant patient if indicated. The choice of antiarrhythmic drug depends on the specific arrhythmia being treated, the cardiac condition of the patient or fetus, and the known or anticipated actions of the antiarrhythmic drug being considered. The management of specific arrhythmias encountered in pregnant women are also discussed. For benign arrhythmias, a conservative approach starting first with preventive measures is appropriate. For more severe or symptomatic arrhythmias, pharmacologic therapy should be instituted using drugs with proven safety to the fetus, if possible. Electrical cardioversion of the patient may be performed with relative safety in more emergent situations.

Section snippets

Digoxin

Digoxin has a long history of safe and effective use in pregnant women.2 It has minimal binding to the fetal heart during the first half of gestation, which may contribute to fetal tolerance.1 Digoxin is not teratogenic, nor is it associated with other adverse fetal outcomes when dosed appropriately. On the other hand, digitalis toxicity during pregnancy has been associated with miscarriage4 and fetal death,5 probably due to maternal cardiac instability and subsequent uterine hypoperfusion.

Antiarrhythmic drugs and lactation

Essentially all of the antiarrhythmic drugs discussed thus far are excreted into breast milk to some extent. No data are available on the passage of adenosine into breast milk, but the short half-life of the drug would make it unlikely to present a problem.8 For most drugs, the amount consumed by an average nursing infant would be very small and not expected to be of clinical significance.1 There are, however, a few important exceptions. Acebutolol should be avoided because it is highly

Management of specific maternal arrhythmias during pregnancy

Any arrhythmia can occur in pregnant women. The frequency and symptomatic severity of atrial38 and ventricular39 ectopy as well as atrioventricular node-dependent tachycardias38 may be increased during pregnancy. The reasons for this increase in incidence remain speculative.

Some general principles apply to antiarrhythmic drug therapy in pregnancy. Primarily, all antiarrhythmic drugs should be considered potentially toxic to the fetus, and, whenever possible, nonpharmacologic or preventive

Management of fetal tachycardias

A detailed review of fetal arrhythmias and their treatment is beyond the scope of this discussion. Supraventricular tachycardias are the most common fetal tachycardias; however, in rare cases, VTs have been reported.46 Fetal supraventricular tachyarrhythmias may be either intermittent or sustained, and may cause hydrops fetalis.46 Antiarrhythmic agents that have been used to treat fetal supraventricular tachycardias include digoxin, verapamil, procainamide, and quinidine. In cases of fetal VT,

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Cited by (98)

2023 HRS expert consensus statement on the management of arrhythmias during pregnancy
2023, Heart Rhythm
This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.
The Use of Cardiac Drugs During Pregnancy
2022, Maternal Cardiac Care: A Guide to Managing Pregnant Women with Heart Disease
This chapter reviews the use of cardiac drugs during pregnancy. A core principle of drug therapy during pregnancy is that if a drug can be avoided, it should be avoided. However, in many cases, the potential benefits outweigh the potential risks, and physicians should not be intimidated by pregnancy into withholding appropriate therapy. For the most part, the treatment of cardiac conditions is the same as in nonpregnant women. However, some drugs that are commonly used to treat patients with heart conditions should not be used during pregnancy. These include atenolol, which has been associated with fetal growth retardation when given in the first trimester; propafenone; and diltiazem, which, although it has been used safely in pregnancy, has caused embryopathy in animal studies. In addition, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, both of which are mainstays in the treatment of systolic left-sided heart failure in nonpregnant patients, have been associated with fetal hypoperfusion, dysgenesis, and renal failure. They may be used postpartum. If anticoagulation is required, heparin and heparin derivatives are generally safest. The direct anticoagulants should not be used in pregnancy or breastfeeding. In rare cases, such as mechanical prosthetic valves, low-dose warfarin can be used safely.
Arrhythmias During Pregnancy
2022, Maternal Cardiac Care: A Guide to Managing Pregnant Women with Heart Disease
The diagnosis and management of arrythmias in pregnant and nonpregnant patients is similar. Palpitations are a common complaint in pregnancy. The frequency of sinus tachycardia as well as premature atrial and premature ventricular contractions increases in pregnancy. Only a small percent (0.2% to 0.3%) of such complaints are due to significant arrhythmias. Most antiarrhythmic drugs can be used safely in pregnancy. Cardioversion with propofol for sedation can safely be performed. Atrial fibrillation and atrial flutter are difficult to manage in pregnancy, mainly because of the need for anticoagulation. Intravenous heparin or enoxaprin are preferred.
Breastfeeding
2022, Maternal Cardiac Care: A Guide to Managing Pregnant Women with Heart Disease
The remarkable beneficial effects for both the mother and child serve as the major rationale for most obstetric and pediatric societies to promote the practice of breastfeeding whenever possible. The interplay between cardiac disease and pregnancy often raises concerns by patients and the health care team about the safety of breastfeeding in the setting of certain medications and conditions. For instance, some evidence linking the fragmented prolactin molecule with the etiology of peripartum cardiomyopathy has led some researchers to recommend against breastfeeding in women with confirmation of this diagnosis. Other concerns for cardiac patients are the excretion of certain drugs into the breast milk and their potential effects on infants and children. Fortunately, most drugs have a negligible concentration in breast milk and can be given safely to breastfeeding mothers.
Ischemic Heart Disease in Pregnancy
2021, Cardiology Clinics
Pregnancy and Cardiovascular Disease
2021, Sex Differences in Cardiac Diseases: Pathophysiology, Presentation, Diagnosis and Management
A 34-year-old, G1P1, asymptomatic woman, who grew up in Ethiopia presents for preconception counseling. She has a history of rheumatic heart disease resulting in mitral stenosis as a child.
She has no cardiac symptoms, at rest or with exertion. On physical exam, she has a regular rate and rhythm, with a loud S1, and normal S2. There is an opening snap followed by a 2/6 diastolic murmur at the left ventricular apex. No other extracardiac sounds are present. Lungs are clear to auscultation. Her current echocardiogram demonstrates a mitral valve area by pressure half-time method of 1.2 cm², mean gradient across the valve of 7 mmHg at a heart of 70 beats per minute, and a mitral valve score of 8, with trace mitral regurgitation. What are her pregnancy-associated risks and how do we optimize her preconception?
Maternal mortality in the United States is rising and cardiovascular disease causes 26.5% of these pregnancy-related deaths. The rising trend appears to be secondary to acquired heart disease with many factors contributing, including increasing maternal age, rise in multifetal pregnancies, and the increased burden of preexisting cardiovascular risk factors in the pregnant population. Pregnancy itself causes a significant hemodynamic burden and may cause decompensation in a patient with preexisting cardiovascular disease. Risk stratification for pregnancy should ideally occur preconception and there are several risk assessment tools that can aid decision making.
The care of the pregnant woman with heart disease also implicates several stakeholders including obstetrics, obstetric anesthesia, and cardiology. Unlike many cardiovascular diseases, there are no randomized controlled data to support decision making, and guidelines are largely built on expert consensus. It is therefore vital for cardiologists to continue to build on their knowledge on the management of cardiovascular disease during pregnancy and work in a multidisciplinary fashion to improve care.

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Original ArticlesAntiarrhythmic drug therapy in pregnancy and lactation

Abstract

Section snippets

Digoxin

Antiarrhythmic drugs and lactation

Management of specific maternal arrhythmias during pregnancy

Management of fetal tachycardias

Prog Cardiovasc Dis

Am Heart J

Am J Cardiol

Am J Obstet Gynecol

Am Heart J

Br J Anaesth

Am J Obstet Gynecol

Am Heart J

J Pediatr

J Pediatr

J Pediatr

Am J Cardiol

Am Heart J

Am J Obstet Gynecol

Lancet

The pharmacokinetics of antiarrhythmic agents in pregnancy and lactation

Clin Pharmacokinet

Congenital rhabdomyoma of the heart and intrauterine digitalis poisoning

J Forensic Sci

Treatment of cardiovascular diseases

BMJ

Antiarrhythmic drug therapy during pregnancy

Ann Intern Med

Drugs in Pregnancy and Lactation. A Reference Guide to Fetal and Neonatal Risk

Management of cardiac arrhythmias during pregnancycurrent concepts

Drugs

Paroxysmal tachycardia in pregnancy

JAMA

Original Articles
Antiarrhythmic drug therapy in pregnancy and lactation