Management of Supraventricular Tachycardia (SVT) in Pregnancy

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Management of Supraventricular Tachycardia (SVT) in Pregnancy

Medical Student Clinical Pearl

 

Tyson Fitzherbert, DMNB Class of 2024

Reviewed by Dr. Luke Taylor and Dr. David Lewis

 

Case:

A 30-year-old pregnant (32 weeks) female presents to the emergency department with palpitations and chest discomfort. On ECG they are diagnosed with supraventricular tachycardia, a narrow complex arrythmia – how would you proceed?

 

Introduction:

Pregnant women have a higher incidence of cardiac arrhythmias. The exact mechanism of increased arrhythmia burden during pregnancy is unclear, but has been attributed to hemodynamic, hormonal, and autonomic changes related to pregnancy. A common arrhythmia in pregnancy is supraventricular tachycardia (SVT). SVT is a dysrhythmia originating at or above the atrioventricular (AV) node and is defined by a narrow complex (QRS < 120 milliseconds) at a rate > 100 beats per minute (bpm). The presentations of SVT in pregnancy are the same as the nonpregnant state and include symptoms of palpitations that may be associated with presyncope, syncope, dyspnea, and/or chest pain. Diagnosis is confirmed by electrocardiogram (ECG).

 

Figure 1: Rhythm strip demonstrating a regular, narrow-complex tachycardia, or supraventricular tachycardia (SVT).

In general, the approach to the treatment of arrhythmias in pregnancy is similar to that in the nonpregnant patient. However, due to the theoretical or known adverse effects of antiarrhythmic drugs on the fetus, antiarrhythmic drugs are often reserved for the treatment of arrhythmias associated with clinically significant symptoms or hemodynamic compromise. Below is a detailed description of the management of SVT in pregnancy.

 

Management:

Figure 2: Treatment algorithm for SVT in pregnancy.

 

General Considerations:

  • Non‐pharmacological treatment including vagal manoeuvres such as carotid massage and Valsalva manoeuvre are well tolerated and aid in management.
  • Intravenous adenosine can be used in all three trimesters, including labor.
  • Electrical cardioversion is an effective treatment method for hemodynamically unstable or drug-refractory patients, which has proven to be safe in all three trimesters, including labor. There are some examples of this leading to pre-term labor in the third trimester.
  • AV nodal blocking agents and anti-arrhythmic agents may be considered for cardioversion; see table below for effects in pregnancy and breast feeding.

 

 

Case Continued:

A modified Valsalva manoeuvre is performed with resolution to sinus rhythm after 2 attempts. The patient is discharged with OBGYN follow-up.

https://sjrhem.ca/modified-valsalva-maneuver-in-the-treatment-of-svt-revert-trial/

 

Further Reading

References:

  1. Patti L, Ashurst JV. Supraventricular Tachycardia. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www-ncbi-nlm-nih-gov.ezproxy.library.dal.ca/books/NBK441972/
  2. UpToDate – https://www.uptodate.com/contents/supraventricular-arrhythmias-during-pregnancy#H11407709
  3. Ibetoh CN, Stratulat E, Liu F, Wuni GY, Bahuva R, Shafiq MA, Gattas BS, Gordon DK. Supraventricular Tachycardia in Pregnancy: Gestational and Labor Differences in Treatment. Cureus. 2021 Oct 4;13(10):e18479. doi: 10.7759/cureus.18479. PMID: 34659918; PMCID: PMC8494174. https://www-ncbi-nlm-nih-gov.ezproxy.library.dal.ca/pmc/articles/PMC8494174/
  4. Ramlakhan KP, Kauling RM, Schenkelaars N, et al, Supraventricular arrhythmia in pregnancy, Heart 2022;108:1674-1681. https://heart.bmj.com/content/early/2022/01/26/heartjnl-2021-320451#T2
  5. Goyal A, Hill J, Singhal M. Pharmacological Cardioversion. [Updated 2022 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www-ncbi-nlm-nih-gov.ezproxy.library.dal.ca/books/NBK470536/
  6. Vaibhav R. Vaidya, Nandini S. Mehra, Alan M. Sugrue, Samuel J. Asirvatham, Chapter 60 – Supraventricular tachycardia in pregnancy, Sex and Cardiac Electrophysiology. https://www-sciencedirect-com.ezproxy.library.dal.ca/science/article/pii/B9780128177280000607

 

 

 

 

 

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