Arrhythmia in pregnancy: Approaches to diagnosis and management

Arrhythmias are common during pregnancy and, although most are benign, they are associated with increased rates of maternal and fetal morbidity and mortality. The most frequent arrhythmias during pregnancy are sinus tachycardia and premature atrial complexes or ventricular complexes, which are often benign and resolve post-partum. However, tachyarrhythmias such as supraventricular tachycardia, atrial fibrillation and ventricular tachycardia are also more prevalent in pregnancy and require careful management, as they are associated with adverse maternal and fetal outcomes. A systematic approach to diagnosis is essential to identify the women with benign conditions and those with serious pathology. This involves thorough history taking, including past medical and family history, physical examination, and consideration of additional investigations such as electrocardiograms. The key diagnostic test is often a heart rhythm recording at the time of symptoms. When an arrhythmia has been identified, management strategies must balance maternal health with fetal safety. Beta-blockers, the first-line pharmacological treatment for many symptomatic arrhythmias, are not teratogenic but are associated with fetal growth restriction. Adenosine, flecainide, calcium channel blockers, digoxin and sotalol can also be safely used. Electrical cardioversion is safe at all stages of pregnancy and should not be delayed in emergencies. Procedures, such as the implantation of cardiac devices or ablations, can also be performed during pregnancy. Arrhythmias during pregnancy require individualised and multidisciplinary management plans to ensure optimal outcomes for both mother and fetus. This narrative review discusses the diagnosis and management of arrhythmias in pregnancy, including diagnostic work-up, pharmacological therapy, cardiac devices and electrophysiological procedures.