Arrhythmias in pregnancy are common and may cause concern for the wellbeing of both the mother and the fetus. For some mothers the arrhythmias may be a recurrence of a previously diagnosed arrhythmia or the first presentation in a woman with known structural heart disease. In most cases, however, there is no previous history of heart disease, and the new occurrence of a cardiac problem can generate considerable anxiety. The majority of arrhythmias that occur during pregnancy are benign, and simply troublesome; hence, advice about appropriate actions during symptomatic episodes, together with reassurance, is usually all that is required. In the remaining minority of cases, judicious use of antiarrhythmic drugs will lead to a safe and successful outcome for both mother and baby. it is not surprising that the antenatal clinic encounters its fair share of palpitations.3 In pregnancy, heart rate (HR) increases by 25%; thus sinus tachycardia, particularly in the third trimester, is not uncommon. Ectopic beats and non‐sustained arrhythmia are encountered in more than 50% of pregnant women investigated for palpitations while sustained tachycardias are less common at around 2–3/1000 The mechanism of arrhythmia generation is shown in table 11.. The cardiovascular system undergoes significant change in adaptation to pregnancy, including an increased heart rate and cardiac output, reduced systemic resistance, increased plasma catecholamine concentrations and adrenergic receptor sensitivity, atrial stretch and increased end‐diastolic volumes due to intravascular volume expansion, as well as hormonal and emotional changes. A combination of these and the heightened visceral awareness experienced in pregnancy may lead a woman to seek advice on symptoms that are within the normal range and may otherwise have been ignored. The pregnant state is unlikely to generate a new arrhythmia substrate, however; such physiological changes may render a pre‐existing substrate capable of sustaining an arrhythmia. A bigger heart can sustain re‐entry more easily and mechanical stretch is well known to be arrhythmogenic. Pregnancy may also affect the trigger for arrhythmia generation. Most tachycardia episodes are initiated by ectopic beats and the occurrence of arrhythmia episodes may therefore increase during pregnancy in line with the increased propensity to ectopic activity. There are three elements to the diagnosis of arrhythmia in pregnancy: firstly, obtain an accurate diagnosis of the arrhythmia in order to give a reliable opinion about the prognosis and appropriate treatment; secondly, determine whether or not there is additional heart disease associated with the arrhythmia; finally, exclude systemic disorders that may present with arrhythmias—for example, abnormalities of thyroid function should always

1. DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS MA(PSY)
Director & Consultant At Mukherjee Multispecialty
Hospital
MMC ACCREDITATED SPEAKER
MMC OBSERVER MMC MAO – 01017 / 2016
Present Position
 Director of Mukherjee Multispecialty Hospital
 Hon.Secretary INTERNATIONAL COUNCIL FOR HUMAN
RIGHTS
 Hon.Secretary NARCHI NAGPUR CHAPTER (2018-2020)
 Hon.Secretary AMWN (2018-2021)
 Hon.Secretary ISOPARB (2019-2021)
 Organizing secretary AMWICON – 2019
 Life member, IMA, NOGS, NARCHI, AMWN &
Menopause Society, India, Indian medico-legal &
ethics association(IMLEA), ISOPARB, HUMAN RIGHTS
 Founder Member of South Rapid Action Group,
Nagpur.
 On Board of Super Specialty, GMC, IGGMC, AIIMS
Nagpur, NKPSIMS, ESIS and Treasury, Nagpur for “
WOMEN SEXUAL HARASSMENT COMMITTEE.”
mukherjeehospital@yahoo.com
www.mukherjeehospital.com
https://www.facebook.com/
Mukherjee Multispeciality
https://www.instagram.com/
Achievement
 Winner of NOGS GOLD MEDAL – 2017-18
 Winner of BEST COUPLE AWARD in Social
Work - 2014
 VIDARBHA RATNA PURASKAR - 2019
Past Position
 Vice President of NOGS(2016-2017)
 Organizing joint secretary ENDO-GYN
 Vice President IMA Nagpur (2017-2018)
 Organizing joint secretary ENDO-GYN 2019
1DR ALKA MUKHERJEE

2. PALPITATIONS IN PREGNANCY
DR ALKA MUKHERJEE
DR APURVA MUKHERJEE
NAGPUR M.S.
2DR ALKA MUKHERJEE

3. INTRODUCTION
• Palpitation is a distressing symptom in which there is an
annoying and unpleasant awareness of one's heartbeat
• It may point to an underlying heart disease such as
valvular heart disease, congenital heart disease, or a
cardiomyopathy.
• The most common cause is primary cardiac arrhythmia,
where there is no obvious pathology.
• The incidence of clinically significant heart disease in
pregnancy may vary from 2% to 4%.
• Instances of acute cardiac episodes in pregnancy are
rising with increasing maternal age during pregnancy
and associated hypertension and obesity.
3DR ALKA MUKHERJEE

4. GENDER PREPONDERANCE
• Women tend to have higher heart rates and the sinus nodal
recovery ürne gets reduced.
• The sex hormones also affect myocardial repolarisation and
this makes them more vulnerable to arrhythmias.
• Women also have longer QT intervals and have a higher
incidence of 'AV nodal and atrial reentrant tachycardia'.
• They are more prone to an arrhythmia called 'torsade de
pointes' which is either drug induced or as a result of
electrolyte imbalance (low sodium and/or low magnesium)
• Besides, women are emotionally more labile and suffer more
anxiety, all of which can cause palpitations. Atrial fibrillation
is less common, but, if present, it is more ominous
4DR ALKA MUKHERJEE

5. PHYSIOLOGICAL CHANGES IN
PREGNANCY
• The incidence of palpitations in pregnant women is higher
than in normal non-pregnant women.
• This is to a large extent due to the tremendous physiological
changes in the cardiovascular system during pregnancy.
• The increase in the cardiac output on account of the
increased blood volume necessarily means that the heart has
to pump faster and more forcefully.
• This can cause asynchronicity of the normal rhythm leading
to palpitations.
• The stretching of the myocardial fibres also makes them more
vulnerable to arrhythmias.
• Other arrhythmogenic factors in pregnancy are the higher
levels of oestrogen, hCG and catecholamines and the overall
higher Sensitivity of the adrenergic receptors.
• The palpitations due to the physiological changes in
pregnancy typically last only a few seconds and are not
associated with other symptoms.
5DR ALKA MUKHERJEE

6. CAUSES OF PALPITATIONS
• Cardiac causes: Arrhythmias extrasystoles, paroxysmal
tachycardia, atrial flutter or fibrillation, heart block,
hypertension, valvular lesions, especially aortic
regurgitation, and rarely, congenital heart disease and
cardiomyopathy.
• Other illnesses: Thyrotoxicosis, anaemia, indigestion due
to gallbladder dys-function, pulmonary tuberculosis,
pleural effusion, ascites and pheochromo- cytoma.
• Physiological and functional: Pregnancy, excessive
consumption of coffee tea and alcohol, anxiety, neurosis,
following exertion and after an emotional upset. An
important cause is primary cardiac arrhythmia, where
there is no apparent aetiology.
6DR ALKA MUKHERJEE

7. OTHER ASSOCIATED SYMPTOMS
• Palpitation may be - an isolated symptom or
- it could be associated with other
symptoms such as dyspnoea, syncope, fatigue, oedema
feet, decrease in exercise capacity, etc.
• It needs to be emphasised that presence of other
symptoms does not necessarily indicate heart disease,
as all of these can occur in a normal pregnancy with a
healthy heart.
• On the other hand, a patient who complains of
palpitations only, with the exclusion of other symptoms,
does not mean that she has a normal heart. This
happens very often in supra-ventricular tachycardia.
7DR ALKA MUKHERJEE

8. A WORD OF CAUTION..
• If the patient is a known case of heart disease, it makes
matters simpler, and one only needs to review the
severity, particularly on account of the increased
demands that pregnancy puts on the heart.
• One should also review the drugs one is taking and make
adjustments keeping teratogenesis in mind.
• For example patients with valvular regurgitation with
hypertension may be on ACE inhibitors which are
contraindicated in pregnancy and must be substituted.
• Amiodarone - a type 3 antiarrhythmic, is commonly used
in atrial fibrillation and ventricular tachycardia, must be
used with caution in pregnancy because Of the possibility
of congenital malformation in the baby
8DR ALKA MUKHERJEE

9. 9DR ALKA MUKHERJEE

10. PHYSICAL EXAMINATION
• The physiological changes in pregnancy may produce
signs that mimic cardiac disease and hence the confusion
• The pulse rate, rhythm and volume form the basic step of
the examination.
• Tachycardia up to 10% more than basal rate is known in a
normal pregnancy.
• The jugular venous pulse is raised by about I cm in a
normal pregnancy because of increased cardiac output.
• Measurement of blood pressure and looking for edema
feet, cyanosis both central and peripheral and clubbing
are other aspects of a physical examination
10DR ALKA MUKHERJEE

11. Examination of the cardiovascular system
• Palpation of the precordium may reveal a 'thrill', which is
the palpable equivalent of a murmur and is usually found
associated with loud murmurs.
• On auscultation, a loud first heart sound, an exaggerated
splitting of the second heart sound, and, sometimes, a
third heart sound, are common in a normal pregnancy.
So is an ejection systolic murmur at the left lower sternal
border.
• Murmurs occur in patients with turbulent blood flow, as
with increased cardiac output in a normal pregnancy and
in anaemia.
• They are also heard in patients with an abnormal leak
back as in valvular regurgitation.
11DR ALKA MUKHERJEE

12. CERTAIN OMINOUS SIGNS IN A PREGNANT
WOMAN
• loud fourth heart sound,
• an opening snap,
• a loud systolic murmur grade 3/6 or more, or
• a diastolic murmur.
• These patients will require further evaluation.
• Sometimes, a systolic or a continuous murmur may arise
from the increased blood flow to the breast and can be
misleading. It is generally high-pitched and can be
abolished by gentle finger pressure in the intercostal
space lateral to the stethoscope.
12DR ALKA MUKHERJEE

13. INVESTIGATIONS
ELECTROCARDIOGRAM
• Basic investigations in a woman with palpitations.
• Helps in the diagnosis of:
a) Ischaemic heart disease,
b) Presence and type of arrhythmia and in conduction defects
c) Electrolyte imbalance,
d) Hypertrophy of the various chambers of the heart and
e) Suspected cases of digitalis overdose.
• A normal pregnancy does not induce any changes in the ECG
except for slight deviation of its axis towards the left causing the
presence of Q waves and an inverted T-wave in lead 3
13DR ALKA MUKHERJEE

14. DR ALKA MUKHERJEE 14
ECG – SINUS TACHYCARDIA
VENTRICULAR TACHYCARDIA
SUPRA-VENTRICULAR
TACHYCARDIA

15. 2D ECHOCARDIOGRAPHY
Ultrasound waves are reflected from the interfaces
between blood and solid tissues of the heart and these are
used to identify structural defects in the valves and
measure their dimensions:
• In congenital heart disease, it helps to specify the
defect.
• It also gives a fair assessment of the functional capacity
of the heart to pump the blood.
• Finally, it provides vital information about intra-cardiac
masses such as thrombi, tumours and endocarditic
vegetations.
15DR ALKA MUKHERJEE

16. HOLTER (AMBULATORY ECG)
MONITORING
• This is a 24-hour recording of the ECG
• Particularly useful in detecting transient episodes of
arrhythmia, which are likely to be missed on a routine
ECG.
• The patient should also maintain a diary of symptoms so
that these could be correlated with abnormalities on the
Holter.
• It is important to note that up to 60% of normal people
below the age of 40 are likely to have arrhythmias on
Holter.
16DR ALKA MUKHERJEE

17. X-RAY CHEST
• Use of this investigation in pregnancy is almost
redundant because of radiation exposure to the foetus.
• Besides, the same information can be obtained through
other safer modes of investigations.
• one should be cautious in making a diagnosis of
cardiomegaly, which may be apparent because of
elevation and rotation of the heart in a normal
pregnancy,
17DR ALKA MUKHERJEE

18. CARDIAC CATHETERISATION
• This is an invasive procedure and rarely performed
unless the patient is a case of tight mitral stenosis and
is for balloon valvotomy
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19. FLUOROSCOPY
• It is rarely used because of radiation exposure,
but may, sometimes, be required to diagnose
dysfunction in mechanical prosthetic valves.
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20. CT SCAN
• This is used
in suspected pulmonary embolism, where a 2D
echo has not confirmed the diagnosis, and
before starting medical thrombolysis or
surgical endarterectomy.
20DR ALKA MUKHERJEE

21. TREADMILL TESTS
• These are not recommended because peak exercise is
sometimes associated with foetal bradycardia.
OTHER USEFUL TESTS
 serum electrolytes,
 TSH, free T3, free T4, etc.
21DR ALKA MUKHERJEE

22. CARDIAC DISEASE IN PREGNANCY (CARPREG)
RISK SCORE
This is a predictor of a likely maternal cardiovascular
event in pregnancy.
• New York Heart Association (NYHA) functional class
greater than 2
• Cyanosis (Sp02 <90% with room air)
• Prior cardiovascular event
• LVEF
• Left heart obstruction
• For each predictor that is present, a point is assigned:
22DR ALKA MUKHERJEE

23. NO OF PREDICTORS RISK OF CARDIAC EVENT
IN PREGNANCY
0 5%
1 27%
2 or >2 75%
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24. ARRHYTHMIAS
• Most common causes of palpitations in pregnancy.
• They are also one of five independent predictors of a
likely cardiac event in pregnancy
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25. Benign arrhythmias can be minimised with reassurance and
avoidance of stimulants like caffeine and alcohol.
The more serious ones require specific treatment
25DR ALKA MUKHERJEE

26. SUPRAVENTRICULAR TACHYCARDIA
Paroxysmal supravenfricular tachycardia (SVT) is common in
pregnancy
Usually presents with palpitations or dyspnoea.
Thyroid disorders must be excluded.
On ecg, pulse rate >1oo bpm and regular p waves +/-
First line of treatment is a Carotid Massage Or Breath Holding
If these do not work, then parenteral adenosine is given.
(very short half-life, data on its use in the first trimester
inadequate.)
Other drugs- iv beta blockers - Propranolol Or Metoprolol.
Atenolol is avoided - chances of IUGR and Preterm delivery.
26DR ALKA MUKHERJEE

27. DC defibrillation
• If chemical cardioversion fails, one can try electrical
cardioversion in the form of DC defibrillation, which is
safe in pregnancy.
• Ablation is an option in drug-resistant cases or in
women with poorly tolerated SVT, who are planning a
pregnancy.
• If performed during an ongoing pregnancy, it is done in
the second trimester because the radiation exposure is
higher than in balloon valvuloplasty.
27DR ALKA MUKHERJEE

28. ATRIAL FIBRILLATION AND FLUTTER
• These may be a pointer to underlying cardiac disease
(congenital or Rheumatic) or a thyroid problem.
• Patients present with palpitations or dyspnoea, rarely
pain or syncope.
• ECG shows an irregular heart rate with absence - P
Flutter may cause a 'saw-tooth' pattern.
• Treatment is usually beta blocker Digoxin may be given
to decrease the ventricular rate.
• Anticoagulants may required in chronic AF.
• If drug therapy fails, one may resort to catheter ablation,
particularly in flutter.
28DR ALKA MUKHERJEE

29. VENTRICULAR TACHYCARDIA
• Idiopathic VT - benign.
• ECG - broad QRS complex with a rate >100 bpm.
• Occasionally, a characteristic oscillating baseline called
'torsade de pointes
• With structural cardiac disease, maternal risks high
• Idiopathic are treated with adenosine, Verapamil or beta
blocker
• Other VTs are treated with Lignocaine, Procainamide or
• Quinidine.
• An implantable cardioverter.
• For Prophylaxix - Quinidine or Sotalol
29DR ALKA MUKHERJEE

30. • Long QT syndrome is a form of VT, which generally
manifests in the puerperium.
• Patient presents with syncope.
• Rarely, the syndrome may cause sudden death.
• In pregnancy, renal and hepatic blood flows increase,
and therefore, dose adjustments may be required.
• Combination drugs in low dose are preferable to single
agents in high dose.
30DR ALKA MUKHERJEE

31. LABOUR AND DELIVERY
• Dramatic changes in hemodynamics occur during this
period and may lead to complications.
• Some of the measures adopted are
 Nasal oxygen,
 Diuretics,
 Propped up position,
 Prophylactic antibiotics and
 Assisted vaginal deliveries
• LSCS is generally performed only for obstetric
indications.
• The preferred anaesthesia is epidural.
31DR ALKA MUKHERJEE

32. MATERNAL MORTALITY
Cardiac problems are associated with 25% to 50% mortality :
 Primary pulmonary hypertension,
 Eisenmenger syndrome,
 Coarctation of aorta with valve involvement,
 Marfans syndrome with aortic involvement,
 Peripartum cardiomyopathy with LV dysfunction
with 5 to 15% mortality:
 Mitral stenosis (NYHA class a and 4),
 Aortic stenosis,
 Uncorrected tetralogy of fallot,
 Previous myocardial infarction,
 Coarctation of aorta and
 Marfan's syndrome without valve involvement.
32DR ALKA MUKHERJEE

33. 33DR ALKA MUKHERJEE

34. Mortality rate of less than 1%.
• Atrial Septal Defect (ASD),
• Ventricular Septal Defect (VSD),
• Patent Ductus Arteriosus (PDA),
• Pulmonary Or Tricuspid Valve Disease And
• Mild Mitral Stenosis
34DR ALKA MUKHERJEE

35. CONCLUSION
• Heart disease in pregnancy is a wide spectrum of
illnesses from the ones for whom pregnancy poses no
problem to the more severe ones that can cause
tremendous morbidity and even mortality to the foetus
or the mother
• Recognising the problem and its special needs, is the
first obstacle that the clinicians has to overcome,
keeping in mind the physiological changes in pregnancy.
• Overdiagnosis and seeking the opinion of a cardiologist
is a better option than missing an existing cardiac
problem.
35DR ALKA MUKHERJEE

36. KEY PEARLS
• CARDIOVERSION – Safe in all trimesters, can be used
• Women with repair of Congenital heart defects – high
risk
• Multidisciplinary approach – Cardiologist, Obstetrician,
Anesthetist – antepartum, intrapartum & peripartum
stage
• Physiological changes of pregnancy affect the
pharmacology , serum conc, reduced, changes in
protein – binding affinity
• No cause found in up to 16% patients
36DR ALKA MUKHERJEE

37. 37DR ALKA MUKHERJEE