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Management of New-Onset Atrial Fibrillation in Pregnancy: When Should Early Delivery Be Considered?
CASE REPORT
Management of New-Onset Atrial Fibrillation in Pregnancy: When Should Early Delivery Be Considered? Marie-Julie Trahan, MD;1 Marie-Pier Bastrash, MD;1 Vartan Mardigyan, MD;2 Stephanie Klam, MD1,3 al, QC Department of Obstetrics and Gynecology, McGill University, Montre
1
al, QC Department of Cardiology, Jewish General Hospital, Montre
2
al, QC Department of Maternal-Fetal Medicine, Jewish General Hospital, Montre
3
M.-J. Trahan
Abstract Background: The hemodynamic and physiological changes of pregnancy may predispose women to cardiac arrhythmias such as atrial fibrillation (AF). Nevertheless, new-onset AF in pregnancy remains rare, and treatment is challenging. Current recommendations are to treat pregnant women with AF as non-pregnant adults, by using pharmacological or synchronized electrical cardioversion, without mention of gestational age or possibility of delivery. Case: A 23-year-old nulliparous woman developed new-onset symptomatic AF at 362 weeks gestation, but presented to our hospital was delivered at 364 weeks gestation. Beta-blockers were administered for heart rate control. After 48 hours, the decision was made to proceed with delivery rather than cardioversion. The patient’s arrhythmia resolved spontaneously postpartum without further treatment. Conclusion: In pregnant patients near or at term, delivery should be considered in the management of new-onset AF after consultation with cardiology, anaesthesiology, and maternal-fetal medicine.
rent de est difficile de la traiter. Les recommandations actuelles sugge sentant une FA comme des adultes traiter les femmes enceintes pre non enceintes et d’utiliser la cardioversion pharmacologique ou la lectrique synchronise e, sans mention relative a l’a ^ge cardioversion e la possibilite d’accouchement. gestationnel ou a prouve une FA Cas : Une femme nullipare de 23 ans a e 362 semaines de symptomatique nouvellement apparue a te transfe re e a l’ho ^ pital pour accoucher a 364 grossesse et a e des be ^ tabloquants afin semaines de grossesse. On lui a administre tablir sa fre quence cardiaque. Apre s 48 heures, les me decins de re cision de proce der a l’accouchement au lieu de ont pris la de sorbe e pratiquer la cardioversion. L’arythmie de la patiente s’est re ment sans que d’autres traitements soient requis. spontane Conclusion : Il convient de tenir compte de l’accouchement dans la prise en charge d’une FA nouvellement apparue chez les patientes terme ou a terme, suivant enceintes en cas de grossesse presque a cialistes en cardiologie, en une consultation avec les spe siologie et en me decine fœto-maternelle. anesthe
Résumé
© 2019 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
modynamiques et physiologiques de la Contexte : Les changements he disposer les femmes aux arythmies grossesse peuvent pre cardiaques, notamment la fibrillation auriculaire (FA). L’apparition anmoins rare et il nouvelle de la FA pendant la grossesse demeure ne
J Obstet Gynaecol Can 2019;000(000):1−4 https://doi.org/10.1016/j.jogc.2019.09.010
Key Words: Pregnancy, atrial fibrillation, arrhythmia, cardioversion, delivery Corresponding author: Dr. Marie-Julie Trahan, Department of al, QC. Obstetrics and Gynecology, McGill University, Montre [email protected] Competing interests: The authors declare that they have no competing interests. The authors have indicated that they meet the journal’s requirements for authorship. Received on May 27, 2019 Accepted on September 9, 2019
he hemodynamic and physiological changes of pregnancy may predispose women to cardiac arrhythmias such as atrial fibrillation (AF). Although the incidence of cardiac arrhythmias is increased in pregnancy, these remain rare, especially among pregnant women with structurally normal hearts.1
T
Current recommendations are to treat AF in pregnant women as in non-pregnant adults, by using pharmacological 000 JOGC 000 2019
1
CASE REPORT
or synchronized electrical cardioversion.1 Although maternal treatment is prioritized, careful consideration of the potential effects of treatment on fetal well-being must always be considered. Despite the potential effects of cardioversion on the fetus, including fetal bradycardia, current recommendations do not take into account gestational age or mention the role of delivery in the management of new-onset AF during pregnancy. We present here a case of new-onset AF near term that did not convert spontaneously after 48 hours, but resolved shortly following delivery without cardioversion. The objective of this case presentation is to discuss the importance of considering gestational age in patients with newonset AF during pregnancy and the potential role of delivery in the management of AF near or at term.
Caesarean delivery was planned because of the patient’s nulliparity, unfavorable Bishop score (<6), symptoms, and preference. The patient delivered of a male infant by Caesarean section at 364 weeks gestational age, under spinal anaesthesia. Birth weight was 3580 g. Apgar scores were 9 and 9 at 1 and 5 minutes of life, respectively. Postoperatively, the patient returned to the cardiovascular intensive care unit, where she spontaneously converted to sinus rhythm overnight, 6 hours following delivery. There was no recurrence of her arrhythmia, and she was discharged home on postoperative day 3 with outpatient cardiology follow-up. Prophylactic anticoagulation with low-molecular-weight heparin was administered postpartum while she was in hospital. DISCUSSION
CASE 4
A 23-year-old nulliparous woman at 36 weeks gestation was transferred to our tertiary care centre from a nearby community hospital after a diagnosis of new-onset AF. She first presented to hospital two days earlier following an accidental fall on her back. While in the hospital, she developed palpitations and shortness of breath, and was diagnosed with new-onset AF, with a rapid ventricular response of 150 beats per minute and a blood pressure of 110/60 mm Hg. She had no history of cardiovascular disease and denied prior similar symptoms. Initial workup included complete blood count, serum electrolytes, thyroid profile, and drug screen. Results were as follows: hemoglobin 123 g/L; sodium 136 mmol/L; potassium 3.4 mmol/L; thyroid stimulating hormone 0.39 mU/L; free thyroxine 9.52 pmol/L (normal value, 9−26 pmol/L); and a negative drug screen. A transthoracic echocardiogram showed no evidence of structural heart disease, and computed tomography pulmonary angiography was negative for pulmonary embolism. She was initially treated with intravenous metoprolol (2.5 mg, 5 mg, 5 mg, 2.5 mg) and then started on oral metoprolol (50 mg twice daily.) Twenty-four hours later, she remained in AF with an irregular heart rate of 120 to 150 beats per minute and a stable blood pressure of 110/60 mm Hg. The patient was then transferred to our hospital, where the high-risk obstetrics team saw her in the cardiovascular intensive care unit. Given the possible risks associated with cardioversion, the duration of AF for longer than 48 hours, and the near-term gestational age, an early delivery was considered to allow the arrhythmia to be managed postpartum without concern for the fetus. Cardiology and anaesthesia were consulted, and after discussion with the patient, the decision was made to proceed with delivery. A
2
000 JOGC 000 2019
In patients with structurally normal hearts, new-onset AF is believed to be a result of the physiological and hemodynamic changes of pregnancy. It is logical then that newonset arrhythmias may resolve following delivery, as the cardiovascular system returns to its pre-pregnancy state. Among published case reports of AF in pregnancy, we identified six cases of new-onset AF in the third trimester in patients with no pre-existing heart disease and no clear precipitating factor (Table 1) by searching PubMed and Medline for articles using the key words “atrial fibrillation” and “pregnancy.” Spontaneous conversion to sinus rhythm was observed in three cases at 34 to 38 weeks gestation. Pharmacological cardioversion with flecainide was performed successfully in one case at 33 weeks gestation, and electrical cardioversion was performed successfully in another case at 33 weeks gestation. In one patient at 35 weeks gestation, electrical cardioversion was performed following failed pharmacological cardioversion. Although the patient converted to sinus rhythm afterwards, there was recurrence of the arrhythmia five days later, at which time the patient also presented with significant vaginal bleeding requiring an emergency Caesarean section.2−7 In a case series of 30 women with AF in pregnancy, Sauve et al. reported on five cases in which AF influenced delivery.8 However, this series included cases of AF with a clear precipitating factor, and the details of previous treatments and postpartum courses of those cases were not provided. Thus, to our knowledge, our report is the first to detail a case in which delivery was effected prematurely to manage AF and in which AF resolved spontaneously shortly after delivery without further treatment. Although a causal relationship cannot be inferred, this outcome suggests that there may be a role for delivery in the management of new-onset AF in pregnant women near or at term.
Management of New-Onset Atrial Fibrillation in Pregnancy: When Should Early Delivery Be Considered?
Table 1. Description of published cases of new-onset atrial fibrillation in the third trimester of pregnancy Author, year, reference
Case description
Treatment
Gowda et al., 2003
29-year-old G3P1A1 at 38 weeks gestation presented with palpitations and dyspnea
None
Spontaneous conversion to sinus rhythm after only a few minutes; no recurrence of arrhythmia
Cacciotti et al., 20103
35-year-old at 36 weeks gestation presented with palpitations
Rate control with metoprolol; no cardioversion
Spontaneous conversion to sinus rhythm; no recurrence of arrhythmia
Anugu et al., 20164
30-year-old G3P0A2 at 34 weeks gestation presented with 2-hour history of palpitations, dyspnea, and chest tightness
Rate control with diltiazem; no cardioversion
Spontaneous conversion to sinus rhythm; no recurrence of arrhythmia
Walsh et al., 20085
41-year-old G3P1A1 at 334 weeks gestation presented with 1-day history of palpitations
Murphy et al., 20146
Brown et al., 20017
2
Outcome
Rate control with atenolol; pharmacological cardioversion with flecainide
Conversion to sinus rhythm; no recurrence of arrhythmia
37-year-old G3P2 at 33 weeks gestation presented with sudden-onset palpitations
Rate control with metoprolol; electrical cardioversion
Conversion to sinus rhythm; no recurrence of arrhythmia
32-year-old G3P2 at 35 weeks gestation presented with palpitations
Pharmacological cardioversion with flecainide followed by electrical cardioversion
Treatment of AF in pregnancy is challenging, and there is little consensus regarding optimal treatment of this rare condition. According to the European Society of Cardiology (ESC) guidelines on the management of cardiovascular diseases during pregnancy, if AF does not resolve within 24 hours after rate control, pharmacological cardioversion with antiarrhythmic agents is recommended.1 Flecainide and ibutilide are generally considered the preferred first-line pharmacological agents, and amiodarone and propafenone should be avoided. The ESC guidelines suggest limiting the use of synchronized electrical cardioversion to cases complicated by maternal hemodynamic compromise.1 However, in a survey of obstetrical medicine practitioners on the management of AF in pregnancy, respondents preferred electrical cardioversion to chemical cardioversion and described electrical cardioversion as safer, more predictable, and more effective.9 The ESC guidelines also recommend anticoagulation with unfractionated heparin or low-molecular-weight heparin before cardioversion when the duration of AF is greater than 48 hours. In addition, in the presence of AF for more than 48 hours or additional risk factors for thromboembolism, continued anticoagulation for four weeks following cardioversion is recommended because of the increased risk of thromboembolism secondary to “atrial stunning.”1 Therefore, health practitioners must consider the potential risks of cardioversion, as well as the implications of prolonged anticoagulation, in the near-term and term
Conversion to sinus rhythm following electrical cardioversion; recurrence of arrhythmia 5 days later, at which time there was significant vaginal bleeding requiring an emergency Caesarean section
period when managing cases of new-onset AF in the third trimester. In our case, antiarrhythmic therapy was deferred because of the near-term gestational age of the patient, the possible risks associated with cardioversion, and the duration of AF for longer than 48 hours. The patient’s arrhythmia resolved postpartum without further treatment. Delivery allows for more therapeutic options without the risk of potential harm to the fetus, and it may result in spontaneous conversion to sinus rhythm. However, decisions regarding early delivery should be made on a case-by-case basis after consultation with cardiology, anaesthesiology, and maternal-fetal medicine. The risks and benefits of treatment versus early delivery in preterm patients must be carefully weighed, and neonatology consultation may be warranted. REFERENCES 1. European Society of Gynecology (ESG). Association for European Paediatric Cardiology (AEPC). German Society for Gender Medicine (DGesGM). ESC guidelines on the management of cardiovascular diseases during pregnancy: the task force on the management of cardiovascular diseases during pregnancy of the European Society of Cardiology (ESC). Eur Heart J 2011;32:3147–97. 2. Gowda RM, Punukollu G, Khan IA, et al. Lone atrial fibrillation during pregnancy. Int J Cardiol 2003;88:123–4. 3. Cacciotti L, Camastra GS, Ansalone G. Atrial fibrillation in a pregnant woman with a normal heart. Intern Emerg Med 2010;5:87–8.
000 JOGC 000 2019
3
CASE REPORT
4. Anugu VR, Nalluri N, Asti D, et al. New-onset lone atrial fibrillation in pregnancy. Ther Adv Cardiovasc Dis 2016;10:274–6.
7. Brown O, Davidson N, Palmer J. Cardioversion in the third trimester of pregnancy. Aust N Z J Obstet Gynaecol 2001;41:241–2.
5. Walsh CA, Manias T, Patient C. Atrial fibrillation in pregnancy. Eur J Obst Gynecol Reprod Biol 2008;138:119–20.
8. Sauve N, Rey E, Cumyn A, et al. Atrial fibrillation in a structurally normal heart during pregnancy: a review of cases from a registry and from the literature. J Obstet Gynaecol Can 2017;39:18–24.
6. Murphy N, Sugrue D, McKenna P. Case report on the treatment of atrial fibrillation in a pregnant woman of 33 weeks’ gestation. Open J Obstet Gynecol 2014;2:8–9.
9. Cumyn A, Sauve N, Rey E. Atrial fibrillation with a structurally normal heart in pregnancy: an international survey on current practice. Obstet Med 2017;10:74–8.
4
000 JOGC 000 2019
Management of New-Onset Atrial Fibrillation in Pregnancy: When Should Early Delivery Be Considered? Marie-Julie Trahan, MD;1 Marie-Pier Bastrash, MD;1 Vartan Mardigyan, MD;2 Stephanie Klam, MD1,3 al, QC Department of Obstetrics and Gynecology, McGill University, Montre
1
al, QC Department of Cardiology, Jewish General Hospital, Montre
2
al, QC Department of Maternal-Fetal Medicine, Jewish General Hospital, Montre
3
M.-J. Trahan
Abstract Background: The hemodynamic and physiological changes of pregnancy may predispose women to cardiac arrhythmias such as atrial fibrillation (AF). Nevertheless, new-onset AF in pregnancy remains rare, and treatment is challenging. Current recommendations are to treat pregnant women with AF as non-pregnant adults, by using pharmacological or synchronized electrical cardioversion, without mention of gestational age or possibility of delivery. Case: A 23-year-old nulliparous woman developed new-onset symptomatic AF at 362 weeks gestation, but presented to our hospital was delivered at 364 weeks gestation. Beta-blockers were administered for heart rate control. After 48 hours, the decision was made to proceed with delivery rather than cardioversion. The patient’s arrhythmia resolved spontaneously postpartum without further treatment. Conclusion: In pregnant patients near or at term, delivery should be considered in the management of new-onset AF after consultation with cardiology, anaesthesiology, and maternal-fetal medicine.
rent de est difficile de la traiter. Les recommandations actuelles sugge sentant une FA comme des adultes traiter les femmes enceintes pre non enceintes et d’utiliser la cardioversion pharmacologique ou la lectrique synchronise e, sans mention relative a l’a ^ge cardioversion e la possibilite d’accouchement. gestationnel ou a prouve une FA Cas : Une femme nullipare de 23 ans a e 362 semaines de symptomatique nouvellement apparue a te transfe re e a l’ho ^ pital pour accoucher a 364 grossesse et a e des be ^ tabloquants afin semaines de grossesse. On lui a administre tablir sa fre quence cardiaque. Apre s 48 heures, les me decins de re cision de proce der a l’accouchement au lieu de ont pris la de sorbe e pratiquer la cardioversion. L’arythmie de la patiente s’est re ment sans que d’autres traitements soient requis. spontane Conclusion : Il convient de tenir compte de l’accouchement dans la prise en charge d’une FA nouvellement apparue chez les patientes terme ou a terme, suivant enceintes en cas de grossesse presque a cialistes en cardiologie, en une consultation avec les spe siologie et en me decine fœto-maternelle. anesthe
Résumé
© 2019 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
modynamiques et physiologiques de la Contexte : Les changements he disposer les femmes aux arythmies grossesse peuvent pre cardiaques, notamment la fibrillation auriculaire (FA). L’apparition anmoins rare et il nouvelle de la FA pendant la grossesse demeure ne
J Obstet Gynaecol Can 2019;000(000):1−4 https://doi.org/10.1016/j.jogc.2019.09.010
Key Words: Pregnancy, atrial fibrillation, arrhythmia, cardioversion, delivery Corresponding author: Dr. Marie-Julie Trahan, Department of al, QC. Obstetrics and Gynecology, McGill University, Montre [email protected] Competing interests: The authors declare that they have no competing interests. The authors have indicated that they meet the journal’s requirements for authorship. Received on May 27, 2019 Accepted on September 9, 2019
he hemodynamic and physiological changes of pregnancy may predispose women to cardiac arrhythmias such as atrial fibrillation (AF). Although the incidence of cardiac arrhythmias is increased in pregnancy, these remain rare, especially among pregnant women with structurally normal hearts.1
T
Current recommendations are to treat AF in pregnant women as in non-pregnant adults, by using pharmacological 000 JOGC 000 2019
1
CASE REPORT
or synchronized electrical cardioversion.1 Although maternal treatment is prioritized, careful consideration of the potential effects of treatment on fetal well-being must always be considered. Despite the potential effects of cardioversion on the fetus, including fetal bradycardia, current recommendations do not take into account gestational age or mention the role of delivery in the management of new-onset AF during pregnancy. We present here a case of new-onset AF near term that did not convert spontaneously after 48 hours, but resolved shortly following delivery without cardioversion. The objective of this case presentation is to discuss the importance of considering gestational age in patients with newonset AF during pregnancy and the potential role of delivery in the management of AF near or at term.
Caesarean delivery was planned because of the patient’s nulliparity, unfavorable Bishop score (<6), symptoms, and preference. The patient delivered of a male infant by Caesarean section at 364 weeks gestational age, under spinal anaesthesia. Birth weight was 3580 g. Apgar scores were 9 and 9 at 1 and 5 minutes of life, respectively. Postoperatively, the patient returned to the cardiovascular intensive care unit, where she spontaneously converted to sinus rhythm overnight, 6 hours following delivery. There was no recurrence of her arrhythmia, and she was discharged home on postoperative day 3 with outpatient cardiology follow-up. Prophylactic anticoagulation with low-molecular-weight heparin was administered postpartum while she was in hospital. DISCUSSION
CASE 4
A 23-year-old nulliparous woman at 36 weeks gestation was transferred to our tertiary care centre from a nearby community hospital after a diagnosis of new-onset AF. She first presented to hospital two days earlier following an accidental fall on her back. While in the hospital, she developed palpitations and shortness of breath, and was diagnosed with new-onset AF, with a rapid ventricular response of 150 beats per minute and a blood pressure of 110/60 mm Hg. She had no history of cardiovascular disease and denied prior similar symptoms. Initial workup included complete blood count, serum electrolytes, thyroid profile, and drug screen. Results were as follows: hemoglobin 123 g/L; sodium 136 mmol/L; potassium 3.4 mmol/L; thyroid stimulating hormone 0.39 mU/L; free thyroxine 9.52 pmol/L (normal value, 9−26 pmol/L); and a negative drug screen. A transthoracic echocardiogram showed no evidence of structural heart disease, and computed tomography pulmonary angiography was negative for pulmonary embolism. She was initially treated with intravenous metoprolol (2.5 mg, 5 mg, 5 mg, 2.5 mg) and then started on oral metoprolol (50 mg twice daily.) Twenty-four hours later, she remained in AF with an irregular heart rate of 120 to 150 beats per minute and a stable blood pressure of 110/60 mm Hg. The patient was then transferred to our hospital, where the high-risk obstetrics team saw her in the cardiovascular intensive care unit. Given the possible risks associated with cardioversion, the duration of AF for longer than 48 hours, and the near-term gestational age, an early delivery was considered to allow the arrhythmia to be managed postpartum without concern for the fetus. Cardiology and anaesthesia were consulted, and after discussion with the patient, the decision was made to proceed with delivery. A
2
000 JOGC 000 2019
In patients with structurally normal hearts, new-onset AF is believed to be a result of the physiological and hemodynamic changes of pregnancy. It is logical then that newonset arrhythmias may resolve following delivery, as the cardiovascular system returns to its pre-pregnancy state. Among published case reports of AF in pregnancy, we identified six cases of new-onset AF in the third trimester in patients with no pre-existing heart disease and no clear precipitating factor (Table 1) by searching PubMed and Medline for articles using the key words “atrial fibrillation” and “pregnancy.” Spontaneous conversion to sinus rhythm was observed in three cases at 34 to 38 weeks gestation. Pharmacological cardioversion with flecainide was performed successfully in one case at 33 weeks gestation, and electrical cardioversion was performed successfully in another case at 33 weeks gestation. In one patient at 35 weeks gestation, electrical cardioversion was performed following failed pharmacological cardioversion. Although the patient converted to sinus rhythm afterwards, there was recurrence of the arrhythmia five days later, at which time the patient also presented with significant vaginal bleeding requiring an emergency Caesarean section.2−7 In a case series of 30 women with AF in pregnancy, Sauve et al. reported on five cases in which AF influenced delivery.8 However, this series included cases of AF with a clear precipitating factor, and the details of previous treatments and postpartum courses of those cases were not provided. Thus, to our knowledge, our report is the first to detail a case in which delivery was effected prematurely to manage AF and in which AF resolved spontaneously shortly after delivery without further treatment. Although a causal relationship cannot be inferred, this outcome suggests that there may be a role for delivery in the management of new-onset AF in pregnant women near or at term.
Management of New-Onset Atrial Fibrillation in Pregnancy: When Should Early Delivery Be Considered?
Table 1. Description of published cases of new-onset atrial fibrillation in the third trimester of pregnancy Author, year, reference
Case description
Treatment
Gowda et al., 2003
29-year-old G3P1A1 at 38 weeks gestation presented with palpitations and dyspnea
None
Spontaneous conversion to sinus rhythm after only a few minutes; no recurrence of arrhythmia
Cacciotti et al., 20103
35-year-old at 36 weeks gestation presented with palpitations
Rate control with metoprolol; no cardioversion
Spontaneous conversion to sinus rhythm; no recurrence of arrhythmia
Anugu et al., 20164
30-year-old G3P0A2 at 34 weeks gestation presented with 2-hour history of palpitations, dyspnea, and chest tightness
Rate control with diltiazem; no cardioversion
Spontaneous conversion to sinus rhythm; no recurrence of arrhythmia
Walsh et al., 20085
41-year-old G3P1A1 at 334 weeks gestation presented with 1-day history of palpitations
Murphy et al., 20146
Brown et al., 20017
2
Outcome
Rate control with atenolol; pharmacological cardioversion with flecainide
Conversion to sinus rhythm; no recurrence of arrhythmia
37-year-old G3P2 at 33 weeks gestation presented with sudden-onset palpitations
Rate control with metoprolol; electrical cardioversion
Conversion to sinus rhythm; no recurrence of arrhythmia
32-year-old G3P2 at 35 weeks gestation presented with palpitations
Pharmacological cardioversion with flecainide followed by electrical cardioversion
Treatment of AF in pregnancy is challenging, and there is little consensus regarding optimal treatment of this rare condition. According to the European Society of Cardiology (ESC) guidelines on the management of cardiovascular diseases during pregnancy, if AF does not resolve within 24 hours after rate control, pharmacological cardioversion with antiarrhythmic agents is recommended.1 Flecainide and ibutilide are generally considered the preferred first-line pharmacological agents, and amiodarone and propafenone should be avoided. The ESC guidelines suggest limiting the use of synchronized electrical cardioversion to cases complicated by maternal hemodynamic compromise.1 However, in a survey of obstetrical medicine practitioners on the management of AF in pregnancy, respondents preferred electrical cardioversion to chemical cardioversion and described electrical cardioversion as safer, more predictable, and more effective.9 The ESC guidelines also recommend anticoagulation with unfractionated heparin or low-molecular-weight heparin before cardioversion when the duration of AF is greater than 48 hours. In addition, in the presence of AF for more than 48 hours or additional risk factors for thromboembolism, continued anticoagulation for four weeks following cardioversion is recommended because of the increased risk of thromboembolism secondary to “atrial stunning.”1 Therefore, health practitioners must consider the potential risks of cardioversion, as well as the implications of prolonged anticoagulation, in the near-term and term
Conversion to sinus rhythm following electrical cardioversion; recurrence of arrhythmia 5 days later, at which time there was significant vaginal bleeding requiring an emergency Caesarean section
period when managing cases of new-onset AF in the third trimester. In our case, antiarrhythmic therapy was deferred because of the near-term gestational age of the patient, the possible risks associated with cardioversion, and the duration of AF for longer than 48 hours. The patient’s arrhythmia resolved postpartum without further treatment. Delivery allows for more therapeutic options without the risk of potential harm to the fetus, and it may result in spontaneous conversion to sinus rhythm. However, decisions regarding early delivery should be made on a case-by-case basis after consultation with cardiology, anaesthesiology, and maternal-fetal medicine. The risks and benefits of treatment versus early delivery in preterm patients must be carefully weighed, and neonatology consultation may be warranted. REFERENCES 1. European Society of Gynecology (ESG). Association for European Paediatric Cardiology (AEPC). German Society for Gender Medicine (DGesGM). ESC guidelines on the management of cardiovascular diseases during pregnancy: the task force on the management of cardiovascular diseases during pregnancy of the European Society of Cardiology (ESC). Eur Heart J 2011;32:3147–97. 2. Gowda RM, Punukollu G, Khan IA, et al. Lone atrial fibrillation during pregnancy. Int J Cardiol 2003;88:123–4. 3. Cacciotti L, Camastra GS, Ansalone G. Atrial fibrillation in a pregnant woman with a normal heart. Intern Emerg Med 2010;5:87–8.
000 JOGC 000 2019
3
CASE REPORT
4. Anugu VR, Nalluri N, Asti D, et al. New-onset lone atrial fibrillation in pregnancy. Ther Adv Cardiovasc Dis 2016;10:274–6.
7. Brown O, Davidson N, Palmer J. Cardioversion in the third trimester of pregnancy. Aust N Z J Obstet Gynaecol 2001;41:241–2.
5. Walsh CA, Manias T, Patient C. Atrial fibrillation in pregnancy. Eur J Obst Gynecol Reprod Biol 2008;138:119–20.
8. Sauve N, Rey E, Cumyn A, et al. Atrial fibrillation in a structurally normal heart during pregnancy: a review of cases from a registry and from the literature. J Obstet Gynaecol Can 2017;39:18–24.
6. Murphy N, Sugrue D, McKenna P. Case report on the treatment of atrial fibrillation in a pregnant woman of 33 weeks’ gestation. Open J Obstet Gynecol 2014;2:8–9.
9. Cumyn A, Sauve N, Rey E. Atrial fibrillation with a structurally normal heart in pregnancy: an international survey on current practice. Obstet Med 2017;10:74–8.
4
000 JOGC 000 2019