Fetal Cardiac Arrhythmia: Diagnosis and Management fetal heart rate and rhythm Rhythmic contractions...
Transcript of Fetal Cardiac Arrhythmia: Diagnosis and Management fetal heart rate and rhythm Rhythmic contractions...
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Anitha Parthiban MD, FAAP
Director , Pediatric Echocardiography
Children’s Mercy Hospitals & Clinics
Fetal Cardiac Arrhythmia:
Diagnosis and Management
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Objectives
Evaluation of fetal heart rate and rhythm
Recognize abnormal heart rhythm
Indications for referral
Differential diagnosis of fetal tachycardia
and management
Differential diagnosis of fetal bradycardia
and management
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Fetal Cardiac Arrhythmia
Occur in 1-3 % of pregnancies
10-20% fetal cardiology referrals
Majority are benign
Can cause fetal morbidity (hydrops) and
demise
Potential to alter course with therapy
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Fetal Cardiac Arrhythmia
Fetal heart rate and rhythm assessment
mandatory component of fetal
echocardiogram per recent published
guidelines
AHA 2014
AIUM 2013
ASE 2004
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Normal Cardiac Conduction
Wang P J , and Estes N A M Circulation.
2002;106:e206-e208 AHA .org
Surface EKG
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Normal fetal heart rate and rhythm
Rhythmic contractions begin at 22 days post
conception
Atrio-ventricular synchrony by 6 weeks
(110bpm)
Average HR 170 bpm at 10 weeks,150 bpm at
16 weeks,140bpm at 20weeks, 130 bpm at term
Normal range : 110-180 bpm
Beat to beat variability of 5-15 bpm
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Assessment of Fetal Rhythm
Echocardiography is the mainstay
Pulse Doppler, M-mode, Tissue Doppler
Direct electrocardiographic assessment of
rhythm (fetal electrocardiography)-limited
use due to poor quality
Magnetocardiography- higher quality,
limited availability
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Echocardiographic analysis
of fetal cardiac rhythm
Heart rate
Demonstrate sequential atrioventricular
contraction
Mechanism of tachycardia / bradycardia
Measurements- ex. mechanical PR
interval
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Echocardiographic analysis of fetal
cardiac rhythm: M-Mode echo
Simultaneous
M-mode
recording of
atrium and
ventricle
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Echocardiographic analysis of fetal
cardiac rhythm : Doppler
Simultaneous
Doppler
tracing of left
ventricular
inflow and
outflow
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Echocardiographic analysis of fetal
cardiac rhythm : Doppler
Simultaneous
Doppler
tracing of
pulmonary
vein (below)
and pulmonary
artery (above)
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Echocardiographic analysis of fetal
cardiac rhythm : Doppler
Simultaneous
Doppler tracing
of ascending
aorta (below
baseline) and
SVC (above)
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Abnormal Fetal Rhythm
Irregular
Tachycardia
Bradycardia
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Irregular cardiac rhythm
Premature atrial contractions (PAC’s)
Premature ventricular contrcations (PVC’s)
2nd degree atrioventricular block (AVB)
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Irregular cardiac rhythm
Premature beats occur in 1-3 % pregnancies
Benign
Rare- myocarditis, tumors, aneurysm, diverticulum,
maternal stimulants
Atrial ectopy 10- fold more common
Frequent or persistent ectopy (more than 2 weeks)
needs further evaluation
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Premature atrial contractions
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Premature atrial contractions
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PACs: Conducted and non-
conducted
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Ventricular bigeminy
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2nd degree AV block
Parthiban, Swaminathan Cardiol in the Young Vol 14, Issue 4: 432- 34
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Ectopy- Management
Pharmacotherapy not recommended
0.5 to 1% risk of supraventricular tachycardia with
PAC’s
Unknown risk of ventricular tachycardia with PVC’s
Differentiate from 2 nd degree AV block
Observation with weekly heart rate assessment ,
function assessment if myocarditis or other structural
disease
Referral for fetal echocardiogram
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Fetal tachycardia
HR> 160 bpm
Sinus (160-200 bpm)
Pathologic mechanisms (180-280 bpm)
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Pathologic fetal tachycardia
Accessory pathway mediated supraventricular
tachycardia (SVT)
Atrial flutter
Ventricular tachycardia – tumor, aneurysm,
myocarditis, Long QT syndrome
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Fetal tachycardia
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SVT : Accessory pathway
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Atrial flutter
Atrial rate usually 300-500 bpm. Panel above shows 2:1
atrio ventricular conduction
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Fetal Tachycardia- Management
Sustained tachycardia can result in hydrops
fetalis
In utero pharmacotherapy is usually successful
Management depends on gestational age, fetal
compromise, maternal and fetal risk factors, type
of tachycardia
Referral for fetal echocardiogram and cardiac
evaluation – assess mechanism and therapy
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Fetal Tachycardia- Management
Digoxin, flecainide, sotalol, amiodarone, IV
magnesium, lidocaine
Direct fetal therapy (Intramuscular or
intracordal) digoxin, amiodarone
Risks to mother and fetus
Little data to support specific treatment
protocols for maximal efficiency and least risk
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Fetal Bradycardia
Heart rate <100 bpm
Sinus bradycardia
Atrial or junctional bigeminy with non-
conducted extrasystoles
AV block (high grade or complete)
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Persistent bradycardia:
Differential diagnosis
Sinus bradycardia
Atrial bigeminy
with block
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Complete ( 3rd degree) AV block
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3d Degree AV block
A rate 140 bpm
V rate 60 bpm
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3d Degree AV block
Autoimmune : Maternal collagen vascular
disease (SLE, Sjögren’s)
Associated with congenital heart disease
Indices of poor prognosis: Ventricular rate<55
bpm, endocardial fibroelastosis, myocardial
dysfunction, hydrops fetalis
Worse prognosis when associated with CHD
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Fetal bradycardia- Management
Referral for fetal cardiac evaluation and
echocardiogram
Sinus bradycardia- treat mechanism (maternal
hypothyroidism, medications, autoimmune, long
QT syndrome)
Atrial bigeminy with block- observation , rule out
complete /high grade AV block, risk of SVT 10%
Immune mediated AV block- dexamethasone,
IVIg, terbutaline, fetal pacing
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Summary
Assessment of fetal heart rate and rhythm is
important part of evaluation of the fetus
Though uncommon, fetal arrhythmia can cause
significant fetal morbidity and mortality
Pharmacotherapy is often successful in
managing most common forms of tachycardia
Early cardiac referral important in management