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Decompensated supraventricular tachycardia in late pregnancy resistant to conventional treatment: A case report
Abstract Number: F-16
Abstract Type: Case Report/Case Series
Sustained tachy-arrhythmias have an incidence of 2-3 per 1000 in pregnancy for those who develop supraventricular tachycardia (SVT)1.
A 38-year-old pregnant woman (G2P1) at 35 weeks of gestation attended the emergency department (ED) with a 2-hour history of feeling unwell and palpitations. Her past obstetric and medical history were largely unremarkable apart from a previous caesarean delivery for breech presentation. Initial examination in the ED showed she had a heart rate of 170 beats per minute and blood pressure 100/64 mmgHg with no other significant findings. She was sat up on a chair and could talk in full sentences. 12 lead electrocardiogram showed a supraventricular tachycardia and routine blood tests were within normal range. Vasavagal manoeuvres followed by medical treatment of SVT with repeated doses of adenosine and metoprolol failed to resolve the arrhythmia. It was decided that electrocardioversion as the next line of treatment should be carried out in the operating theatre with obstetric and paediatric teams on standby. On arrival to theatre, the patient rapidly decompensated, SpO2 falling to 75% on 15L oxygen and became haemodynamically unstable. The patient had clinical signs of pulmonary oedema at this stage. A rapid sequence induction was done and IPPV commenced. PEEP of 12 cmH2O and FiO2 of 70% were required to maintain SpO2 above 90%. Immediately after this the patient received 3 synchronized direct current shocks of 50J, 100J and 150J. With each shock the heart rhythm transiently returned to sinus rhythm for approximately 30 seconds but then returned to SVT. At this stage the cardiotochograph showed fetal compromise and the decision was taken to perform an emergency caesarean section. Baby APGAR scores were 0 and 1 at 1 and 5 minutes. On delivery of the placenta the maternal heart rate returned to normal sinus rhythm accompanied by rapid improvement in haemodynamic parameters. Lower segment caesarean section was completed in 30 minutes. Fi02 and PEEP requirements remained high to maintain satisfactory oxygenation due to the pulmonary oedema. The patient was transferred to the intensive care unit where she rapidly improved with supportive and diuretic therapy and was discharged successfully within 8 hours.
Conventional medical treatment as per recommended guidelines1 for the treatment of SVT were unsuccessful in this pregnant patient. Change from a sitting posture in ED to a recumbent posture during transfer might have contributed to the rapid hemodynamic instability and development of pulmonary oedema in this patient. Interestingly it was only after delivery of the placenta did the arrhythmia revert spontaneously to normal sinus rhythm.
1. European Society of Cardiology guidelines on the management of cardiovascular diseases during pregnancy. Eur Heart J. 2011 Dec;32(24):3147-97