Abstract
Background: Atrial fibrillation and atrial flutter (AF) during pregnancy may confer increased risk of perinatal complications, particularly since pregnancy is a known hypercoagulable and arrhythmogenic state. However, few studies of outcomes among this population exist, and the optimal management strategy is unclear. We sought to determine the risk of adverse outcomes among pregnant women with AF. Methods: In this single-center study, patients with documented AF in pregnancy (1/1998-9/2018) were retrospectively analyzed. Charts were manually reviewed for demographics, comorbidities, underlying cardiac disease, and medications. Outcomes included arrhythmias, need for cardioversion, and thromboembolic events. Results: Of 66 pregnant women with documented AF, 20 (30.3%) had a diagnosis of AF prior to pregnancy and 46 (69.6%) had new onset AF during pregnancy or immediately postpartum (within six weeks of delivery). Nine women (13.6%) had persistent AF. Thirty women (45.4%) had valve disease and/or congenital heart disease and/or preexisting cardiomyopathy, and eight (12.1%) had AF precipitated by active infection or severe nausea/vomiting. Comorbidities included diabetes mellitus (3%), hypertension (9%), thyroid disease (13.6%), and obesity (32.6%). Electrical cardioversion was performed in 10 women before or after pregnancy, and five women underwent electrical cardioversion during their first or second trimesters of pregnancy. Rate-controlling medications were prescribed in 75.7%, with the most common medication being metoprolol (39.3%). Anticoagulation strategies varied from no intervention (53%), low-dose aspirin monotherapy (18.2%), enoxaparin (13.6%), warfarin (13.6%), or warfarin plus aspirin (3%). AF with rapid rate occurred during labor/delivery in 6/44 (13.6%) women with available telemetry data. One woman had a stroke during pregnancy related to vertebral artery dissection; she was in sinus rhythm at presentation. No other thromboembolic complications occurred. Conclusion: Pregnant women with AF may require rate-controlling medication and/or cardioversion during pregnancy, but appear to be at low risk for thromboembolic complications when appropriately anticoagulated. Larger studies of pregnant women both with and without underlying structural heart disease are needed to further assess complications and thromboembolic risk to optimize management of AF in pregnancy.
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