Key points in management of Arrhythmias during Pregnancy

The following are key points to remember from a Heart Rhythm Society (HRS) Expert Consensus Statement on the management of arrhythmias during pregnancy:

1. Pregnant patients with cardiac arrhythmias should be cared for by a cardio-obstetrics team that includes specialists from maternal-fetal medicine, cardiology/electrophysiology, anesthesiology, and neonatology. Shared decision making about the risks and benefits of medications and procedures, as well as risks of withholding such therapies, is recommended.
2. Palpitations are common in pregnancy and are usually benign. Patients should have a detailed history, physical examination, blood pressure testing, and resting 12-lead electrocardiogram. Unless there are concerns for electrical or structural heart disease, most patients with modest sinus tachycardia or extrasystoles do not need additional testing. 
3. Patients with a family history of inherited arrhythmia syndrome or arrhythmogenic cardiomyopathy should have an evaluation, counseling, and consideration of genetic testing. 
4. During pregnancy, metoprolol, propranolol, nadolol, quinidine, and sotalol are considered safe; mexiletine can be used with caution. When breastfeeding, metoprolol, propranolol, quinidine, and sotalol are considered safe; mexiletine and nadolol can be used with caution.
5. Direct current cardioversion or defibrillation is indicated for unstable supraventricular tachycardia or ventricular tachycardia with energy dosing as in the nonpregnant patient. Synchronized cardioversion is indicated if the pregnant patient is refractory to medical therapy or has contraindications. Avoid placing electrode pads on breast tissue to improve current delivery. 
6. Catheter ablation procedures during pregnancy should use techniques to minimize radiation exposure to as low as reasonably achievable. Placing a pelvic lead apron over the patient does not substantially reduce fetal radiation and is not recommended.
7. For cardiac interventions performed during pregnancy, general anesthesia is preferred over regional, left lateral tilt positioning is recommended, anesthetic medications should be reviewed to avoid exacerbation of arrhythmias, and intraprocedural fetal monitoring may be needed.
8. The route of delivery (vaginal or cesarean) should be selected according to obstetric indications. Antiarrhythmic drug therapy should be continued, and pain control optimized.
9. During lactation, antiarrhythmic medication should be continued as indicated, with preference for medications with the best safety profile. Amiodarone is generally avoided during pregnancy and lactation, but certain situations may warrant discussion of risks/benefits and shared decision making.
10. Advanced cardiac life support (ACLS) is generally performed as in the nonpregnant patient, including standard ACLS medications and defibrillation energy doses. Cardiopulmonary resuscitation performed later in pregnancy (when the uterine fundus is above the maternal umbilicus) should include leftward and upward uterine displacement.

https://www.heartrhythmjournal.com/article/S1547-5271(23)02246-4/fulltext