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Supraventricular Tachycardia in the fetus
Experience and treatment.
Dr. Glicerio Ceballos Puentes
Cardiocenter William Soler Hospital
Piti Fajardo Hospital
Introduction: Cardiac arrhythmias in the fetus are not seen frecuently; one can see premature atrial beats(PAB) or premature ventricular beats(VBP) isolated; others as sinus bradycardia(SB) and sinus tachycardia(ST) are seen very often without any consequence for the fetus. Among supraventricular arrhythmias, supraventricular tachycardia(SVT) and atrial flutter(AF) are the arrhythmias that need some treatment as several authors have described.
General Objectives: To recognize the behaviour of SVT with echocardiographic follow up in the fetus(ECO) after having done the diagnosis and to recognize what will happen once the patient will be born.
Specific Objetives: To recognize what happened with the treatment with digoxin and to support the opinion that echocardiographic test is the best diagnostic tool in face of all cardiac arrhythmias.
Method: We used a Combinson 310, Kretz( M and B mode), in outpatients clinic, in order to study all pregnants women with risk of heart defects in their babies from the municipality of East Havana.
Results: There was a good response after the arrthythmia was diagnosed and treated with digoxin by maternal way. We make a comment of what happened after the baby was born.
Conclusions: It is emphasized that ECO is the best diagnostic method among others. Digoxin is the drug of first line and the maternal route, is a good way.
The use of ultrasound in the fetal world has allowed to discover great unknown things of the behaviour of the fetus and the world around it during the nine months of pregnancy. Cardiac arrhythmias are not isolated of this acquired knowing, and there are a lot of authors which since a few years have begun to speak about their experiences in Fetal Medicine.
Fetal arrhythmias have received different clasifications, one of them is Dr. Oberhansli´s(1):
- Premature atrial contraction (ACP)
- Premature ventricular contraction (VCP)
- Sinus tachycardia(ST)
- Sinus bradycardia(SB)
- Premature atrial contraction blocked.
- Supraventricular tachycardia (SVT)
- Atrial flutter (AF)
- Nodal tachycardia
- Atrioventricular block(A-V) of 2nd grade
- Atrioventricular complete block
- Complex arrhythmias.
Echocardiography in their different forms has permited to diagnose all of them. M mode is the one that is been more used(2,3,4,5)
The different treatments of choice in arrhythmias depend on many factors but Digoxin is the drug of first choice; several authors have confirmed its benefit(6,7,8). Hydropis is a bad sign and when it happens, it will determine the prognosis of the fetus(9)
General objectives: To compare our findings with others diagnostic methods used to diagnose arrhythmias in fetal life and in the afterbirth period.
Specific Objetives: To recognize the benefit of the treatment with digoxin (slow treatment) and the value of its use by maternal route.
Methods: Our country has a programme of Prenatal Diagnostic. The province of Havana inserted Fetal echocardiography in 1989, as a pilot study, in the east of the province. Since the beginning we have used aCombinson 310 Kretz(M and B mode) equipment.
Pregnants women are sent to receive our service when they have some risk:
Maternal risk factors: Extreme ages in life(<18 years and >36 years). Some illness as: Sistemic Eritematous Lupus, IDDM etc. Treatment with some drugs: Dilantin, Ethanol, Retinoic acid etc.
Obstetrical risk factors: Abnormal biometric profile. Amniotic liquid abnormalities or changes, etc.
Fetal risk factors: Fetal arrhythmias. Four chambers abnormal view.
Pregnants women are selected according to the risks by: the Family doctors, Obgyn. doctors, Genetist and others who treat the patients.
MDF, 38 years, white. G2P1. who was sent to our Fetal echocardiographic service because she was 36 years old. The first test was not possible because of the position of the fetus. At 24 5/7 weeks, we repeated the test and found a fetal cardiac frequency around of >200 BPM (M mode) without atrialventricular(A-V) dissociation and without heart defects and with a normal cardiotocographic (CTG) test (fig.1). We began to treat the feto by maternal route with digoxin(slow treatment)( 0.125 mg/day), step by step and in the 3er day, we raised the treatment to 0.25 mg/day.
After 15 days with 0.25 mg/day, cardiac rate in the fetus was normal.(fig.2).
An echocardiographic control test was done just as far as the cardiac rate was normalized and after that, every two weeks was done an echocardiographic control until pregnancy was finished. We never found any arrhythmia during the treatment.
Since the beginning of the treatment and until the end of pregnancy, the pregnant received a close control by Obgyn. department. The fetus was born without any problem(Apgar 9-9). They were discharged from the hospital after 72 hours.
When the baby was 2 weeks old, he began with tachycardia, polypnea and cyanosis (fig.3). We understood what happened when we knew that the treatment was stopped when they went to his house. We began again with digoxin 10 mcg/kg/day and after 72 hours the symptoms and signs disappeared.
The baby did not have any other problem in the first year of his life(ECO and ECG, normal). Now, he is 1 3/12 year old and he is doing well without any treatment.
The treatment with digoxin in a fetus with SVT was reported in 1980 by Lingman(10), he recommended digoxin, 0.25 mg every 12 hours in the first day and later on digoxin 0.25 mg/day and he also found no-correspondence between the CTG test and transabdominal ECG in the fetus. All the authors agree with the good response to digoxin.
In our case it was the first patient that we have treated in 3000 test with 15 simple arrhythmias which did not need any treatment.
We used the slow treatment with digoxin because we could not dosify digoxin in blood. We considered that there was a good response without any bad secondary effects, so much to the mother as to the fetus. The baby proved with his illness that he needed digoxin all the time when he repeated the arrhythmia. He finished the treatment 3 months ago and he is very well.
In face of a fetal arrhythmia we should always do an echocardiographic test.
1. Oberhanli-Weiss, I. Afecciones cardiacas del feto.
Schweiz.Med.Wochenschr. 1995, 125; 294-303.
2. Allan, L.D. Manual of Fetal Echocardiography. 1986. MTP Press Limited, Falcon House, Lancaster, England.
3. DeVore, G.R. et.al. Fetal echocardiography III. The diagnosis of cardiac arrhythmias. Am.J.Obstet.Gynecol. 1983, 146; 792-99.
4. Friedman, D.M. et.al. Benign fetal bradycardias diagnosed by echocardiography. Am.J.Perin. 1995, 12; 2, 295-99.
5. Kleimman, C.S. et.al. Fetal echocardiography. A tool for evaluation of in utero cardiac arrhythmias and monitoring of utero therapy. Am.J.Cardiol. 1983, 51; 2, 237-43.
6. Allan, L.D. Fetal tachycardia. Cardiol Young, 1996, 6; 197.
7. Hallak, M. et.al. Fetal supraventricular tachycardia and hydrops fetalis: Combined intensive, direct and transplacental therapy. Obstet.Gynecol. 1991, 78 ; 523-25.
8. Perry, J.C. Fetal arrhythmias, pediatric arrhythmias, and pediatric electrophysiology. Curr.Opin.Cardiol. 1995, 10; 52-57.
9. Copel, J.A. et.al. Management of fetal cardiac arrhythmias. Fet.Diag.Therap. 1997, 24; 1, 201-11.
10. Lingman, G. et.al. Intrauterine digoxin treatment of fetal paroxismal tachycardia case report. Brit.J.Obstet.Gynecol. 1980, 87; April, 340-43.
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