Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 319e321

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Taiwanese Journal of Obstetrics & Gynecology

journal homepage: www.tjog-online.com

Research Letter

Management of recurrent and refractory ventricular tachycardia in

pregnancy
Li-Te Lin a, b, c, Kuan-Hao Tsui b, c, d, Renin Chang e, Jiin-Tsuey Cheng d,
Ben-Shian Huang c, f, g, Peng-Hui Wang c, f, g, h, i, j, *
a
Division of Gynecology, Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Su-Ao and Yuanshan Branch, Yilan, Taiwan
b
Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
c
Department of Obstetrics and Gynecology, National Yang-Ming University School of Medicine, Taipei, Taiwan
d
Department of Biological Science, National Sun Yat-Sen University, Kaohsiung, Taiwan
e
Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
f
Department of Obstetrics and Gynecology, National Yang-Ming University Hospital, Ilan, Taiwan
g
Division of Gynecology, Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan
h
Infection and Immunity Center, National Yang-Ming University, Taipei, Taiwan
i
Immunology Center, Taipei Veterans General Hospital, Taipei, Taiwan
j
Department of Medical Research, China Medical University Hospital, Taichung, Taiwan

a r t i c l e i n f o

Article history: at 15 weeks of gestation and subsided after electrical cardioversion

Accepted 23 June 2014
An increased incidence of cardiac arrhythmias occurs during
pregnancy [1e5]. However, the most common arrhythmias in
pregnancy such as atrial or ventricular premature beats are benign
and rarely require intervention [1e3]. Malignant ventricular
tachyarrhythmias rarely occur, but may be life-threatening and
need prompt intervention and management to prevent the sudden
death of the mother and fetus [2,3]. The management of arrhyth-
mias in pregnant women may be similar to that for nonpregnant
women; however, the safety of the fetus is of special concern and is
always a challenge [1,3]. In this paper, we report the case of a
pregnant woman with recurrent and refractory ventricular tachy-
cardia (VT). Approaches to the management of these patients are
also discussed.
A 30-year-old pregnant woman (gravida 1, para 0) at 33 weeks
of gestation presented to the emergency department complaining
of palpitations and shortness of breath. She denied having any
structural heart diseases or family history of arrhythmia or sudden
death. Her past medical history was unremarkable, except for
having previously experienced two episodes of VT. The first episode
took place 1 year before the pregnancy and she was effectively
treated with intravenous verapamil. The second episode occurred
* Corresponding author. Division of Gynecology, Department of Obstetrics and
Gynecology, Taipei Veterans General Hospital, and National Yang-Ming University
School of Medicine, 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan.
E-mail addresses: phwang@vghtpe.gov.tw, phwang@ym.edu.tw (P.-H. Wang).
with 100 joules (J).
Physical examination showed 177 regular heartbeats per min-
ute, blood pressure of 116/61 mmHg, and 99% oxygen saturation on
room air. Laboratory investigations revealed normal electrolyte
levels, normal renal function, normal thyroid function, and normal
cardiac markers, although she had anemia with a hemoglobin level
of 10.9 g/dL. A 12-lead electrocardiogram showed wide QRS com-
plex tachycardia with a right bundle branch block (RBBB), which is
consistent with VT originating from the left ventricular outflow
tract (LVOT) (Figure 1). The echocardiogram revealed preserved left
ventricular systolic function, trivial mitral regurgitation, and mild
mitral valve prolapse. She had stable vital signs; therefore, 5 mg of
verapamil was administered intravenously as a first step to control
the ventricular rate. However, the effect was insignificant and her
blood pressure subsequently dropped to 71/50 mmHg, and was
accompanied by disturbed consciousness. Electrical cardioversion
(EC) was applied three successive times with 100 J, 150 J, and 200 J,
respectively, because of resistant VT. However, the symptoms per-
sisted and the vital signs of the patient were unstable. After
detailed discussion and evaluation, an emergency cesarean section
was performed under general anesthesia. Intravenous verapamil
was administered continuously postoperatively for 48 hours.
The fetus was delivered without incident 10 minutes later and
its condition was fair (body weight, 2468 g; Apgar score, 5e8). The
patient's VT disappeared within 10 minutes after delivery in the
operation room. She received intensive care postoperatively and
had a dramatic change with totally absent VT. She was transferred
to the ordinary ward 1 day later, and was discharged home under
stable condition 4 days later. No recurrent VT occurred during the
following 2 years. Figure 2A shows the clinical course and thera-
peutic strategy of this patient.

http://dx.doi.org/10.1016/j.tjog.2015.04.002
1028-4559/Copyright © 2015, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. All rights reserved.
320 L.-T. Lin et al. / Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 319e321

Figure 1. Twelve-lead electrocardiogram (ECG) recording of ventricular tachycardia (VT) originating from the left ventricular outflow tract (LVOT). On the ECG, LVOT VT is identified
with a right bundle branch block (RBBB) in the inferior axis (red frames). The RBBB in the inferior axis has the characteristic slurred S wave in lead I (blue arrows) and R-wave
transition (rsR0 ) in V1 or V2 (brown frames).

Ventricular tachycardia is rare in pregnancy and is usually
associated with structural heart disease such as cardiomyopathy,
congenital heart disease, or valvular heart disease [1,5]. Ventricular
tachycardia complicated by structural heart disease is very prob-
lematic and has a poor prognosis, even after the delivery of the
baby. Monomorphic VT without structural heart disease, which is
regarded as idiopathic VT, has been reported in pregnant women
[2,6,7]. It usually has a benign prognosis [7]. In this case report, the
woman could be classified as having idiopathic VT and pregnancy
contributed to worsening the symptoms. The actual mechanism of
pregnancy-induced arrhythmia remains unclear. However, it has
been attributed to physical changes occurring during pregnancy, for

Figure 2. (A) The condensed clinical course of the pregnant woman. (B) The management algorithm of ventricular tachycardia in pregnancy (solid line), which includes the
management algorithm of the patient (dotted line). LVOT ¼ left ventricular outflow tract; VT ¼ ventricular tachycardia.
 L.-T. Lin et al. / Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 319e321
example, (1) hemodynamic changes such as an increase in blood
volume, heart rate, stroke volume, cardiac output, atrial and ven-
tricular size, and a decrease in peripheral resistance and blood
pressure; (2) autonomic changes such as increased sympathetic
activity; and (3) hormonal changes such as an elevated serum level
of estrogen and/or progesterone [3,4,6,7]. All changes may aggra-
vate cardiac loading, which may induce pregnancy-related ar-
rhythmias. The aforementioned precipitate factors disappear after
the delivery of the baby; therefore, pregnancy-induced arrhythmias
may subside spontaneously or be easily controlled. Intravenous
verapamil continued to be used during the perinatal period.
The management algorithm for VT in pregnancy is listed in
Figure 2B. The solid line indicates the suggested strategy in the
management of pregnant women with VT, and the dotted line in-
dicates the therapy for our current patient. The initial step is to
evaluate maternal hemodynamic stability and the fetal condition
[3,6]. Electrical cardioversion is indicated in the event of maternal
hemodynamic instability or fetal compromise [1,3,4,6,8]. Electrical
cardioversion can be performed during all stages of pregnancy with
minimal harm to the mother and fetus [3,4,6,9], and can be
repeated at higher levels of energy (100e360 J), if necessary [3,6]. If
a resistant rhythm or a nonreassuring fetal heart rate pattern
continues after EC, emergency delivery should be arranged, as in
our patient, although balancing the benefits and risks of fetal pre-
maturity should be always considered [10,11].
Conservative medical treatment is suggested for a hemody-
namically stable pregnant woman with a reassuring fetal heart rate
pattern [3,4,6]. Intravenous procainamide or lidocaine is reasonable
for an initial treatment [1,3,4,8]. Intravenous adenosine can be an
alternative [4,8,12]. Many antiarrhythmia drugs can be used during
pregnancy, based on different electrocardiogram patterns. For
example, ß-blockers are used for VT with a left bundle branch block
(LBBB) and verapamil is used for VT with RBBB l [6,8,13]. If the
disease persists after the aforementioned treatments, EC [4], radi-
ofrequency ablation, or implantable cardioverteredefibrillator
(ICD) can be used step by step [3,8,14e16]. There was no increased
risk of major ICD-related complications during pregnancy [1,4,8,14].
If the maternal rhythm responds to medical therapy, close
follow up with prophylaxis antiarrhythmia drugs is competent, and
includes the first choice of ß1 selective beta-blockers and the
alternative of sotalol. However, if the condition of a pregnant
woman with VT becomes unstable at any time, EC should be
delivered without delay [3]. In addition, the fetus should be deliv-
ered as soon as possible after fetal lung maturity (i.e.,  34 weeks)
to avoid recurrent VT and sudden death.
The first episode of VT in pregnancy in our patient was at 15
weeks of gestation. Electrical cardioversion was used as the first
step because of her syncope on arrival. Her rhythm returned to
normal after EC. However, the fetus was too immature to deliver.
Thus, we monitored her condition closely and planned to perform a
scheduled cesarean section when the fetus had matured, but VT
recurred at 33 weeks of gestation. Verapamil was initially admin-
istered because she was in a stable condition with suspected LVOT
VT. However, her vital signs became unstable. Electrical cardio-
version was performed immediately, but failed to rescue the pa-
tient. Emergency cesarean section was then performed. Our patient
presented a clinical course of VT in its most severe form.
In conclusion, VT is rarely observed during pregnancy and is
usually associated with organic heart disease. The physiological
changes related to pregnancy can worsen preexisting underlying
arrhythmias or result in de novo arrhythmias. The purpose of
initiating acute management of VT during pregnancy is to estimate
321
the maternal and fetal condition. Electrical cardioversion, delivery
of the fetus, antiarrhythmia drugs, radiofrequency ablation, and ICD
are all possible treatments. However, our algorithm may be a good
reference in the management of such patients in the future
(Figures 2A and 2B).
Conflicts of interest
The authors have no conflicts of interest relevant to this article.
Acknowledgments
This work was supported in part by grants from Kaohsiung
Veterans General Hospital in Kaohsiung, Taiwan (KSB1101-032,
KSB2101-005, KSB2102-004, and KSB2103-005), the National Sci-
ence Council of Taiwan in Taipei, Taiwan (NSC 102-2314-B-010-032
and NSC 99-2314-B-010-009-MY3), and the Taipei Veterans Gen-
eral Hospital in Taipei, Taiwan (V103C-112 and V103E4-003).
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