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CASE REPORT
Year : 2013  |  Volume : 3  |  Issue : 2  |  Page : 91-93

Management of resistant supraventricular tachycardia in the immediate postpartum period: A case report


1 Department of Anaesthesiology, Employees State Insurance Medical College, Bangalore, Karnataka, India
2 Department of Obstetrics and Gynecology, Employees State Insurance Medical College, Bangalore, Karnataka, India

Date of Web Publication19-Dec-2013

Correspondence Address:
Nataraj M Srinivasan
Department of Anaesthesiology, Employee's State Insurance Medical College, Rajajinagar, Bangalore - 560 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4472.123303

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  Abstract 

Supraventricular tachycardia (SVT) during pregnancy or immediate postpartum is the commonest arrhythmia during pregnancy. Usually, the clinical symptoms are mild or go unrecognized. Rarely as in our case, can patient present with severe symptoms of agitation and restlessness which can mimic puerperal psychosis. A 12 lead electrocardiogram (ECG) and an echocardiogram usually are sufficient to diagnose SVT. Amiodarone, even though is not the drug recommended to be used during pregnancy, in resistant types of SVT it is an useful drug.

Keywords: Amiodarone, postpartum, supraventricular tachycardia


How to cite this article:
Narasimhaiah G, Srinivasan NM, Hemadribotla A, Ramaiah R. Management of resistant supraventricular tachycardia in the immediate postpartum period: A case report. J Obstet Anaesth Crit Care 2013;3:91-3

How to cite this URL:
Narasimhaiah G, Srinivasan NM, Hemadribotla A, Ramaiah R. Management of resistant supraventricular tachycardia in the immediate postpartum period: A case report. J Obstet Anaesth Crit Care [serial online] 2013 [cited 2019 Dec 6];3:91-3. Available from: http://www.joacc.com/text.asp?2013/3/2/91/123303


  Introduction Top


Supra Ventricular Tachycardia (SVT) is a commonest arrhythmia during pregnancy. [1] It may be the result of associated hormonal and autonomic changes which occurs during pregnancy. [2] Increased estrogen levels may heighten cardiac excitability and sensitize the myocardium to catecholamines by up regulation of alpha-adrenergic receptors. [3] Patients in SVT usually present with shortness of breath, palpitations, dizziness and syncope. [4] Rarely, as in our case, the patient presented with severe restlessness and agitation which mimicked postpartum psychosis. Resolution of symptoms after reverting back to sinus rhythm ruled out the diagnosis of puerperal psychosis. Even though there are reported cases of supraventricular tachycardia (SVT) in literature, there is no case report where patient presented with severe symptoms of restlessness and agitation making us to strongly suspect coexisting psychotic features.


  Case Report Top


A 28-year-old primigravida with term gestation was admitted for safe confinement. She had regular antinatal visits and was detected with no comorbidities. Labor was induced with oxytocin 5 U intravenous (IV) infusion in Ringer's lactate. She delivered a live female baby 4 h after induction. Post induction, oxytocin 10 U infusion was started. Mild postpartum hemorrhage was suspected and methylergometrine 0.2 mg intramuscular (IM) and carboprostadin 200 μg IM were given with which the uterus was well contracted and bleeding per vagina had stopped. Patient had become increasing anxious over the next 15 min after delivery and was very restless. She complained of vague chest discomfort and a sense of impending death. On examination, there was no bleeding per vagina and uterus was well contracted. There was no pallor, heart rate was 220 beats per min and blood pressure was 122/78 mmHg. Respiratory rate was 30 per min with labored breathing pattern. There was no wheeze or crepitations. Oxygen saturation by pulse oximetry was 100%. Her previous vital signs recordings were normal and all her symptoms had started just after delivery. In view of her unusually high heart rate and being very restless, she was shifted to intensive care unit for further monitoring. A 12 lead electrocardiogram (ECG) was done which showed absent P waves and normal QRS complexes and a rate of 220 beats per min. A diagnosis of stable SVT was made. She had become increasing restless and agitated. Vagal maneuvers were tried to revert to sinus rhythm and was unsuccessful. Adenosine 12 mg IV was given with a saline push of 20 ml. As there was no response a repeat dose of 12 mg IV was given. There was only transient decrease in heart rate to 165 beats per min with no P waves. She was sedated with haloperidol 5 mg lorazepam 2 mg IV as she was becoming very aggressive and difficult to restrain in bed. Further rate control measures with diltiazem 12.5 mg IV and metaprolol 5 mg IV were not effective. Blood gas measurement showed uncompensated respiratory alkalosis with normal oxygenation. Serum electrolytes were normal. As she was extremely agitated in spite of sedation and as there was a need to shift her for computed tomography (CT) scan to rule out intracerebral pathology, anesthesia was induced with propofol 100 mg and muscle relaxation obtained with succinylcholine 50 mg IV. Trachea was intubated with 8.0 mm cuffed oral endotracheal tube and ventilation was controlled. Right subclavian vein was cannulated with triple lumen catheter and the measured venous pressure was normal. Bedside echocardiogram was normal with no clots in the cardiac chambers. A decision to cardiovert was made and synchronized cardioversion was attempted with 100 J and then with 200 J with a biphasic defibrillator which was also ineffective. Amiodarone 150 mg IV was given over 10 min and an infusion of 1 mg/kg/min was started along with midazolam infusion and was monitored. CT scan of brain was also normal. Slowly over half an hour the heart rate decreased to 120 beats per min with appearance of P waves. Sedation was stopped and repeat blood gas showed normal acid base status and trachea was extubated. She was quiet and comfortable. Restless and agitation had subsided. Repeat 12 lead ECG showed normal sinus rhythm.


  Discussion Top


SVT is the commonest arrhythmia in women of reproductive age with an incidence of about 35 per 100,000 person-years in general population. [5] Atrioventricular nodal reentry and Wolf-Parkinson-White syndrome account for the majority of SVT. In pregnant women, increased levels of catecholamines increased adrenergic receptor sensitivity, increased maternal effective circulating volume causing atrial streach, and use of oxytocin to augment labor can precipitate SVT. [6] Also, use of oxytocin results in several cardiovascular adverse effects like hypotension, tachycardia, myocardial ischemia, and arrhythmias. [7] Most of the time patients are usually are asymptomatic. It is unusual for an SVT to significantly compromise maternal or fetal health. [8] However, at extremes of heart rates or in the presence of underlying cardiac disease, severe symptoms and hemodynamic instability may occur.

Management of SVT in pregnancy is similar to that of in nonpregnant patient. In hemodynamically unstable patient electrical cardioversion is indicated (American College of Cardiology (ACC)/American Heart Association (AHA) Class I recommendation, Level of Evidence C). In the stable patient with SVT, vagal maneuvers (ACC/AHA Class I recommendation, Level of Evidence C) should be employed first and, if unsuccessful, should be followed by adenosine (ACC/AHA Class I recommendation, Level of Evidence C). β-blockers are generally considered safe in pregnancy (ACC/AHA Class IIa recommendation, Level of Evidence C). [9] Cardioselective β-1 blockers (metoprolol) are preferred due to the theoretical advantage of less interference with β-2 mediated peripheral vasodilatation and uterine relaxation. [10] Both verapamil and diltiazem have been used in pregnancy to successfully treat SVT if beta blocker therapy does not convert the arrhythmia (ACC/AHA Class IIb recommendation, Level of Evidence C). [9] Even though amiodarone is not considered safe during pregnancy due to multiple adverse effects on the fetus and it is recommended to be only for life-threatening conditions refractory to other treatments. [11] In a setting of acute paroxysmal SVT (PSVT) resistant to other conventional drugs, the risk-benefit ratio of using amiodarone has to be considered. Acute onset of puerperal psychosis particularly of maniac type was another possibility to be considered in our patient before the diagnosis of SVT was established. Subsiding of the symptoms on reversion to normal sinus rhythm rules out in favor of pyschosis.

 
  References Top

1.Nelson-Piercy C. Handbook of Obstetric Medicine. 2 nd ed. London: Martin Dunitz; 2002. p. 22-3.  Back to cited text no. 1
    
2.Widerhorn J, Widerhorn AL, Rahimtoola SH, Elkayam U. WPW syndrome in pregnancy: Increased incidence of supraventricular arrhythmias. Am Heart J 1992;123:796-8.  Back to cited text no. 2
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3.Roberts JM, Insel PA, Goldfien A. Regulation of myometrial adrenoreceptors and adrenergic response by sex steroids. Mol Pharmacol 1981;20:52-8.  Back to cited text no. 3
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4.Robins K, Lyons G. Supraventricular tachycardia in pregnancy. Br J Anaesth 2004;92:140-3.  Back to cited text no. 4
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5.Orejarena LA, Vidaillet H Jr, DeStefano F, Nordstrom DL, Vierkant RA, Smith PN, et al. Paroxysmal supraventricular tachycardia in the general population. J Am Coll Cardiol 1998;31:150-7.  Back to cited text no. 5
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6.Tan HL, Lie KI. Treatment of tachyarrhythmias during pregnancy and lactation. Eur Heart J 2001;22:458-64.  Back to cited text no. 6
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7.Dyer RA, Butwick AJ, Carvalho B. Oxytocin for labour and caesarean delivery: Implications for the anaesthesiologist. Curr Opin Anesthesiol 2011;24:255-61.  Back to cited text no. 7
    
8.Trohman RG, Parrillo JE. Direct current cardioversion: Indications, techniques, and recent advances. Crit Care Med 2000;28(10 Suppl):N170-3.  Back to cited text no. 8
    
9.Blomstrom-Lundqvist C, Scheinman MM, Alio EM, Alpert JS, Calkins H, Camm J, et al. European Society of Cardiology Committee, NASPE-Heart Rhythm Society. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias - executive summary. A report of the American college of cardiology/American heart association taskforce on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society. J Am Coll Cardiol 2003;42:1493-531.  Back to cited text no. 9
    
10.Kron J, Conti JB. Arrhythmias in the pregnant patient: Current concepts in evaluation and management. J Interv Card Electrophysiol 2007;19:95-107.  Back to cited text no. 10
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11.Magee LA, Downar E, Sermer M, Boulton BC, Allen LC, Koren G. Pregnancy outcome after gestational exposure to amiodarone in Canada. Am J Obstet Gynecol 1995;172:1307-11.  Back to cited text no. 11
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