Management of Supraventricular Tachycardia in Pregnant Patients

Acute Management

The American Heart Association recommends vagal maneuvers as the first-line treatment for supraventricular tachycardia (SVT) in pregnant patients, followed by adenosine if necessary, with beta-blockers or cardioversion reserved for refractory cases 1, 2
Vagal maneuvers should be performed with the patient in the supine position as the initial intervention, including techniques such as the Valsalva maneuver, carotid sinus massage, and cold stimulus 2, 3, 1
Adenosine is the first-line pharmacological option for SVT in pregnant patients, with an initial dose of 6 mg rapid IV bolus, and is considered safe during pregnancy due to its short half-life 1, 2, 3, 4
Synchronized cardioversion is recommended for hemodynamically unstable patients, with energy dosing the same as in non-pregnant patients, and fetal monitoring during and after cardioversion is recommended 2, 3, 4, 1

Metoprolol is a first-line agent for prophylactic therapy, with a Class I recommendation and level B evidence, and is considered safe during the second trimester 3, 4
Propranolol is a reasonable alternative, with a Class IIa recommendation and level B evidence, and is generally considered safe in the second trimester 3, 4, 5
Digoxin is another first-line option, with a Class I recommendation and level C evidence, and has a long track record of safety during pregnancy 3, 4

The American College of Cardiology recommends avoiding amiodarone during pregnancy due to potential fetal harm, with a Class III recommendation 3, 4
Atenolol should be avoided during pregnancy due to risk of intrauterine growth retardation, with a Class III recommendation 3, 5
Flecainide should not be used in patients with significant ventricular dysfunction 6
Antiarrhythmic drugs should only be used if symptoms are intolerable or if tachycardia causes hemodynamic compromise, and the lowest recommended dose of medications should be used with regular monitoring of clinical response 3, 6, 1