Management of Atrial Fibrillation in Pregnancy

Evaluation and Multidisciplinary Approach

Atrial fibrillation (AF) is one of the most common arrhythmias during pregnancy, with increasing prevalence due to advanced maternal age and lifestyle changes, according to the European Society of Cardiology 1, 2
Rapid atrioventricular conduction can have severe hemodynamic consequences for the mother and fetus, as noted by the European Heart Journal 2
A multidisciplinary approach is essential, involving obstetricians, neonatologists, maternal medicine specialists, anesthesiologists, and experienced cardiologists in pregnancy, as recommended by the European Heart Journal 1, 2

First-line: Selective beta-1 blockers (except atenolol) are recommended for heart rate control, as suggested by the European Heart Journal 1, 2, 4
Second-line: Digoxin may be considered if beta-blockers are ineffective or not tolerated, according to the European Heart Journal 2, 3
Other options: Non-dihydropyridine calcium channel blockers (verapamil, diltiazem) may be considered with caution, as noted by the American College of Cardiology 5

Immediate electrical cardioversion is recommended in cases of hemodynamic instability or pre-excited AF, as suggested by the European Heart Journal 2, 3
For stable patients with structurally normal hearts:
- Ibutilide or flecainide intravenous may be considered for AF termination, according to the European Heart Journal 2, 3
- Flecainide or propafenone may be considered for long-term rhythm control if rate control medications are ineffective, as noted by the European Heart Journal 2, 3

Pregnancy is associated with a hypercoagulable state and increased risk of thromboembolism, as noted by the European Heart Journal 2
For patients at high risk of thromboembolism:
- Recommended: Low molecular weight heparin (LMWH) or unfractionated heparin that does not cross the placenta, as suggested by the European Heart Journal 1, 2
- Vitamin K antagonists (VKAs) should be avoided in the first trimester (risk of miscarriage, teratogenicity) and from the 36th week (risk of fetal intracranial hemorrhage), according to the European Heart Journal 2, 6
- Direct oral anticoagulants are not recommended during pregnancy due to safety concerns, as noted by the European Heart Journal 2

Vaginal delivery is recommended for most women, but is contraindicated during VKA treatment due to the risk of fetal intracranial hemorrhage, as noted by the European Heart Journal 2
Accidental exposure to direct oral anticoagulants during pregnancy should not lead to a recommendation for pregnancy termination, according to the European Heart Journal 2
The same rules for assessing thromboembolic risk should be used as in non-pregnant women, as suggested by the European Heart Journal 2

Continuous monitoring of fetal heart rate is essential before and after any cardioversion, as noted by the European Heart Journal 4
Regular surveillance of anticoagulation with periodic evaluation of anti-Xa factor for LMWH is recommended, according to the European Heart Journal 4