Management of Arrhythmias During Pregnancy in Africa

Summary

Cardiac arrhythmias represent a significant clinical concern that have been always addressed. Moreover, Pregnancy introduces profound hormonal, autonomic, and hemodynamic changes that add more risk to cardiac patients and increase arrhythmia susceptibility. In our continent, Africa, there is an added risk because of the high prevalence of rheumatic heart disease, peripartum cardiomyopathy, and limited access to healthcare, contributing to adverse maternal and fetal outcomes. This article addresses the epidemics, mechanisms, and management of arrhythmias during pregnancy in African settings, highlighting high-yield real-life cases. We focus on guideline-based management strategies, emphasizing fetal safety, and discuss unique regional challenges, including limited access to drugs and restricted electrophysiology services. Data from a high-volume tertiary center in Egypt demonstrate that the key factors in such settings are multi-team cardio-obstetric care, timely intervention, and a balanced use of advanced electrophysiological techniques, which can achieve the best maternal and fetal outcomes despite constraints.

Pregnancy is accompanied by physiologic changes including profound hormonal, autonomic, and hemodynamic changes. These changes affect all body systems and especially increase susceptibility to cardiac arrhythmias. High estrogen and progesterone levels affect cardiac ion channel expression, autonomic tone, and adrenergic receptor sensitivity, thus increasing arrhythmogenesis through increased sympathetic activity, atrial and ventricular stretch, and altered repolarization. These changes, along with increased plasma volume and cardiac output, play a significant role in the occurrence of both benign and pathologic arrhythmias, and these changes and effects tend to peak in the second and third trimesters resulting in higher incidence of arrhythmias in these trimesters [1,2,3,5,7,9] (Fig. 1).

Fig. 1.

Maternal physiological adaptation in pregnancy predisposes to cardiac arrhythmias.

Arrhythmia risk is more prominent as pregnancy progresses, peaking in the second and third trimesters due to maximal hemodynamic and hormonal stress. Furthermore, Labor and delivery add more risk due to acute autonomic and electrolyte shifts associated with them. Fetal outcomes depend on arrhythmia type, timing, severity, and maternal stability. Most benign maternal arrhythmias have minimal fetal impact, but sustained high risk maternal arrhythmias, especially those causing hemodynamic instability, always put the fetus at increased risk of distress, hydrops fetalis, preterm delivery, and, in severe cases, fetal loss or neurologic impairment [1,2,3,4,5,6,7,8,9,11].

In Africa, these physiological changes are compounded by a high prevalence of rheumatic heart disease, peripartum cardiomyopathy, and HIV, all of which further increase arrhythmia risk. Younger maternal age and limited preconception screening are common, and the burden of cardiovascular disease is a leading indirect cause of maternal mortality [8,9,11].

Recent epidemiological data show a rise in pregnancy-related hospitalizations for arrhythmias, attributed to advanced maternal age, increased prevalence of structural heart disease, and cardiovascular risk factors. Black women and those with underlying heart disease are at higher risk. Most palpitations in pregnancy are due to sinus tachycardia or atrial/ventricular ectopy, which are usually benign and self-limited, requiring no pharmacological treatment. However, sustained arrhythmias are more frequent in patients with structural heart disease, thyroid dysfunction, or electrolyte disturbances, and may require a multidisciplinary cardio-obstetrics team approach [1,2,3,6,7,8,11] (Table 1).

Table 1.

Types of arrhythmias recorded during pregnancy in a tertiary high-volume cardiology center in Egypt [17].

Age 29.9 (± 6.7) years
Type of Arrhythmia	Total Patients (n)	Percentage (%)
AVNRT	32	52.5%
AT	3	4.9%
WPW	7	11.5%
PVCs	6	9.8%
CHB	5	8.2%
AF	4	6.6%
Postpartum CM	3	4.9%
VT	1	1.6%

In African populations, supraventricular tachycardia (SVT) is the most common arrhythmia in pregnancy (about 60%), followed by atrial fibrillation/flutter (15%), ventricular arrhythmias (10%), and bradyarrhythmias/AV block (5%). The high prevalence of rheumatic mitral valve disease and peripartum cardiomyopathy drives the increased rates of atrial fibrillation and ventricular arrhythmias, with a significant impact on maternal and fetal outcomes [8,11].

Tachyarrhythmias are the most common arrhythmias in pregnancy. SVT and atrial fibrillation (AF) are the most frequent pathologic arrhythmias, with AF incidence rising due to advanced maternal age and structural heart disease. SVT is often benign but can cause significant morbidity, including heart failure and increased risk of cesarean delivery. Management of stable SVT begins with vagal maneuvers; if unsuccessful, intravenous adenosine is safe and effective. Beta-blockers (excluding atenolol due to fetal growth restriction) are preferred for long-term prevention, with digoxin and verapamil as alternatives [3,5,6,7,8,10]. Flecainide and propafenone may be considered in patients with Wolff-Parkinson-White syndrome. Amiodarone and dronedarone are generally contraindicated due to fetal toxicity. Catheter ablation is reserved for drug-refractory cases and should be performed with minimal or zero fluoroscopy, ideally in the second trimester [1,2,3,4,5,7,10].

In Africa, access to antiarrhythmic drugs is often limited by stockouts, and referral delays are common due to fragmented health systems and reliance on general practitioners and midwives for frontline care. There is also a shortage of arrhythmia specialists and electrophysiology labs, making advanced interventions such as ablation or device therapy rarely available [8].

Atrial fibrillation in pregnancy usually indicates underlying heart disease and warrants inpatient management. Rate control can be achieved with beta-blockers, digoxin, or calcium channel blockers, while amiodarone should be avoided. Direct current cardioversion is safe and effective for unstable arrhythmias in any trimester. For stroke prevention in patients with valvular heart disease or high stroke risk, low-molecular-weight heparin is preferred during the first trimester and near delivery, with vitamin K antagonists considered after organogenesis. Direct oral anticoagulants are not recommended due to lack of safety data [1,2,3,4,5,6,7,8].

In sub-Saharan Africa, atrial fibrillation is strongly associated with rheumatic heart disease, hypertension, and cardiomyopathy. The prevalence of AF in patients with rheumatic heart disease can reach up to 47%, and complications such as heart failure and stroke are common. The use of anticoagulation for stroke prevention is suboptimal, and the cost of management is often prohibitive for many patients [8,11].

Ventricular arrhythmias are less common but pose significant risks, especially in women with cardiomyopathy, congenital heart disease, or long QT syndrome. Management includes intravenous lidocaine or procainamide, with electrical cardioversion for instability. Beta-blocker therapy should be continued throughout pregnancy and postpartum in women with long QT syndrome [1,3,4,5,6,7,8].

In Africa, bradyarrhythmias and AV block are the least common arrhythmias in pregnancy, but when they occur, access to pacing is often unavailable due to the lack of pacemaker centers in many countries [8].

In Africa, the clinical impact of arrhythmias is magnified by delayed diagnosis and limited access to care, resulting in higher rates of maternal complications (stroke, sudden cardiac death) and fetal complications (intrauterine growth restriction, preterm delivery, stillbirth). Maternal mortality rates remain substantially higher than in high-income countries, with underdiagnosis and delayed care being key drivers of adverse outcomes [8,11].

The clinical experience at a high-volume tertiary center demonstrates that pregnant women with symptomatic or recurrent arrhythmias face a substantially increased risk of preterm labor, cesarean delivery, and neonatal complications compared to the general obstetric population. Supraventricular tachycardia (SVT) is the most frequent arrhythmia, often presenting in the third trimester when hemodynamic and hormonal stressors peak. These findings are consistent with large registry data and recent guidelines, which note that arrhythmias in pregnancy, particularly SVT and atrial fibrillation, are increasingly common and associated with adverse maternal and fetal outcomes, especially in the presence of underlying structural heart disease or recurrent arrhythmia episodes [17].

Pharmacologic management and antiarrhythmic therapy are often required for symptomatic cases, but both the arrhythmia and its treatment may contribute to obstetric intervention and neonatal morbidity. Beta-blockers, digoxin, and adenosine remain the mainstays of therapy, with careful consideration of fetal safety and avoidance of teratogenic agents, especially in the first trimester. Electrical cardioversion is safe for unstable arrhythmias, and catheter ablation is reserved for refractory cases, ideally performed with minimal radiation exposure and after organogenesis [1,3,8,17] (Table 2).

Table 2.

Summary data regarding the most common arrhythmia in pregnancy, its mechanisms, management and fetal outcomes.

Arrhythmia Type	Mechanism/Hormonal Influence	Timing (Trimester)	Management (AHA/ESC)	Fetal Outcomes	References
Sinus tachycardia, ectopy	Increased sympathetic tone, stretch	All, ↑ in 2nd/3rd	Usually, no treatment	Benign	[1,2,3,4]
SVT	Adrenergic, stretch, Structural Heart Disease (SHD)	All, ↑ in 2nd/3rd	Vagal, adenosine, β-blocker	Usually, benign	[1,2,3,4,5]
AF	Age, SHD, hormonal, autonomic	Peak 23–30 weeks	β-blocker, digoxin, Direct Current Cardioversion (DCCV)	↑ maternal/fetal risk	[4,5,6,7]
Ventricular arrhythmia	SHD, long QT, adrenergic	All, ↑ in SHD	Lidocaine, procainamide, DCCV	Fetal distress, sudden cardiac death risk	[3,5,8,9]
Bradyarrhythmia	Conduction disease, drugs	Rare, any trimester	Pacemaker if symptomatic	Usually, benign	[1,5,7]

Arrhythmia recurrence during labor and the need for antiarrhythmic therapy are both associated with increased risk of preterm birth and neonatal complications, underscoring the importance of early rhythm control and close interdisciplinary monitoring. The absence of maternal mortality in this cohort highlights the benefit of specialized cardio-obstetric care and timely intervention, as recommended by consensus guidelines [1,3,17].

Key modifications to CPR in pregnancy include manual left lateral uterine displacement for women with a uterine fundus at or above the umbilicus, prioritization of airway management due to increased risk of hypoxemia and aspiration, and early preparation for resuscitative delivery if return of spontaneous circulation (ROSC) is not achieved within 4–5 minutes [18] (Fig. 2).

Fig. 2.

Left lateral uterine displacement for women with a uterine fundus at or above the umbilicus during CPR. Notice the one-hand technique (a) and the two-hand technique (b).

Indications for CPR in pregnancy are the same as in nonpregnant adults: any cardiac arrest, including those due to arrhythmias, trauma, hemorrhage, or other causes. Cardiac arrest in pregnancy is most often related to arrhythmias, embolism, hemorrhage, or preeclampsia/eclampsia.

These modifications are essential to optimize maternal and fetal survival during cardiac arrest in pregnancy, especially when arrhythmias are the underlying cause.

As discussed throughout our article, Arrhythmias during pregnancy are a serious threat posing a unique challenge due to the need to balance maternal safety and fetal well-being. In some cases, pregnant women tolerate arrhythmias well, some experience refractory or life-threatening tachyarrhythmias requiring advanced interventions.

We present two representative clinical cases of arrhythmia during pregnancy, managed successfully at Ain Shams University, Cairo, Egypt, highlighting the multidisciplinary approach, advanced electrophysiological interventions, and tailored peripartum management strategies. These cases demonstrate how state-of-the-art mapping and ablation techniques, along with careful pharmacologic management, can restore sinus rhythm and optimize outcomes for both mother and child.

Case (1)

A 20-year-old female, in her 6th month of pregnancy, presented with palpitations lasting 10 days. ECG showed incessant atrial tachycardia at 170 BPM. Echocardiography demonstrated preserved left and right ventricular function, mild eccentric mitral regurgitation with anterior mitral leaflet prolapse, moderate tricuspid regurgitation, and no segmental wall motion abnormalities or pericardial effusion. The tachycardia was not terminated by beta-blockers, digoxin, and calcium channel blockers, and even four direct current (DC) cardioversions. The patient continued to experience incessant atrial tachycardia (Fig. 3). Given the refractory nature of her arrhythmia, an electrophysiology study (EPS) with 3D electroanatomic mapping (EAM) and radiofrequency (RF) ablation was planned, minimizing fluoroscopy exposure; fluoroscopy was only used for transseptal puncture due to unavailability of intracardiac echocardiography (ICE).

Fig. 3.

Case (1): (A) 12-Lead ECG during the attack showing incessant atrial tachycardia with variable AV nodal conduction. (B) 12-Lead ECG after ablation showing restoration of normal sinus rhythm. (C) Fluoroscopic picture of transseptal puncture in left anterior oblique view. (D) Local activation time electro-anatomical mapping of the left atrium (CARTO, Biosense Webster) showing area of ablation (arrow) at the ligament of Marshall leading to termination of the tachycardia and restoration of sinus rhythm.

The procedure successfully identified and ablated atrial tachycardia originating from the ligament of Marshall, resulting in restoration of sinus rhythm post-ablation. The patient was followed throughout the remainder of her pregnancy and subsequently delivered a healthy infant via elective cesarean section.

Case (2)

A 26-year-old woman in her second trimester of pregnancy presented with recurrent palpitations and documented supraventricular tachycardia. Her cardiac history was notable for mitral valve repair performed four years prior for parachute mitral valve, and a radiofrequency ablation of a concealed left-sided accessory pathway one year before conception. Despite initial success, she experienced recurrence of palpitations one month after the ablation, with a marked increase in frequency and severity during pregnancy.

She arrived at the emergency department with incessant atrioventricular reentrant tachycardia (AVRT). Pharmacologic therapy including intravenous verapamil and propranolol resulted in only partial and transient control of the tachycardia. Electrical cardioversion was attempted but was followed by immediate recurrence of the arrhythmia. ECG between the attacks of AVRT showed a manifest left anterolateral accessory pathway (Fig. 4).

Fig. 4.

Case (2): (A) 12-Lead ECG showing narrow complex SVT most commonly AVRT. (B) 12-Lead ECG after cardioversion showing manifest anterolateral accessory pathway. (C) ECG after ablation showing normalization of the ECG and loss of pre-excitation.

Given the persistent tachyarrhythmia and the patient's symptomatic burden, she underwent emergency electrophysiological study. Mapping was performed using a 3-dimensional electro-anatomical mapping system (CARTO), and radiofrequency catheter ablation of the accessory pathway was successfully done (Fig. 5). The procedure terminated the tachycardia without complications, and both maternal and fetal conditions remained stable throughout. She continued routine follow-up for the rest of her pregnancy and ultimately underwent elective cesarean delivery, resulting in the birth of a healthy newborn.

Fig. 5.

Case (2): (A) Intracardiac 12- lead ECG recording during AVRT, right ventricular pacing at the last two beats. ECG leads: II, V1, V2, CS: Coronary sinus, AbL1,2: Ablation, H: HIS catheter. (B) Local activation time electro-anatomical mapping of lateral mitral annulus (CARTO, Biosense Webster) showing area of ablation (arrow) during mapping of AVRT. (C) Right Anterior Oblique (RAO) fluoroscopic picture of mitral ring and ablation catheter (Arrow) at the anterolateral mitral annulus. (D) Left Anterior Oblique (LAO) fluoroscopic picture of mitral ring and ablation catheter (Arrow) at the anterolateral mitral annulus. Notice in RAO and LAO Decapolar catheter in Coronary Sinus (CS) and Quadripolar in Right Ventricle (RV).

Clinical implications

Arrhythmias in pregnancy remain a challenging clinical problem, made even more demanding in many African regions where resources, trained specialists, and timely access to care are limited. To improve outcomes, there is an urgent need to expand local expertise, ensure reliable availability of safe antiarrhythmic medications, and more fully integrate electrophysiology services into maternal health systems. Strengthening cardio-obstetric programs across the continent is key to protecting both mothers and their babies.

In Africa, inconsistent guidelines for pregnancy-safe care, stockouts of safe antiarrhythmic drugs, and lack of multidisciplinary teams further complicate management. There is a need for policy advocacy, integration of ECG screening into antenatal care, and training of frontline providers in arrhythmia recognition and intervention. Implementing these strategies will significantly improve maternal and fetal outcomes across the continent.

Acknowledgment

The authors would like to express their sincere gratitude to Dr. Rania Samir and Dr. John Kamel, Professors of Cardiology at Ain Shams University, for their invaluable contributions and their exceptional dedication in the care and successful management of these patients. Their expertise and commitment were instrumental to the outcomes presented in this work.

Disclosure of benefit

The author has no conflict of interests and the work was not supported or funded by any drug company.

AI disclosure

Artificial intelligence tools were not used in the conception of the study, case selection, data collection, data analysis, interpretation of results, or creation of tables or figures. AI tools were used solely for language refinement, including vocabulary enhancement, grammar correction, sentence structure, and punctuation.