TABLE 6.

Recommendations for the management of AF during pregnancy

Recommendations	Classa	Levelb
Acute management
Immediate electrical cardioversionc is recommended in case of haemodynamic instability or pre-excited AF	I	C
In pregnant women with HCM, cardioversionc should be considered for persistent AF	IIa	C
Ibutilide or flecainide IV may be considered for termination of AF in stable patients with structurally normal hearts	IIb	C
Long-term management (oral administration of drugs)
Therapeutic anticoagulation with heparin or VKA according to the stage of pregnancy is recommended for patients with AF	I	C
β-Selective blockers are recommended for rate control in AFd	I	C
Flecainide,e propafenone,e or sotalolf should be considered to prevent AF if atrioventricular nodal-blocking drugsf fail	IIa	C
Digoxing or verapamilg should be considered for rate control if β-blockers fail	IIa	C

Note: Note that the former A to X categories of drugs—the classification system for counselling of pregnant women requiring drug therapy—was replaced by the Pregnancy and Lactation Labelling Rule, which provides a descriptive risk summary and detailed information on animal and clinical data, by the US FDA in June 15.

Abbreviations: AF, atrial fibrillation; ECG, electrocardiogram; HCM, hypertrophic cardiomyopathy; IV, intravenous; LV, left ventricular; QTc, corrected QT interval; US FDA, United States Food and Drug Administration; VKA, vitamin K antagonist.

^aClass of recommendation.

^bLevel of evidence.

^cCardioversion of AF should generally be preceded by anticoagulation.

^dAtenolol has been associated with higher rates of foetal growth retardation and is not recommended.

^eFlecainide and propafenone should be combined with atrioventricular nodal-blocking drugs, but structural heart disease, reduced LV function, and bundle branch block should be excluded.

^fClass III drugs should not be used in prolonged QTc.

^gAtrioventricular nodal-blocking drugs should not be used in patients with pre-excitation on resting ECG or pre-excited AF.

Source: 2020 Update of European AF guidelines⁶² Copyright obtained on December 9, 2020, from Oxford University Press.