Table 1.

Arrhythmias and heart failure management in pregnancy.

	Arrhythmias Management in Pregnancy
Supraventricular Tachycardia (SVT)	First-line treatment: Vagal maneuver. If ongoing arrhythmias: 1. Beta blockers (e.g., Metoprolol, Propranolol). 2. Calcium channel blocker (e.g., Verapamil, Diltiazem) 3. Digoxin [with monitoring for digoxin toxicity] 4. Anti-arrhythmic agents (e.g., Flecainide) If medically resistant: 1. Direct Current Cardioversion (DCCV) [especially if hemodynamic compromise] 2. SVT ablation with minimal/zero fluoroscopy
Atrial Flutter & Atrial Fibrillation	1. Anticoagulation: Use the same risk assessment for cardio embolic events. a. Mechanical prosthetic valves with <5 mg/day of Warfarin dose → can continue anticoagulants throughout pregnancy with a change to unfractionated heparin before delivery (better to avoid warfarin until 12 weeks) b. Mechanical prosthetic valves with higher doses, switching to LMWH during the first trimester with strict anti-X1 monitoring is recommended with a change to unfractionated heparin before delivery. 2. Acute rate control a. Intravenous beta-blockers (e.g., Metoprolol) b. Intravenous Verapamil, Digoxin c. If medically-resistant to rate control (especially if hemodynamic instability) consider DCCV 3. Long-term treatment a. Beta-1 selective blockers (e.g., Metoprolol) (class Ia) b. If fails, Verapamil and/or Digoxin (class IIa) c. Rhythm control with flecainide, propafenone or sotalol (class IIa)
	Arrhythmias Management in Pregnancy
Ventricular Tachycar-dia	Acute management (hemodynamically stable) 1. Beta-blocker (e.g. Metoprolol and Propranolol) 2. Lidocaine 3. Verapamil (first line for fascicular VT) 4. IV magnesium (in the setting of polymorphic VT due to Long QT syndrome) If ongoing arrhythmia: 1. Quinidine and/or procainamide (excluding underlying heart disease) 2. Flecainide, sotalol or quinidine (to prevent recurrence) 3. Amiodarone (in the shortest possible duration for the use of refractory fetal arrhythmias for duration of one to 15 weeks). Acute management (hemodynamically unstable) Cardioversion with energy levels between 50 to 400 Joules.
Cardiac Arrest	Cardiopulmonary resuscitation protocols, including medical doses, frequency of chest compressions, and defibrillation in pregnancy are similar to non-pregnancy, with the exception of lateral displacement of the uterus after 20 weeks of gestation.
	Heart Failure Management in Pregnancy
Heart failure with reduced ejection fraction (HFrEF)	e.g., Dilated cardiomyopathy; Peripartum cardiomyopathy. Guideline-line directed medical therapy (GDMT) contraindicated due to teratogenic nature include: angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, angiotensin receptor-neprilysin inhibitors and mineralocorticoid antagonists. GDMT safe to use with pregnancy: 1. Beta-blockers Symptomatic management: 1. Diuretics 2. Digoxin 3. Advance therapies such as inotropic and vasoactive agents should be considered temporary or during mechanical circulatory support for unstable patients with acute or acute on chronic HF.
Heart failure with preserved ejection fraction (HFpEF)	e.g., Restrictive Cardiomyopathy; Hypertrophic cardiomyopathy, ARVC. First-line: Beta blockers and/or calcium channel blockers to reduce the heart rate and increase diastolic filling time (Peripheral vasodilators should be avoided to prevent the worsening of the left ventricular outflow tract gradient)