Pregnancy and Atrial Fibrillation

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Atrial fibrillation (AF) is the most common arrhythmia during pregnancy.

The prevalence of AF during pregnancy is increasing; the main risk factors are:

• advanced maternal age, pregnancy in the presence of congenital heart disease, stress.

The greatest risk is associated with tachy-AF (heart rate >100/min.),

• when haemodynamic instability of the patient may occur.

Occurrence of atrial fibrillation (AF) episodes during pregnancy
AF occurrence	Pregnancy
< 0.5 %	Healthy pregnant woman
3 – 5 %	Pregnant woman with structural heart disease
5 – 10 %	Pregnant woman with hyperthyroidism
15 – 30 %	Pregnant woman with a history of paroxysmal AF

If anticoagulation therapy is required during pregnancy, only LMWH (low molecular weight heparin) at a therapeutic dose should be administered:

• Enoxaparin (Clexane) – 1 mg/kg twice daily
• Nadroparin (Fraxiparine) – 86 IU/kg twice daily

NOACs are not recommended during pregnancy.

Warfarin is not recommended during pregnancy and is contraindicated in:

• the first trimester, when it is teratogenic and associated with miscarriage risk
• after week 36, as it may cause intracranial haemorrhage during vaginal delivery

For rate control of AF, β₁-selective beta-blockers may be administered: Metoprolol.

• Atenolol is not recommended – it causes intrauterine growth restriction.

If rate control of AF with a beta-blocker fails, the following may be considered:

• Digoxin or verapamil – but not in the first trimester

In case of tachy-AF with haemodynamic instability, electrical cardioversion is recommended.

• It is relatively safe for both the fetus and the mother; the risk of fetal arrhythmia is minimal.

In severe cases, AF ablation may be performed, but without fluoroscopy (zero fluoro).

• This applies mainly to pre-excited AF (with a delta wave on ECG), when ventricular fibrillation is a risk.

Pregnancy and atrial fibrillation	Class
Electrical cardioversion is recommended in AF with haemodynamic instability.	I
Electrical cardioversion is recommended in pre-excited AF with haemodynamic instability.	I
β₁-selective beta-blockers (except atenolol) are recommended for rate control of AF.	I
Electrical cardioversion should be considered in hypertrophic cardiomyopathy and persistent AF.	IIa
Digoxin may be administered for rate control of AF if beta-blockers are ineffective or not tolerated.	IIa
Ibutilide or flecainide (intravenous) may be considered for termination of AF in a stable patient without structural heart disease.	IIb
Flecainide or propafenone may be considered for long-term rhythm control if rate-control drugs (beta-blockers, digoxin) fail.	IIb
In pre-excited AF, the following are contraindicated: adenosine verapamil diltiazem beta-blockers digoxin amiodarone	III
If anticoagulation therapy is indicated, LMWH is recommended.	I
Warfarin is contraindicated in the first trimester and after week 36 of pregnancy.	III

LMWH - Low Molecular Weight Heparin (Enoxaparin, Nadroparin)

These guidelines are unofficial and do not represent formal guidelines issued by any professional cardiology society. They are intended for educational and informational purposes only.