Pediatr Cardiol 18:78–82, 1997
Pediatric
Original Articles
Outcome of Intermittent Tachyarrhythmias in the Fetus
J.M. Simpson,1 A. Milburn,1 R.W. Yates,1 D.J. Maxwell,2 G.K. Sharland1
1
Department of Fetal Cardiology, Guy’s Hospital, London SE1 9RT, UK
2
Department of Fetal Medicine, Guy’s Hospital, London SE1 9RT, UK
Abstract. Persistent fetal tachycardias are known to have
an adverse effect on fetal outcome. The outcomes of
intermittent fetal tachyarrhythmias over a 12-year period
at a tertiary fetal cardiology center were studied. Main
outcome criteria included control of arrhythmia and
death during the prenatal or postnatal period. A total of
28 fetuses had an intermittent tachyarrhythmia: 4 had
intermittent atrial flutter and 24 had supraventricular
tachycardia. At the time of presentation 14 fetuses were
hydropic, and in 5 of the 14 an arrhythmia had not been
noted prior to referral. Of the 28 fetuses, 23 were treated
by drug administration to the mother. Control of arrhyth-
mia was achieved in 10 of 11 (91%) nonhydropic fetuses
and 8 of 12 (67%) hydropic fetuses, with resolution of
hydrops in four cases. In the overall group there was one
intrauterine death, two neonatal deaths, and one infant
death, all of which occurred in the hydropic group. The
arrhythmia recurred postnatally in 11 of 23 (48%) fe-
tuses. We conclude that intermittent tachyarrhythmias
may have a deleterious effect on the fetus with a signifi-
cant risk of death pre- or postnatally. The fetus with
nonimmune hydrops should be evaluated for a cardiac
cause. Maternal antiarrhythmic therapy is indicated for
intermittent fetal tachyarrhythmias. There is a high risk
of recurrence of the arrhythmia during infancy, particu-
larly if hydrops was documented during the prenatal pe-
riod or if Wolff-Parkinson-White syndrome is diagnosed.
Fetal echocardiography is a useful tool for diagnosis and
for monitoring the progress of the fetus.
Key words: Fetal heart — Tachyarrhythmia — Hydrops
fetalis
Fetal cardiac arrhythmias can be evaluated by cross-
sectional and M-mode echocardiography [1, 5], which
may demonstrate unremitting tachycardia with heart
rates in excess of 200 bpm. Persistent fetal tachyarrhyth-
Correspondence to: J.M. Simpson
Cardiology
© Springer-Verlag New York Inc. 1997
mias can lead to intrauterine cardiac failure, hydrops fe-
talis, and death. Maternal hydramnios and preterm de-
livery, frequently associated with tachyarrhythmia, may
further complicate clinical management [6]. Some fe-
tuses, however, show periods of tachycardia interspersed
with periods of normal heart rate. The significance of
intermittent tachycardia is much less clear than persistent
tachycardia. Short periods of fetal tachycardia have been
observed in normal pregnancies with no apparent delete-
rious effect on the fetus [8]. Some authors have sug-
gested that an intermittent tachycardia has little clinical
significance [2, 9], whereas others have taken the oppo-
site view, citing intermittent tachyarrhythmia as a cause
of nonimmune hydrops [10]. We report the outcome of
28 fetuses with intermittent tachyarrhythmias seen over a
12-year period.
Materials and Methods
Fetuses with intermittent tachyarrhythmias referred to the Department
of Fetal Cardiology at Guy’s Hospital between January 1982 and Oc-
tober 1994 were included. The case histories and echocardiograms
were reviewed retrospectively. Tachyarrhythmias were classified as
‘‘persistent’’ (i.e., present throughout the echocardiographic studies) or
‘‘intermittent’’ (where the tachyarrhythmia was interspersed with pe-
riods of normal sinus rhythm at the time of the initial scan). They were
classified on the basis of the scans prior to the commencement of any
drug therapy.
No attempt was made to assess the amount of time in tachycardia
or in sinus rhythm, as such assessment would have required long pe-
riods of ultrasound examination because cardiotocographic monitoring
is unreliable when the heart rates are fast. Fetal echocardiograms were
performed using Hewlett-Packard 77020A (Sonos 1000 or Sonos 500),
Advanced Technologies Laboratory Ultramark 4, or Toshiba Sonolayer
SSA-270A ultrasound machines. Images were obtained using a 5.0 or
3.5 MHz probe.
The median time of follow-up was 4 years (range 1 month to 12
years). Comparisons of group characteristics were performed using the
Mann-Whitney U test.
Results
Twenty-eight fetuses with intermittent tachyarrhythmia
were seen over the 12-year study period. The median
Simpson et al.: Fetal Intermittent Tachyarrhythmias 79

Table 1. Details of nonhydropic and hydropic fetuses with intermittent tachyarrhythmias

Case no. Gestation at Reason for Maternal Arrhythmia Rate Control Gestation Outcome
presentation referral drugs (bpm) at birth
(weeks) (weeks)

Nonhydropic fetuses
1 24 Arrhythmia Digoxin SVT 250 Yes 40 Survived
2 27 Poor Obs Hx Declined SVT 240 NA 38 Survived
3 22 Arrhythmia Digoxin SVT 250 Yes 38 Survived
4 19 Arrhythmia Digoxin SVT 250 Yes 37 Survived
5 31 Arrhythmia Digoxin SVT 260 Yes 40 Survived
6 19 Arrhythmia Nil SVT 240 NA 38 Survived
7 30 Arrhythmia Digoxin SVT 240 Yes 33 Survived
8 30 Arrhythmia Digoxin SVT 240 Yes 38 Survived
9 33 Arrhythmia Nil SVT 240 NA 40 Survived
10 34 Arrhythmia Digoxin SVT 240 Yes NK Survived
11 32 Arrhythmia Digoxin SVT 240 No 38 Survived
Verapamil
12 18 Arrhythmia Digoxin SVT 240 Yes 38 Survived
13 32 Arrhythmia Digoxin AF 240 Yes 36 Survived
14 29 Arrhythmia Flecainide SVT 260 Yes 38 Survived
Digoxin
Verapamil
Hydropic fetuses
15 34 Hydrops Flecainide SVT 300 No 34 Stillborn
16 32 Hydrops Digoxin SVT 285 No 32 Survived
17 33 Hydrops Digoxin SVT 300 Yes 39 Survived
Flecainide
18 33 Hydrops Flecainide SVT 260 Yes 37 Survived
19 27 Hydrops Digoxin AF 240 No 31 Survived
Verapamil
20 29 Arrhythmia Digoxin SVT 240 Yes 33 Neonatal death
Flecainide
Verapamil
21 31 Arrhythmia Flecainide SVT 260 Yes 32 Survived
22 28 Arrhythmia Flecainide SVT 240 Yes 32 ‘‘Cot death’’
at 3 months
23 34 Arrhythmia Digoxin SVT 260 Yes NK Survived
Verapamil
24 34 Arrhythmia Flecainide AF 240 Yes 38 Survived
Digoxin
Verapamil
25 36 Arrhythmia Nil AF 240 NA 38 Survived
26 35 Arrhythmia Nil SVT 300 NA 35 Survived
27 29 Arrhythmia Flecainide SVT 250 Yes 38 Survived
Digoxin
28 21 Arrhythmia Flecainide SVT 260 No 34 Neonatal death
Digoxin
Verapamil
Amiodarone
(direct therapy)

SVT, supraventricular tachycardia; AF, atrial flutter; Obs Hx, obstetric history; NK, not known; NA, not applicable.

gestation at presentation was 31 weeks (range 18–36
weeks). Of the 28 fetuses, 24 had intermittent supraven-
tricular tachycardia and 4 had intermittent atrial flutter.
The group of fetuses was divided into nonhydropic or
hydropic (Table 1, Fig. 1) at the time of presentation.
Overall, 14 of the 28 (50%) fetuses were hydropic at
presentation.
In 22 fetuses a tachyarrhythmia was documented at
the referring hospital; and of these, 9 were hydropic at
presentation. In five fetuses (cases 15–19, Table 1), the
referral was made because of nonimmune fetal hydrops,
and a cardiac arrhythmia was not identified prior to re-
ferral. One fetus (case 2, Table 1) was referred because
of a poor maternal obstetric history, which included re-
80
Fig. 1. Flowchart of outcome of intermittent fetal tachyarrhythmias. InfD, infant death; NND, neonatal death; IUD, intrauterine death.
current miscarriages and a previous child with truncus
arteriosus.
Nonhydropic Fetuses
Thirteen of the fourteen nonhydropic fetuses had inter-
mittent supraventricular tachycardia, and there was a
single fetus with atrial flutter (Table 1). Eleven of the
fourteen were treated by drug therapy given to the
mother (Table 1, Fig. 1). In three fetuses the tachycardia
was not treated because the parents declined (case 2), the
episodes appeared short-lived on scanning (case 9), or
the referring hospital elected not to treat (case 6). The
fetuses who were treated received digoxin alone (n 4 9),
digoxin and verapamil (n 4 1), or digoxin, verapamil,
and flecainide (n 4 1, see below).
One fetus (case 14) was nonhydropic at the time of
presentation but went on to develop hydrops. Digoxin
did not control the tachycardia, and so verapamil was
added after 2 weeks. Ten days later the fetus was hy-
dropic with marked ascites and a pericardial effusion.
Oral flecainide was commenced, and the other drugs
were withdrawn. Flecainide therapy led to control of the
arrhythmia and resolution of the hydrops. The infant was
delivered at 38 weeks’ gestation in sinus rhythm with no
evidence of hydrops.
Pediatric Cardiology Vol. 18, No. 2, 1997
Overall, control of the arrhythmia was achieved in
all but one of the treated fetuses. All the fetuses survived
to delivery, and none died postnatally.
Hydropic Fetuses
The details of the hydropic fetuses are shown in Table 1.
Five of the fourteen (36%) hydropic fetuses were re-
ferred for investigation of nonimmune hydrops, and tach-
yarrhythmia was discovered after referral. Eleven hy-
dropic fetuses had supraventricular tachycardia, and
three had atrial flutter. Twelve of the fetuses were treated
with drugs (Fig. 1); and in two cases, near term, it was
decided to deliver the baby without giving antenatal
drugs. Drug therapy consisted of flecainide alone (n 4
4), digoxin alone (n 4 1), digoxin and verapamil (n 4
2), flecainide with digoxin (n 4 2), flecainide, digoxin,
and verapamil (n 4 2), and flecainide, digoxin, vera-
pamil, and amiodarone (n 4 1).
Control of the arrhythmias was achieved with drug
treatment in eight cases, and in four of these (cases 17,
18, 24, 27) the hydrops resolved prior to delivery. Thir-
teen of the fourteen fetuses survived to delivery. There
was one intrauterine death. This fetus (case 15) died 1
day after starting flecainide therapy. One severely hy-
dropic baby, delivered at 33 weeks’ gestation, could not
Simpson et al.: Fetal Intermittent Tachyarrhythmias
be resuscitated and died during the first hour of life (case
20). Intrauterine therapy with digoxin, flecainide, and
verapamil had been given; but despite reversion to sinus
rhythm, the severe hydrops had not resolved.
The second neonatal death (case 28) occurred in a
baby who had failed to respond to maternal oral therapy
with flecainide, digoxin, and verapamil. In view of this
failure, direct fetal therapy with adenosine (200 mg) and
amiodarone (15 mg) was given at 29 weeks’ gestation. It
resulted in a slower heart rate (175 bpm) but no resolu-
tion of the hydrops. One week later another direct injec-
tion of amiodarone (15 mg) was given along with a
packed red blood cell transfusion for fetal anemia (he-
moglobin 8.7 g/dl, packed cell volume 27%). Maternal
treatment with amiodarone 300 mg/day was commenced.
The baby was delivered before term, at 33 weeks, after
spontaneous onset of labor. The infant initially everted to
sinus rhythm, but the arrhythmia subsequently recurred
accompanied by profound hypotension, metabolic acido-
sis, and disseminated intravascular coagulation. Treat-
ment with direct-current cardioversion, amiodarone, di-
goxin, dialysis, and ventilation was ineffective, and the
infant died on day 3 of life.
Another infant died at the age of 3 months having
had no documented postnatal arrhythmias and was not on
any drug therapy at the time of death. Death was certified
as sudden infant death syndrome.
Timing of Presentation and Delivery
The gestation at the presentation of the hydropic fetuses
(median 32 weeks, range 21–36 weeks) was more ad-
vanced than that of the nonhydropic fetuses (median 29
weeks, range 18–34 weeks). The hydropic fetuses were
delivered earlier in gestation (median 34 weeks, range
31–39 weeks) than the nonhydropic fetuses (median 38
weeks, range 33–40 weeks). The differences in the tim-
ing of presentation and delivery reached statistical sig-
nificance (p 4 0.04, p 4 0.01, respectively; Mann-
Whitney U test).
Arrhythmia Recurrence During the Postnatal Period
Data regarding arrhythmia recurrence postnatally were
obtained for 23 of the 25 fetuses who survived the neo-
natal period. Overall to date, 11 of the 23 (48%) infants
have had a recurrence of tachycardia: 7 of 11 (64%)
hydropic fetuses and 4 of 12 (33%) nonhydropic fetuses.
Wolff-Parkinson-White syndrome was documented post-
natally in three patients (cases 8, 17, 26), all of whom
had a recurrence of tachycardia. Fourteen infants have
been maintained on long-term antiarrhythmia therapy in-
cluding digoxin (n 4 11), flecainide (n 4 2), and a
b-blocker (n 4 1). The median duration of maintenance
81
on antiarrhythmic drugs was 34 weeks (range 4–104
weeks).
Discussion
The significance of intermittent fetal tachyarrhythmias is
controversial. Southall et al. [8], in a study of 934 un-
complicated pregnancies, found intermittent tachycardia
(180–200 bpm) ranging from 30 to 90 seconds duration
in 0.4% (n 4 4) of fetuses at 36–41 weeks’ gestation and
in a single fetus at 30–35 weeks. None of these tachy-
cardias had a rate in excess of 200 bpm, and all of the
fetuses had an uneventful outcome. Steinfeld et al. [9]
described three fetuses with unsustained supraventricular
tachycardia who had an uncomplicated course. These
studies have led some authors to suggest that ‘‘short’’
periods of tachyarrhythmia are of little clinical signifi-
cance [2]. In our study, ventricular rates were signifi-
cantly higher, at 240–300 bpm, and fetal compromise
was observed. It is apparent, therefore, that data regard-
ing outcome of fetuses with intermittent ventricular rates
of 180–200 bpm should not be extrapolated to fetuses
with intermittent tachycardia at a higher rate.
Half of the fetuses in this study were hydropic at
presentation (Fig. 1), and in five an intermittent arrhyth-
mia was not noted prior to referral (Table 1), suggesting
that an intermittent tachyarrhythmia should be sought in
the fetus with nonimmune hydrops. Between 1982 and
1993 a total of 214 fetuses have been referred to this unit
for evaluation of fetal hydrops. A significant proportion
had a cardiac cause of hydrops including persistent tach-
yarrhythmias (n 4 38), complete heart block (n 4 15),
or a structural abnormality of the heart (n 4 55) (G.K.
Sharland, unpublished observations). Detailed ultraso-
nography of the fetal heart seems to be of value in this
situation to assess both cardiac structure and rhythm.
Good outcome was observed both with and without
drug therapy in the nonhydropic fetus with an intermit-
tent tachyarrhythmia (Table 1, Fig. 1). Two fetuses, for
whom treatment was either declined or not given by the
referring hospital (Table 1, cases 2 and 6), survived with-
out developing hydrops. A conservative approach might
be to monitor the nonhydropic fetus echocardiographi-
cally and withhold drug therapy unless the fetus shows
signs of compromise. In another case, however (Table 1,
case 14), the fetus progressed from a nonhydropic to a
hydropic state, which resolved only after controlling the
arrhythmia. To prevent the development of fetal hydrops,
it is our usual policy to treat nonhydropic fetuses with in-
termittent tachyarrhythmias by maternal drug adminis-
tration.
The hydropic fetuses in this series were delivered
significantly earlier in gestation than the nonhydropic
fetuses, and control of the arrhythmia was more difficult
in this group (Table 1). In 10 of 11 (91%) nonhydropic
82 Pediatric Cardiology Vol. 18, No. 2, 1997

fetuses treated with drugs the arrhythmia was controlled
prenatally compared with 8 of 12 (67%) hydropic fetuses
(Fig. 1). The hydrops resolved prenatally in only four of
the eight (50%) hydropic fetuses in whom control of the
arrhythmia was achieved.
The generally poor response of hydropic fetuses to
drug therapy is well recognized and may be due to re-
duced transplacental delivery of antiarrhythmia drugs [3,
4]. This poor response has led to the use of direct fetal
therapy, which was used in one case in this series (Table
1). This procedure avoids the problem of transplacental
drug delivery and has been used successfully in other
series [3]. The risk of such procedures, however, ap-
proaches 25% in this high risk group [7]. There have as
yet been no controlled trials to investigate optimal drug
regimens and routes of administration.
There were two early neonatal deaths of hydropic
infants (Table 1). Both these infants were delivered pre-
maturely owing to spontaneous onset of labor, and their
management was complicated by the hydrops and pre-
maturity. These infants frequently require aggressive re-
suscitation, which may include ventilation, placement of
chest and abdominal drains, and antiarrhythmia drugs
[10]. It therefore seems prudent to deliver these high-risk
infants at neonatal centers where appropriate intensive
care facilities are available.
Maintenance antiarrhythmia drugs were used post-
natally in more than half of the infants in this series.
There was a high postnatal recurrence (11 of 23, 48%) of
tachyarrhythmias, which was more likely if the infant
had been hydropic during fetal life. Among these infants
7 of 11 (64%) had a recurrence, compared with 4 of 12
(33%) who were nonhydropic during fetal life. Recur-
rence was seen in all three infants with Wolff-Parkinson-
White syndrome.
In conclusion, this study shows that an intermittent
tachyarrhythmia is not a benign finding in the fetus. The
affected fetus risks hydrops and death. Drug therapy is
frequently indicated to control the arrhythmia pre- and
postnatally. The fetus with nonimmune hydrops should
be carefully investigated for a cardiac cause.
Acknowledgment. We acknowledge the contribution of Professor L.D.
Allan to the management of some of the patients in the series.
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70:F151–F154

Eloquence in Description
Over the past few decades medical literature has lost its linguistic luster. Most descriptions are composed of short
and dry sentences, void of any emotions. In today’s medical articles, objectivity and scientific accuracy over-
whelm any sense of intuition or subjective wit of the writer. No longer can we find such eloquent case presen-
tations as the following, written by J. Hope in 1842 [1]:
“Mary Collins, act. 8, applied to me October 22nd, 1830. Lips, nose, cheeks, palpebrae, hands and feet, of a violet colour:
tongue and mouth still darker. On a frosty day, after walking or ascending stairs, the hue of the parts enumerated, as
witnessed by myself and several medical friends, is equal to the deep stain communicated to the skin by black currants
or the small black cherry, and the face and hands universally are as dark as those of mulatto. Children in the streets often
inquire in winter, “where she got blackberries at that season.” Dyspnea on the slightest exertion, particularly ascending;
cough when hurried, not otherwise: sternum very prominent; great sensitivity to cold—constantly steals to the fire, even in
summer; headache, vertigo, drowsiness, and sluggishness. Pulse very small and weak, and when hurried, it is irregular,
intermittent and unequal.”

Ra-id Abdulla, M.D.

1. Hope J (1842) Diseases of the heart and great vessels. Haswell & Johnson, Philadelphia, p. 485