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Pediatr Cardiol 18:78–82, 1997

Pediatric
Cardiology
© Springer-Verlag New York Inc. 1997

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 mias can lead to intrauterine cardiac failure, hydrops fe-
an adverse effect on fetal outcome. The outcomes of talis, and death. Maternal hydramnios and preterm de-
intermittent fetal tachyarrhythmias over a 12-year period livery, frequently associated with tachyarrhythmia, may
at a tertiary fetal cardiology center were studied. Main further complicate clinical management [6]. Some fe-
outcome criteria included control of arrhythmia and tuses, however, show periods of tachycardia interspersed
death during the prenatal or postnatal period. A total of with periods of normal heart rate. The significance of
28 fetuses had an intermittent tachyarrhythmia: 4 had intermittent tachycardia is much less clear than persistent
intermittent atrial flutter and 24 had supraventricular tachycardia. Short periods of fetal tachycardia have been
tachycardia. At the time of presentation 14 fetuses were observed in normal pregnancies with no apparent delete-
hydropic, and in 5 of the 14 an arrhythmia had not been rious effect on the fetus [8]. Some authors have sug-
noted prior to referral. Of the 28 fetuses, 23 were treated gested that an intermittent tachycardia has little clinical
by drug administration to the mother. Control of arrhyth- significance [2, 9], whereas others have taken the oppo-
mia was achieved in 10 of 11 (91%) nonhydropic fetuses site view, citing intermittent tachyarrhythmia as a cause
and 8 of 12 (67%) hydropic fetuses, with resolution of of nonimmune hydrops [10]. We report the outcome of
hydrops in four cases. In the overall group there was one 28 fetuses with intermittent tachyarrhythmias seen over a
intrauterine death, two neonatal deaths, and one infant 12-year period.
death, all of which occurred in the hydropic group. The
arrhythmia recurred postnatally in 11 of 23 (48%) fe- Materials and Methods
tuses. We conclude that intermittent tachyarrhythmias
Fetuses with intermittent tachyarrhythmias referred to the Department
may have a deleterious effect on the fetus with a signifi-
of Fetal Cardiology at Guy’s Hospital between January 1982 and Oc-
cant risk of death pre- or postnatally. The fetus with tober 1994 were included. The case histories and echocardiograms
nonimmune hydrops should be evaluated for a cardiac were reviewed retrospectively. Tachyarrhythmias were classified as
cause. Maternal antiarrhythmic therapy is indicated for ‘‘persistent’’ (i.e., present throughout the echocardiographic studies) or
intermittent fetal tachyarrhythmias. There is a high risk ‘‘intermittent’’ (where the tachyarrhythmia was interspersed with pe-
of recurrence of the arrhythmia during infancy, particu- riods of normal sinus rhythm at the time of the initial scan). They were
larly if hydrops was documented during the prenatal pe- classified on the basis of the scans prior to the commencement of any
drug therapy.
riod or if Wolff-Parkinson-White syndrome is diagnosed.
No attempt was made to assess the amount of time in tachycardia
Fetal echocardiography is a useful tool for diagnosis and or in sinus rhythm, as such assessment would have required long pe-
for monitoring the progress of the fetus. riods of ultrasound examination because cardiotocographic monitoring
is unreliable when the heart rates are fast. Fetal echocardiograms were
Key words: Fetal heart — Tachyarrhythmia — Hydrops performed using Hewlett-Packard 77020A (Sonos 1000 or Sonos 500),
fetalis 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
Fetal cardiac arrhythmias can be evaluated by cross- years). Comparisons of group characteristics were performed using the
sectional and M-mode echocardiography [1, 5], which Mann-Whitney U test.
may demonstrate unremitting tachycardia with heart
rates in excess of 200 bpm. Persistent fetal tachyarrhyth- Results
Twenty-eight fetuses with intermittent tachyarrhythmia
Correspondence to: J.M. Simpson 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 In 22 fetuses a tachyarrhythmia was documented at
weeks). Of the 28 fetuses, 24 had intermittent supraven- the referring hospital; and of these, 9 were hydropic at
tricular tachycardia and 4 had intermittent atrial flutter. presentation. In five fetuses (cases 15–19, Table 1), the
The group of fetuses was divided into nonhydropic or referral was made because of nonimmune fetal hydrops,
hydropic (Table 1, Fig. 1) at the time of presentation. and a cardiac arrhythmia was not identified prior to re-
Overall, 14 of the 28 (50%) fetuses were hydropic at ferral. One fetus (case 2, Table 1) was referred because
presentation. of a poor maternal obstetric history, which included re-
80 Pediatric Cardiology Vol. 18, No. 2, 1997

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 Overall, control of the arrhythmia was achieved in
arteriosus. all but one of the treated fetuses. All the fetuses survived
to delivery, and none died postnatally.

Nonhydropic Fetuses
Hydropic Fetuses
Thirteen of the fourteen nonhydropic fetuses had inter-
mittent supraventricular tachycardia, and there was a The details of the hydropic fetuses are shown in Table 1.
single fetus with atrial flutter (Table 1). Eleven of the Five of the fourteen (36%) hydropic fetuses were re-
fourteen were treated by drug therapy given to the ferred for investigation of nonimmune hydrops, and tach-
mother (Table 1, Fig. 1). In three fetuses the tachycardia yarrhythmia was discovered after referral. Eleven hy-
was not treated because the parents declined (case 2), the dropic fetuses had supraventricular tachycardia, and
episodes appeared short-lived on scanning (case 9), or three had atrial flutter. Twelve of the fetuses were treated
the referring hospital elected not to treat (case 6). The with drugs (Fig. 1); and in two cases, near term, it was
fetuses who were treated received digoxin alone (n 4 9), decided to deliver the baby without giving antenatal
digoxin and verapamil (n 4 1), or digoxin, verapamil, drugs. Drug therapy consisted of flecainide alone (n 4
and flecainide (n 4 1, see below). 4), digoxin alone (n 4 1), digoxin and verapamil (n 4
One fetus (case 14) was nonhydropic at the time of 2), flecainide with digoxin (n 4 2), flecainide, digoxin,
presentation but went on to develop hydrops. Digoxin and verapamil (n 4 2), and flecainide, digoxin, vera-
did not control the tachycardia, and so verapamil was pamil, and amiodarone (n 4 1).
added after 2 weeks. Ten days later the fetus was hy- Control of the arrhythmias was achieved with drug
dropic with marked ascites and a pericardial effusion. treatment in eight cases, and in four of these (cases 17,
Oral flecainide was commenced, and the other drugs 18, 24, 27) the hydrops resolved prior to delivery. Thir-
were withdrawn. Flecainide therapy led to control of the teen of the fourteen fetuses survived to delivery. There
arrhythmia and resolution of the hydrops. The infant was was one intrauterine death. This fetus (case 15) died 1
delivered at 38 weeks’ gestation in sinus rhythm with no day after starting flecainide therapy. One severely hy-
evidence of hydrops. dropic baby, delivered at 33 weeks’ gestation, could not
Simpson et al.: Fetal Intermittent Tachyarrhythmias 81

be resuscitated and died during the first hour of life (case on antiarrhythmic drugs was 34 weeks (range 4–104
20). Intrauterine therapy with digoxin, flecainide, and weeks).
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 Discussion
baby who had failed to respond to maternal oral therapy
with flecainide, digoxin, and verapamil. In view of this The significance of intermittent fetal tachyarrhythmias is
failure, direct fetal therapy with adenosine (200 mg) and controversial. Southall et al. [8], in a study of 934 un-
amiodarone (15 mg) was given at 29 weeks’ gestation. It complicated pregnancies, found intermittent tachycardia
resulted in a slower heart rate (175 bpm) but no resolu- (180–200 bpm) ranging from 30 to 90 seconds duration
tion of the hydrops. One week later another direct injec- in 0.4% (n 4 4) of fetuses at 36–41 weeks’ gestation and
tion of amiodarone (15 mg) was given along with a in a single fetus at 30–35 weeks. None of these tachy-
packed red blood cell transfusion for fetal anemia (he- cardias had a rate in excess of 200 bpm, and all of the
moglobin 8.7 g/dl, packed cell volume 27%). Maternal fetuses had an uneventful outcome. Steinfeld et al. [9]
treatment with amiodarone 300 mg/day was commenced. described three fetuses with unsustained supraventricular
The baby was delivered before term, at 33 weeks, after tachycardia who had an uncomplicated course. These
spontaneous onset of labor. The infant initially everted to studies have led some authors to suggest that ‘‘short’’
sinus rhythm, but the arrhythmia subsequently recurred periods of tachyarrhythmia are of little clinical signifi-
accompanied by profound hypotension, metabolic acido- cance [2]. In our study, ventricular rates were signifi-
sis, and disseminated intravascular coagulation. Treat- cantly higher, at 240–300 bpm, and fetal compromise
ment with direct-current cardioversion, amiodarone, di- was observed. It is apparent, therefore, that data regard-
goxin, dialysis, and ventilation was ineffective, and the ing outcome of fetuses with intermittent ventricular rates
infant died on day 3 of life. of 180–200 bpm should not be extrapolated to fetuses
Another infant died at the age of 3 months having with intermittent tachycardia at a higher rate.
had no documented postnatal arrhythmias and was not on Half of the fetuses in this study were hydropic at
any drug therapy at the time of death. Death was certified presentation (Fig. 1), and in five an intermittent arrhyth-
as sudden infant death syndrome. 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
Timing of Presentation and Delivery 1993 a total of 214 fetuses have been referred to this unit
for evaluation of fetal hydrops. A significant proportion
The gestation at the presentation of the hydropic fetuses had a cardiac cause of hydrops including persistent tach-
(median 32 weeks, range 21–36 weeks) was more ad- yarrhythmias (n 4 38), complete heart block (n 4 15),
vanced than that of the nonhydropic fetuses (median 29 or a structural abnormality of the heart (n 4 55) (G.K.
weeks, range 18–34 weeks). The hydropic fetuses were Sharland, unpublished observations). Detailed ultraso-
delivered earlier in gestation (median 34 weeks, range nography of the fetal heart seems to be of value in this
31–39 weeks) than the nonhydropic fetuses (median 38 situation to assess both cardiac structure and rhythm.
weeks, range 33–40 weeks). The differences in the tim- Good outcome was observed both with and without
ing of presentation and delivery reached statistical sig- drug therapy in the nonhydropic fetus with an intermit-
nificance (p 4 0.04, p 4 0.01, respectively; Mann- tent tachyarrhythmia (Table 1, Fig. 1). Two fetuses, for
Whitney U test). 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
Arrhythmia Recurrence During the Postnatal Period be to monitor the nonhydropic fetus echocardiographi-
cally and withhold drug therapy unless the fetus shows
Data regarding arrhythmia recurrence postnatally were signs of compromise. In another case, however (Table 1,
obtained for 23 of the 25 fetuses who survived the neo- case 14), the fetus progressed from a nonhydropic to a
natal period. Overall to date, 11 of the 23 (48%) infants hydropic state, which resolved only after controlling the
have had a recurrence of tachycardia: 7 of 11 (64%) arrhythmia. To prevent the development of fetal hydrops,
hydropic fetuses and 4 of 12 (33%) nonhydropic fetuses. it is our usual policy to treat nonhydropic fetuses with in-
Wolff-Parkinson-White syndrome was documented post- termittent tachyarrhythmias by maternal drug adminis-
natally in three patients (cases 8, 17, 26), all of whom tration.
had a recurrence of tachycardia. Fourteen infants have The hydropic fetuses in this series were delivered
been maintained on long-term antiarrhythmia therapy in- significantly earlier in gestation than the nonhydropic
cluding digoxin (n 4 11), flecainide (n 4 2), and a fetuses, and control of the arrhythmia was more difficult
b-blocker (n 4 1). The median duration of maintenance 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 tachyarrhythmia is not a benign finding in the fetus. The
prenatally compared with 8 of 12 (67%) hydropic fetuses affected fetus risks hydrops and death. Drug therapy is
(Fig. 1). The hydrops resolved prenatally in only four of frequently indicated to control the arrhythmia pre- and
the eight (50%) hydropic fetuses in whom control of the postnatally. The fetus with nonimmune hydrops should
arrhythmia was achieved. be carefully investigated for a cardiac cause.
The generally poor response of hydropic fetuses to
drug therapy is well recognized and may be due to re- Acknowledgment. We acknowledge the contribution of Professor L.D.
Allan to the management of some of the patients in the series.
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 References
drug delivery and has been used successfully in other
1. Allan L, Anderson R, Sullivan I, et al (1981) Evaluation of fetal
series [3]. The risk of such procedures, however, ap- arrhythmias by echocardiography. Br Heart J 50:240–245
proaches 25% in this high risk group [7]. There have as 2. Bergmans M, Jonker G, Kock H (1985) Fetal supraventricular
yet been no controlled trials to investigate optimal drug tachycardia: review of the literature. Obstet Gynecol 40:61–68
regimens and routes of administration. 3. Hansmann M, Gembruch U, Bald R, Manz M, Redel DA (1991)
There were two early neonatal deaths of hydropic Fetal tachyarrhythmias: transplacental and direct treatment of the
infants (Table 1). Both these infants were delivered pre- fetus—a report of sixty cases. Ultrasound Obstet Gynecol 1:162–
170
maturely owing to spontaneous onset of labor, and their 4. Ito S, Magee L, Smallhorn J (1994) Drug therapy for fetal arrhyth-
management was complicated by the hydrops and pre- mias. Clin Perinatol 21:543–572
maturity. These infants frequently require aggressive re- 5. Kleinman C, Donnerstein R, Jaffe C, et al (1983) Fetal echocar-
suscitation, which may include ventilation, placement of diography: a tool for evaluation of in utero cardiac arrhythmias and
chest and abdominal drains, and antiarrhythmia drugs monitoring of in utero therapy; analysis of 71 patients. Am J Car-
[10]. It therefore seems prudent to deliver these high-risk diol 51:237–243
6. Maxwell D, Crawford D, Curry P, Tynan M, Allan L (1988) Ob-
infants at neonatal centers where appropriate intensive
stetric importance, diagnosis, and management of fetal tachycar-
care facilities are available. dias. BMJ 297:107–110
Maintenance antiarrhythmia drugs were used post- 7. Maxwell DJ, Johnson P, Hurley P, et al (1991) Fetal blood sam-
natally in more than half of the infants in this series. pling and pregnancy loss in relation to indication. Br J Obstet
There was a high postnatal recurrence (11 of 23, 48%) of Gynaecol 98:892–897
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7 of 11 (64%) had a recurrence, compared with 4 of 12
nosis of fetal arrhythmias using echocardiographic and Doppler
(33%) who were nonhydropic during fetal life. Recur- techniques. J Am Coll Cardiol 8:1425–1433
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In conclusion, this study shows that an intermittent 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