Postpartum Atrial Fibrillation in a Pre-Eclamptic Patient
Journal of the American College of Cardiology
Background: Postpartum atrial fibrillation (AF) is an uncommon tachyarrhythmia that can present clinical challenges to the treatment team. There are certain management considerations in treating postpartum women who develop AF including safety and efficacy of anticoagulation, rate or rhythm control as well as drug exposure to infants throughout breastfeeding. Case: A G1P0 23-year-old female with a history of morbid obesity and type 1 gestational diabetes mellitus presented at 37 weeks gestation for routine prenatal visit with pre-eclampsia with severe features with blood pressure 165/103. She underwent induction of labor with oxytocin and had a successful vaginal delivery. On postpartum day 2, the patient complained of palpitations and was noted to be in AF by telemetry. EKG showed AF with rapid ventricular response with rates up to 150 beats per minute. She was started on propranolol, nifedipine, hydralazine, and therapeutic enoxaparin. On postpartum day 4, she spontaneously converted to normal sinus rhythm and was discharged in stable condition. The patient had an unremarkable 4-week follow-up with her obstetrician with no symptoms or signs of arrhythmia. Decision-making: Our patient was diagnosed with gestational hypertension at 37 weeks of gestation and then diagnosed with preeclampsia with severe features. Hypertension is also a well-known known risk factor for AF. The pathophysiology involves cardiac remodeling of the left ventricle and subsequent morphologic changes of the left atria lead to ectopic foci of depolarization and can disrupt electrical pathways precipitating AF. Our patientʼs hypertension was controlled with nifedipine and hydralazine. Rate control was achieved with propranolol. Our patient was anticoagulated with enoxaparin for a CHA2DS2-VASc score of 3 due to gender, preeclampsia and gestational diabetes. These medications were selected due to their efficacy and their safety with respect to breastfeeding. Conclusion: This case highlights management of AF in the postpartum period. Although AF is a common arrhythmia with clear guidelines for management, AF in the postpartum period has not been well explained and appropriate management has not been well defined.
Li S, Sherman A, Holzhausen J, Mehta N. Postpartum atrial fibrillation in a pre-eclamptic patient. J Am Coll Cardiol. 2023 Mar;81(8 Suppl.A):2819. doi:10.1016/S0735-1097(23)03263-1