Zusammenfassung
Supraventrikuläre Extrasystolen werden während einer Schwangerschaft (SWS) häufig beobachtet, supraventrikuläre Tachykardien (atriale Tachykardien, AV-Knoten-Reentry-Tachykardien, „circus-movement“-Tachykardien) dagegen eher seltener. Zur Akut-Therapie (AT) ist bei hämodynamischer Instabilität (HI) eine elektrische Kardioversion (KV) mit 50 - 100 Joule notwendig. Bei stabiler Hämodynamik (SH) sollten primär vagale Manöver durchgeführt werden, bei Versagen vagaler Maßnahmen ist Adenosin das Medikament der 1. Wahl. Für die Langzeit-Therapie (LZ‐T) kommen vor allem β1-selektive Betablocker (BB) infrage, seltener spezifische Antiarrhythmika (AA) der Klasse Ic oder der Klasse III (Sotalol [Sot]). Ventrikuläre Extrasystolen sind während einer SWS ebenfalls relativ häufig und bei den meisten Patientinnen (Pt) harmlos, maligne ventrikuläre Arrhythmien (ventrikuläre Tachykardien [KT], Kammerflattern [KFlat], Kammerflimmern [KF]) werden dagegen eher seltener beobachtet. Als AT sollte bei HI eine elektrische KV erfolgen, bei SH kommen Ajmalin, Procainamid oder Lidocain in Betracht. Für die LZ‐T sollten primär β1-selektive BB eingesetzt werden, bei Therapierefraktärität kommen spezifische AA der Klasse Ic oder Sot in Betracht. Für Pt mit synkopaler KT, KF, KFlat oder überlebtem plötzlichem Tod ist der implantierbare Defibrillator eine therapeutische Alternative. Bei Pt mit symptomatischen Bradykardien kann unter Echokontrolle ein Schrittmachersystem in jedem Stadium der SWS implantiert werden. Trotz notwendiger Besonderheiten im therapeutischen Verhalten während einer SWS können alle supraventrikulären und/oder ventrikulären Arrhythmien adäquat behandelt und bei sorgfältiger Beachtung von Risiken, Nebenwirkungen und Komplikationen aller therapeutischen Maßnahmen können auch komplizierte Schwangerschaften erfolgreich beendet werden. Auch in der Stillzeit können zahlreiche Antiarrhythmika ohne Probleme angewendet werden.
Abstract
Atrial premature beats are frequently diagnosed during pregnancy (PR), supraventricular tachycardia (SVT)(atrial tachycardia, AV nodal reentrant tachycardia, circus movement tachycardia) less frequently. For acute therapy, electrical cardioversion with 50 - 100 Joules is indicated in all unstable patients (pts). In stable SVT the initial therapy includes vagal maneuvers to terminate breakthrough tachycardias. For short-term management, when vagal maneuvers fail, intravenous adenosine is the first choice drug and may safely terminate the arrhythmia. For long-term therapy, β-blocking agents with β1 selectivity are first-line drugs; class Ic agents or the class III drug sotalol (sot) are effective and therapeutic alternatives. Ventricular premature beats are also frequently present during PR and benign in most of the pts; however, malignant ventricular tachyarrhythmias (sustained ventricular tachycardia [VT], ventricular flutter [VFlut], ventricular fibrillation [VF]) were observed less frequently. Electrical cardioversion is necessary in all pts with hemodynamically unstable situation and life-threatening ventricular tachyarrhythmias; in hemodynamically stable pts, initial therapy with ajmaline, procainamide or lidocaine is indicated. If prophylactic therapy is needed, β-blocking agents with β1 selectivity are considered as first choice drugs. If this therapy is ineffective, class Ic agents or sot can be considered. In pts with syncopal VT, VF, VFlut or aborted sudden death an implantable cardioverter-defibrillator is indicated. In pts with symptomatic bradycardia, a pacemaker can be implanted using echocardiography at any stage of PR. The treatment of of the pregnant patient with cardiac arrhythmias requires an important modification of the standard practice of arrhythmia management. The goal of therapy is to protect the patient and fetus through delivery, after which chronic or definitive therapy can be administered. In addition, antiarrhythmic therapy is also possible during breastfeeding.
Schlüsselwörter
Herzrhythmusstörungen - Schwangerschaft - Stillzeit - plötzlicher Tod - automatischer Defibrillator - Antiarrhythmika
Key words
Cardiac arrhythmias - pregnancy - breastfeeding - sudden death - automatic implantable cardioverter defibrillator - antiarrhythmic drugs
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Univ.-Prof. Dr. med. Hans-Joachim Trappe
Medizinische Klinik II (Schwerpunkte Kardiologie und Angiologie)
Ruhr-Universität Bochum
Hölkeskampring 40
44625 Herne
eMail: Hans-Joachim.Trappe@ruhr-uni-bochum.de
