The hydropic fetus with atrial flutter has high risk of fetal demise. In utero treatment is not as successful as SVT with 1:1 conduction. Even after conversion to sinus rhythm, close follow-up of the pregnancy is required for several reasons..
A 25 year old primigravida, at 26 wks of gestation had a fetal ultrasound which showed a tachycardic hydropic fetus with AFI 49. The rhythm was atrial flutter: AR 400 bpm and VR 200 bpm. The heart was structurally normal. Transplacental antiarrhythmic treatment with sotalol was started and 24 hours later, the fetus was still primarily in flutter with rare episodes of sinus rhythm and frequent PAC. Sotalol was increased but the mother’s QTc increased to > 500 ms, so the sotalol dose was reduced. On day 4th direct i.m. of digoxin was given and fetus was in sinus rhythm. Pharmacotherapy was continued. On the 16th day of sinus rhythm (at 33 wks), a marked change in FHR variability was seen. An US revealed the fetus was in sinus rhythm with a normal FHR. Because of the decreased FHR variability, the fetus was delivered by CS and the cord pH was 7.19, Apgars 1, 9 and 9. The neonate received no antiarrhythmic medications. On day 6 of postnatal life, an AV re-entrant tachycardia (AVRT) developed and sinus rhythm was successfully restored with sotalol and digoxin. The infant was treated for 18 months with no episodes of SVT or atrial flutter.
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1. Jaeggi ET Carvalho JS De Groot E Api O Clur SA Rammeloo L McCrindle BW Ryan G Manlhiot C Blom NA. Comparison of transplacental treatment of fetal supraventricular tachyarrhythmias with digoxin flecainide and sotalol: results of a nonrandomized multicenter study. Circulation. 2011;124(16):1747-54.
2. Hansmann M Gembruch U Bald R et. al. Fetal tachyarrhythmias: transplacental and direct treatment of the fetus: a report of 60 cases. Ultrasound Obstet Gynecol 1991; 1:162-170.
4. van der Heijden LB1 Oudijk MA Manten GT ter Heide H Pistorius L Freund MW.v Sotalol as first-line treatment for fetal tachycardia and neonatal follow-up Ultrasound Obstet Gynecol. 2013;42(3):285-93..
5. Cuneo BF and Strasburger BF. Management strategy for fetal tachycardia. Obstet Gynecol 2000; 96:575–81.
6. Parilla BV Strasburger JF Socol ML. Fetal supraventricular tachycardia complicated by hydrops fetalis: A role for direct fetal intramuscular therapy. American J Perinatol 1996;3(6):483-86.
7. Weiner CP Thompson MIB. Direct treatment of fetal supraventricular tachycardia after failed transplacental therapy. Am J Obstet Gynecol 1988; 158:570-573.
8. Till J Wren C. Atrial flutter in the fetus and young infant: An association with accessory connections. Br Heart J. 1992; 67:80-83.
9. Naheed ZJ Strasburger JF Deal BJ Benson DW Jr. Gidding SS. Fetal tachycardia: Mechanisms and predictors of hydrops fetalis. J Am Coll Cardiol. 1996; 27:1736-1740.