The patient, 28 years old, 7th week of 4th pregnancy, with poor obstetric history (two miscarriages in early pregnancy), after surgical correction of the heart defect in 1992 (ventricular septal defect ASD type II, patent ductus arteriosus, supravalvular pulmonary stenosis) with implanted heart chamber pacing system due to the sick sinus syndrome and paroxysmal atrial flutter (in 1992). Additionally prior history of the extraction of the ventricular pacing lead and implantation of the cardiac pacing (in 2011). Echocardiography showed tricuspid insufficiency 2nd/3rd degree. Furthermore prior history of paroxysmal atrial flutter and hepatitis C. The patient was admitted to Outpatient Cardiology Clinic for Pregnant Women in Lublin, treated with Sotalol 40 mg 1 x 1 tablet and Acetylsalicylic Acid 75 mg 1 x 1 tablet. The electrocardiogram examination showed atrial fibrillation with irregular ventricular function ca 70/min and right bundle branch block, duration of atrial fibrillation was difficult to determine. The patient did not feel the arrhythmia. The patient was referred to Cardiology Department in order to stabilize atrial fibrillation. On admission the patient’s condition was stable, with proper circulatory and respiratory parameters, pregnancy alive. Physical examination: visible scar after correction of the heart defect, irregular heart rate 70-100/min, systolic murmur (Levine 3/6) above pulmonary artery, RR 120/70 mmHg, no edema of lower limbs, above lungs normal vesicular murmur. Laboratory test with no significant irregularities, β-HCG – 36048.0 mlU/ml (indicating 8th week of the pregnancy). During observation in the cardiac intensive care unit the patient reported spotting/bleeding from the genital tract, she had multiple gynecological consultations. Fetal ultrasound was performed couple of times, indicating alive pregnancy with the presence of intrauterine hematoma and normal progress of β-HCG. Due to the good tolerability of the arrhythmia, the decision on the restoration of the sinus rhythm was postponed till the stabilization of the obstetric condition. Due to spotting/bleeding from the genital tract the patient was moved to the Pregnancy Pathology Department. On the day of discharge she was receiving Enoxaparin 60 mg 1 x 1 s.c., Progesterone 2 x 100 mg vaginally, Drotaverine 40 mg 3 x 1 tablet, Dydrogesterone 10 mg 2 x 1 tablet. The patient’s condition was gradually improving. In the laboratory tests the elevated level of antibodies against HCV (> 11) was found. The patient was discharged with the alive pregnancy with β-HCG levels corresponding with the age of pregnancy, with no spotting/bleeding, with proper circulatory and respiratory parameters with persistent atrial fibrillation. The patient was again hospitalized in 13th week of pregnancy due to the vaginal bleeding and abdominal pain lasting for several days. On admission the heart rate was irregular due to the atrial fibrillation, RR 130/80 mmHg, with proper circulatory and respiratory parameters. The ultrasound showed retained fetal heart rate. The laboratory tests showed slightly decreased blood cell count (RBC – 3.36, HGB – 11.0, HCT – 31%, MCV – 92.2), elevated level of GGTP 182.00 U/L (N < 31.00 U/L), with normal value of ALP 62 U/L, AST 18 U/L, total bilirubin 0.60 mg/dl, viral load of HCV was determined quantitatively (PCR method) at 3.79 x 10 to 5 IU/ml. The ultrasound showed widened pyelocalyceal system in the right kidney (1.57 cm) and initial section of the ureter (1 cm) with no visible changes in the liver. The patient condition was consulted with the gastroenterologist and infectious diseases specialist. The monitoring of the liver parameters every 2-3 weeks was recommended. The decision on the restoration of the sinus rhythm was postponed till the stabilization of the general condition of the patient. Throughout the hospitalization period the patient was apathetic and depressive, she was discharged at her own request before the end of therapeutic process. On the day of discharge she was receiving Enoxaparin 60 mg 1 x 1 s.c., Progesterone 2 x 2 tablet, Dydrogesteron 2 x 1 tablet, Metoprolol 2 x 25 mg. In the 25th week of the pregnancy the patient was admitted to the Gynecological and Obstetrics Emergency due to weak feeling of the fetal movements. On admission her condition was stable, with persistent atrial fibrillation with normal heart rate around 80/min (the patient did not feel the arrhythmia), RR 110/71 mmHg, normal vesicular murmur. The fetal ultrasound showed large lacunar fluid concentration with sedimenting content, on the fetal surface of the placenta, of total volume of over 250 ml, no signs of intrauterine growth restriction or anemia was determined in fetus. Prophylaxis of neonatal respiratory distress syndrome with betamethasonum was introduced. Obstetrical pessary was inserted. The electrocardiogram showed persistent atrial fibrillation, the patient did not feel the arrhythmia. On the day of discharge she was receiving Enoxaparin 60 mg 1 x 1 s.c., Metoprolol 50 mg 2 x 1/2 tablet, Progesterone vaginally 2 x 100 mg, Dydrogesteron 2 x 1 tablet. Due to the vaginal spotting/bleeding the enoxaparin dose was not altered. The patient gave preterm birth to a healthy boy (1600 g) in the 32nd week of the pregnancy via C-section due to premature abruption of the placenta. During checkup appointment in Cardiac Clinic the ECG showed regular sinus rhythm (spontaneous reversion to sinus rhythm). Currently patient is receiving Warfarin under INR control.

The presented case refers to a patient after correction of structural heart disease with atrial fibrillation of unknown duration. The decision on the restoration of the sinus rhythm was postponed till the end of pregnancy, with prior anticoagulant preparation and TEE examination. The patient was receiving 1 x 60 mg of enoxaparin subcutaneously. After the patient gave birth, there was a spontaneous recovery of sinus rhythm, the patient is receiving warfarin (INR control). The patient remains under constant monitoring of the Cardiology Clinic.

The patient, 28 years old, 16th week of 1st pregnancy, with paroxysmal atrial fibrillation and history of paroxysmal supraventricular tachycardia with prolapse of the anterior leaflet of the mitral valve and 2nd degree regurgitation. The patient was admitted to Outpatient Cardiology Clinic for Pregnant Women. The electrocardiogram showed perpetual arrhythmia with atrial fibrillation, ventricular rate 80-100/min. The patient was not taking any medications. The patient presented the electrocardiogram results from April (same year) showing unstable cardiac rhythm – numerous extrasystole with single impulse with visible P-wave. The patient was unable to determine when the arrhythmia started. The patient was referred to Cardiology Department order to stabilize heart rate. History of frequent recurring fainting with dizziness but no consciousness loss. On admission the patient’s condition was stable, with proper circulatory and respiratory parameters, RR 95/55 mmHg, HR 100/min, normal vesicular murmur, pregnancy alive. Transesophageal echocardiography showed no thrombus, progression of mitral regurgitation (2nd/3rd degree) and tricuspid regurgitation (2nd degree), patent foramen ovale with slight left-to-right shunt. The electrical cardioversion gave no effect. Due to the stable condition of both mother and child, the attempt to restore sinus rhythm was postponed till the end of pregnancy. The patient was discharged from the hospital. Due to difficulties in contacting the patient and lack of cooperation oral anticoagulant therapy was abandoned and Enoxaparin 1 x 60 mg s.c. was recommended. Up to 34th week of pregnancy electrocardiogram showed atrial fibrillation. After giving birth the patient did not report to the Cardiology Clinic.

Patient with atrial fibrillation of unknown duration, patient did not feel the arrhythmia, she was not cooperative and did not comply with doctors recommendations. The electrical cardioversion attempt failed, sinus rhythm was not restored. After giving birth the patient did not continue treatment in the Cardiology Clinic.