Tachycardian Psychology Paper

Lindsay is a 32yo, primigravida, who is currently 31 weeks 3 days as dated by LMP consistent with an 8-week ultrasound. She has a long history of tachycardia. She has been followed several years with Cardiology and had a very significant work-up including prolonged Holter’s, ECHO, stress ECHO, and even evaluation by Electrophysiology Cardiology. She was ultimately diagnosed with syndrome of inappropriate tachycardia and she was treated with atenolol for several years. She stopped atenolol 2 years ago and had been doing well until recently in pregnancy. At baseline, she reports that her heart rate is in the 100’s and since becoming pregnant has been anywhere from the 100’s to 120’s. recently she also started having irregular contractions
and 10 days ago she was admitted to the hospital overnight for contractions every 3 to 8 minutes and received betamethasone. Her cervix has not been dilated and she has been followed closely in your office. She was started on Procardia for symptomatic relief and has noted that when taking the Procardia, the tachycardia has gotten worse. A couple of days ago she had a very significant episode with heartrate persistent in the 170’s to 180’s. She was seen in the emergency room and after a couple of hours her heartrate was able to decrease to the 120’s. She was discharged home. She has since restarted her prior atenolol and is on 25 mg q d. Her heartrate has been around the 90’s to 100’s and was 90 in the office today. She is here today to discuss her history of tachycardia and preterm labor.

On ultrasound there is a live fetus in cephalic presentation.
Fetal biometry is consistent with dates. A limited survey was unremarkable but suboptimal due to late gestational age as noted above. Amniotic fluid and umbilical artery Doppler were within normal limits. BPP is
8/8.

I had a long discussion with Lindsay and her husband today.
Since she is approaching the point in pregnancy with maximum increase in blood volume I feel that the cardiac stretch is likely precipitating some of her increase in symptoms and tachycardia. For now, it appears to be well-controlled with atenolol and since she has had such a significant work-up in the past I do not feel the need to have any further work-up at this time. If however she is no longer controlled on atenolol then I would consider ordering a 24-hr Holter monitor. We could also consider increasing the atenolol if needed but I would not do so until other work-up has been performed. She is also quite concerned since contractions appear to precipitate her tachycardia that she may have complications with pain and stress of labor. Certainly, we will follow maternal pulse oximetry. We also may consider telemetry in labor. She is also quite nervous about the delivery process and we discussed the possibility of even delivering here at UT Medical Center where there is Cardiology services as well as EP services readily available. She also seems to have a reaction to local anesthesia that has caused an increase in her tachycardia creating concern over the epidural. She does note that her magnesium level was slightly low when she was seen in the ER the other day and then once it was replaced she has done somewhat better. The level from your office yesterday is still pending. I would consider replacing and
checking if needed.

In regards to preterm contractions since her cervix has not been significantly dilated despite the frequent contractions that she has had, I do feel overall reassured. As long as they are not painful I would not do anything for treatment of these and simply follow her closely. I did schedule her to return here around 36 to 37 weeks and we can discuss delivery timing and planning. Please do not hesitate to contact our office if you have any questions.

Thank you for referring this patient to our office. Please do not hesitate to call us if you have any questions.

THIS REPORT HAS BEEN DICTATED BUT NOT EDITED
Lynlee Wolfe, M.D.
Maternal-Fetal Medicine