Taiwanese Journal of Obstetrics & Gynecology 62 (2023) 480e484

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Taiwanese Journal of Obstetrics & Gynecology

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Case Report

Fetal arrhythmias case series: Experiences from a fetal screening

center in Taiwan
Wan-Ling Chih a, Ksenia Olisova b, Yu-Hsuan Tung a, Yi-Ling Huang a, Tung-Yao Chang a, *
a
Department of Fetal Medicine, Taiji Clinic, Taiwan
b
Department of Medical Research, Taiji Clinic, Taiwan

a r t i c l e i n f o a b s t r a c t

Article history: Objective: Fetal arrhythmias are common and in rare cases can be associated with severe mortality and
Accepted 9 January 2023 morbidity. Most existing articles are focused on classification of fetal arrhythmias in referral centers. Our
main objective was to analyze types, clinical characteristics, and outcomes for arrhythmia cases in
Keywords: general practice.
Arrhythmias Case report: We retrospectively reviewed a case series of fetal arrhythmias in a fetal medicine clinic
Cardiac
between September 2017 and August 2021.
Diagnostic imaging
Fetal arrhythmias in our sample presented by: Ectopies (86%, n ¼ 57), bradyarrhythmias (11%, n ¼ 7), and
Fetus
General practice
tachyarrhythmias (3%, n ¼ 2). One tachyarrhythmia case was associated with Ebstein's anomaly. Two
Referral and consultation cases of second-degree AV block received transplacental fluorinated steroid therapy with recovery of
fetal cardiac rhythm in later gestation. One case of complete AV block developed hydrops fetalis.
Conclusion: Detection and careful stratification of fetal arrhythmias in obstetric screening is crucial.
While most arrhythmias are benign and self-limited, some require prompt referral and timely
intervention.
© 2023 Taiwan Association of Obstetrics & Gynecology. Publishing services by Elsevier B.V. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction Case report

Fetal arrhythmias are diagnosed in around 1e3% of all preg-
nancies and are typically presented by atrial ectopies and transient
sinus bradycardia [1]. During pregnancy ultrasound screening it is
routine practice to evaluate the presence of a fetal heartbeat.
Although, often heart rhythm is not thoroughly assessed in the
general low-risk population [2]. Common fetal arrhythmias are
benign and do not require treatment or further investigation. On
the other hand, some fetal arrhythmias can lead to severe conse-
quences, such as low cardiac output, hydrops, and intrauterine
death. The incidence of life-threatening arrhythmias is low, around
1 in 5000 pregnancies [3]. Timely detection allows for appropriate
planning of prenatal and postnatal clinical management. There are
limited local data regarding fetal arrhythmias in the general pop-
ulation. A previous study in Taiwan was focused on a case series in a
tertiary specialized medical center [4]. As a result, the main goal of
this study was to present a case series and to discuss commonly
occurring types of fetal arrhythmias in a single primary care fetal
medicine clinic collaborating with pediatric cardiologists.
* Corresponding author. 104, Zhongshan District, Sec. 2, Zhongshan North Road,
Taipei City, Taiwan, ROC.
E-mail address: tychang@fetalmedicine.tw (T.-Y. Chang).
From September 2017 to August 2021, all intermittent or sus-
tained fetal arrhythmia cases detected during fetal anatomical
screening from a primary obstetric screening clinic in Taiwan were
included. We excluded those cases when fetal arrhythmia was
observed for less than 10% of the time during ultrasound exami-
nation. Arrhythmia types and presence of cardiac structural
anomalies were confirmed by pediatric cardiologists either on-site
or in follow-up studies, through fetal echocardiography. Medical
records were reviewed retrospectively. Pregnancy and cardiac
outcomes were acquired by phone follow-ups. Types of arrhyth-
mias, clinical characteristics, and outcomes were analyzed. More
complicated cases are presented in detail to provide an example of
a multidisciplinary approach to fetal arrhythmias management.
A total of 66 cases of intermittent or persistent fetal arrhythmia
were identified during the study period. Ectopy was the most
common diagnosis among all types of fetal arrhythmia, followed by
bradyarrhythmia and tachyarrhythmia. The clinical characteristics
and outcomes were summarized in Table 1. Most ectopy cases had
spontaneous recovery in later gestation. Among the two cases of
tachyarrhythmias, one case of supraventricular tachycardia was
associated with structural heart disease (Ebstein's anomaly). The

https://doi.org/10.1016/j.tjog.2023.01.007
1028-4559/© 2023 Taiwan Association of Obstetrics & Gynecology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
W.-L. Chih, K. Olisova, Y.-H. Tung et al. Taiwanese Journal of Obstetrics & Gynecology 62 (2023) 480e484

Table 1
Characteristics of the fetal arrhythmia cases (n ¼ 66).

Type of arrhythmia n(%) n Clinical characteristics Drug treatment Follow-up Outcome

GA (weeks) SHD Anti-Roþ In utero Postnatal SR Hydrops fetalis IUD TOP LB

Ectopy 57 (86%)
Premature atrial contraction 55 15.7e35.7 0 e 0 0 52 0 0 1a 51
Premature ventricular contraction 2 22, 36.3 0 e 0 0 1 0 0 0 2
Tachyarrhythmia 2 (3%)
Supraventricular tachycardia 2 12.3, 28.6 1 e 0 1 0 1 1 0 1
Bradyarrhythmia 7 (11%)
Sinus bradycardia 2 19.1, 22.4 0 0 0 0 0 0 0 0 2
1st-degree AV block 1 22 0 1 0 0 1 0 0 0 1
2nd-degree AV block 2 19.7, 22.1 0 1 2 0 2 0 0 0 2
Complete AV block 2 18.6, 23 0 2 2 0 0 1 0 2 0
Total 66 1 4 4 1 56 2 1 3 59

y e oral propafenone.
z e Termination of pregnancy due to a brain anomaly.
€gren's-syndrome-related antigen A/Ro autoantibodies positive; AV - atrioventricular; GA - gestational age; IUD - intrauterine death; LB - livebirth; SHD -
Anti-Ro - anti-Sjo
structural heart disease; SR - sinus rhythm; TOP - termination of pregnancy.
a
Transplacental fluorinated steroid therapy.

fetus developed hydrops fetalis later and the pregnancy was
terminated. Another one had intermittent atrial tachycardia which
persists postnatally and is controlled with oral propafenone. In our
series, a majority of bradyarrhythmia cases presented as high-
degree atrioventricular block (AV block), i.e., second- or third-
degree AV block (n ¼ 4/7, 57%). Positive anti-Ro (SSA) antibodies
were found in most mothers conceiving AV block fetuses (n ¼ 4,
80%). All cases of high-degree AV block have had transplacental
fluorinated steroid therapy (n ¼ 4), and consequently, fetal heart
rhythm normalized in patients with second-degree AV block (n ¼ 2)
in later gestation. While cases of complete AV block did not respond
to in utero steroid therapy, and one of them developed hydrops
fetalis. Parents opted for the termination of pregnancies after the
failure of prenatal treatment.
Individual cases of more severe arrhythmias are presented
below as examples of challenging cases treated in cooperation
between fetal medicine specialists and pediatric cardiologists.
Case 1: Ebstein anomaly with supraventricular tachycardia
A 33-year-old singleton pregnant woman visited our clinic at 18
weeks of gestation for fetal anatomical screening. The fetal cardiac
screening revealed an Ebstein anomaly with severe tricuspid valve
regurgitation. Pediatric cardiology consultation at 19 weeks
confirmed the above diagnoses and pulmonary atresia. Car-
diomegaly progressed during serial echocardiographic follow-ups
without any signs of hydrops fetalis. At the gestational age of 28
weeks, sustained fetal tachyarrhythmia was noted on a follow-up
scan. The fetal heart rate was 201/min with 1:1 atrioventricular
conduction (Fig. 1). The parents refused further monitoring or
transplacental drug therapy for fetal supraventricular tachycardia.
After then, she had follow-up scans weekly by her primary obste-
trician. The fetus developed hydrops fetalis later and intrauterine
fetal demise occurred around 30 weeks.
Case 2: Complete AV block complicated with hydrops fetalis
A 32-year-old pregnant woman was referred to our clinic at 18
weeks of gestation due to suspicion of fetal cardiac anomaly. Fetal
echocardiography revealed normal cardiac anatomy but sustained
fetal bradycardia (72/min). The diagnosis of the complete atrio-
ventricular block was confirmed by atrioventricular dissociation in
M-mode (Fig. 2). She was seropositive for anti-SSA antibody (442
AU/ml; <100 (), >120 (þ)). Under the impression of immune-
mediated high-degree AV block, dexamethasone was prescribed.
The fetus developed progressive cardiomegaly, pericardial effusion,
and valvular regurgitations in weekly follow-up scans. Meanwhile,
the fetal ventricular rate decreased to 60/min at 22 weeks of
gestation. Pediatric cardiology counseling suggested a high risk for
intrauterine fetal demise and a permanent pacemaker will possibly
be indicated if liveborn. The family opted for termination of
pregnancy.
Discussion
Similarly to the existing literature, the most common fetal ar-
rhythmias in our case series were ectopies presented by premature
atrial contractions [5]. All the ectopies were benign and resolved
without treatment. Although, fetuses with ectopies are at increased
risk of developing tachyarrhythmias or bradycardia which warrant
follow-ups at later gestation [6].
Previously, a local fetal arrhythmia case series from National
Taiwan University Hospital was described by Hsiao et al., in 2007
[4]. Overall, we can see noticeable differences between the two
samples, as our focus was mostly on general screening, and the
tertiary care center included more referral cases. Premature atrial
contraction was the most common type of arrhythmia presented
in both studies, but the proportion of ectopy was much higher in
the current study (48% in Hsiao's series vs 86% in the current
study). In general, the proportion of fetuses having associated
structural heart disease was higher in Hsiao's series compared to
our series (20% vs 1.5% respectively). The percentage of mothers
having an autoimmune diagnosis was also higher in the referral
center. All cases of complete AV block in our sample had positive
anti-Ro antibodies, although they had no confirmed diagnosis of
autoimmune disease prior. On the other hand, Hsiao et al. re-
ported maternal systemic lupus erythematosus in 2 out of 4
complete AV blocks but left out the anti-Ro antibody testing re-
sults. Since autoimmune AV block was extensively researched in
recent decades, its' association with maternal autoantibodies
(anti-Ro/SSA, anti-La/SS-B), which could be present in women
with or without autoimmune disease, made it crucial to test the
presence and levels of autoantibodies in cases of AV block even in
asymptomatic women.
As for treatment and outcome, Hsiao et al. reported a wide va-
riety of diagnoses that required in-utero or postnatal drug therapy,

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W.-L. Chih, K. Olisova, Y.-H. Tung et al. Taiwanese Journal of Obstetrics & Gynecology 62 (2023) 480e484

Fig. 1. M-mode echocardiography showed fetal tachyarrhythmia with 1:1 atrioventricular conduction in the follow-up scan at 28 weeks for a case of fetal Ebstein anomaly. (A: atrial
contraction; V: ventricular contraction).

Fig. 2. M-mode echocardiography revealed fetal bradycardia with atrioventricular dissociation, which is a typical finding in complete atrioventricular block. (A: atrial contraction;
V: ventricular contraction).

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W.-L. Chih, K. Olisova, Y.-H. Tung et al. Taiwanese Journal of Obstetrics & Gynecology 62 (2023) 480e484

including atrial flutter, multifocal atrial tachycardia, sick sinus
syndrome, complete AV block, and long QT syndrome. In contrast,
our sample's main diagnosis that required in-utero drug therapy
was high-degree AV block. In our experience, complete AV block
proved irreversible, whereas second-degree AV block may resolve
after transplacental fluorinated steroid therapy. Cases with com-
plete AV block were at increased risk for hydrops fetalis, and in
cases when hydrops developed, parents opted for termination of
pregnancy in either sample. It is well-established that typically AV
block cases develop between 16 and 30 weeks of gestation [6].
Likewise, high-degree AV blocks occurred between 18 and 23
weeks in our series. That underlines the importance of detailed
fetal heart rate screening in the second trimester. Features that
should be thoroughly evaluated during fetal heart screening
include heart rate, rhythm regularity, and atrioventricular rela-
tionship, which could be done by either M-mode or Doppler
technique [2,7,8]. Examples are presented in Fig. 3.
While ectopies are generally isolated and the prognosis is
excellent, tachyarrhythmia and bradyarrhythmia may be associated
with cardiac structural anomalies. When brady- or tachyar-
rhythmia persists, the risk of hydrops fetalis should not be over-
looked. Consequently, we recommend a referral to a pediatric
cardiologist. As supported by the literature, close cooperation be-
tween obstetricians and pediatric cardiologists is advantageous in
managing suspected cardiac anomalies [9]. The primary role of
obstetricians is to detect suspicious cases and grant a prompt
referral according to the case severity by utilizing shared decision
making process. The frequency of follow-ups depends on multiple
factors, in general, ectopies require follow-up in 4e6 weeks,
whereas tachy- or bradyarrhythmia need weekly scans for timely
detection of complications, such as hydrops fetalis. On the other
hand, the pediatric cardiologist might provide more diagnostic
details, explicit counseling, propose prenatal and postnatal treat-
ment options, and reassure parents in case of a false-positive
finding. Literature has it that fetal echocardiography performed
by pediatric cardiologists had improved accuracy in diagnosis,
which may influence management [9,10]. In our clinical experience,
the multi-disciplinary approach to fetal cardiac diagnosis was

Fig. 3. (A) M-mode echocardiography well presents the essential components of fetal cardiac rhythm screening: atrial and ventricular heart rate, rhythm regularity, and atrio-
ventricular relationship. Blocked atrial bigeminy is confirmed by irregular atrial contraction and AV block following the premature atrial beat (A0 ). (B) Spectral Doppler of the aorta
and innominate vein demonstrates progressive lengthening of atrioventricular conduction until AV block occurs, i.e. second-degree Mobitz type 1 AV block.

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W.-L. Chih, K. Olisova, Y.-H. Tung et al.
equally valuable for diagnosing fetal arrhythmias and structural
heart diseases. For example, it might be challenging for primary
obstetricians to differentiate blocked atrial bigeminy (Fig. 3A) from
2:1 AV block in cases of persistent bradycardia with 2:1 AV con-
duction. In contrast, a detailed review by a pediatric cardiologist
resolves the dilemma of future management: blocked atrial
bigeminy usually resolves spontaneously, while 2:1 AV block war-
rants furthermore workup and timely intervention.
The results of the current study should be interpreted with
caution as the sample size is limited and might be affected by se-
lection bias. Our prenatal clinic is focused on second-trimester
screening, as a result, those cases diagnosed at earlier gestation
were not included in our sample. Another limitation of the case
series is the lack of long-term postnatal follow-up data. Nonethe-
less, observations from the current case series demonstrates the
importance of second-trimester fetal heart screening and the
importance of multidisciplinary management of fetal arrhythmias
and structural anomalies.
In conclusion, the prognosis for fetal arrhythmias is generally
good, except for cases of hydrops fetalis, concomitant abnormalities,
and complete AV block. A multidisciplinary approach involving ob-
stetricians, fetalematernal medicine specialists, and pediatric car-
diologists might be helpful for the detection of structural anomalies
and optimizing prenatal and postnatal management.
Funding
The study was funded by Taiwan Institute of Fetal Medicine
(Taiwan Registered Non-profit Organization 1080280906).
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Taiwanese Journal of Obstetrics & Gynecology 62 (2023) 480e484
Declaration of competing interest
Authors declare no actual or potential conflicts of interest.
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