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Wolff-Parkinson-White (WPW) syndrome is a rare congenital cardiac pre-excitation syndrome. PW syndrome in pregnancy, this physiological process might be responsible for life threatening arrthymias leading to dangerous outcomes for both mother and the fetus. It is a ventricular pre-excitation syndrome of anterograde activation of the ventricle resulting from aberrant conduction pathway as well as the AV node. Very small percent of patients with WPW syndrome that is less than 1% are at risk of sudden cardiac death. Most of the antiarrthymic drugs are a threat to the fetus therefore careful choice of drug has to be made. Digoxin is the drug that is contraindicated in adults with WPW syndrome and some drugs like verapamil increase danger of ventricular fibrillation and therefore use of drugs are a topic of concern. we report a rare case of Wolff Parkinson White syndrome in a 20yrs old primigravida at 20weeks of gestation presented with palpitations , shortness of breath and chest pain. The diagnosis was made by ECG , 2D ECHO. Holter and electrophysiology study of heart. She underwent radio frequency catheter posterior septal pathway ablation at 24weeks of gestation and was prescribed Metaprolol resulting in symptomatic improvement. Patient had regular antenatal and cardiology checkups until 37 weeks of gestation. At 37 weeks patient underwent LSCS and delivered a live healthy baby. The disease cause, manifestations, diagnostic tests and management and outcome are discussed.
In the early 1900s, Frank Wilson and Alfred Wedd were the first to describe the ECG patterns that later became known as the WPW pattern. In 1930, Wolff, Parkinson, and White detailed the classic pre-excitation syndrome, based on a series of 11 patients who experienced paroxysmal tachycardia along with ECG changes indicative of sinus rhythm, a short PR interval, and a wide QRS complex1.The electrocardiographic alterations associated with pre-excitation were initially correlated with anatomical evidence of anomalous conducting tissue or bypass tracks in 1943. Key ECG changes along with symptoms like palpitations, shortness of breath, anxiety, angina, and fatigue assist in diagnosing WPW syndrome2 .The overall prevalence of WPW has been estimated to be between 0.1% and 0.3% of the population, with an annual incidence of patients developing arrhythmias around 1% to 2%. Although the risk of sudden death is low—less than 1%—it is still a genuine concern. WPW can adversely affect both maternal and fetal health. Accurate diagnosis and effective management during pregnancy are crucial for improving outcomes for both the mother and the baby.
A 20-year-old primigravida, 20 weeks into her pregnancy, known to have hypothyroidism treated with 25 micrograms of tablet Eltroxin, presented with symptoms of shortness of breath, palpitations, and chest pain. She had experienced similar issues previously, but they had worsened over the past two weeks, even with minimal exertion. The patient was admitted for routine tests, including a ECG and 2D ECHO. The ECG revealed a short PR interval with delta waves present in the QRS complex, while the 2Dechocardiogram indicated mild tricuspid regurgitation and mild pulmonary artery hypertension. A cardiology consultation was sought. Patient was monitored 24hrs with Holter monitor and electrophysiology study of heart was done, and diagnosed to have with an aberrant conduction pathway, specifically Wolff-Parkinson-White syndrome. Recommending radio frequency septal pathway ablation as treatment. She underwent radio frequency catheter posterior septal pathway ablation at 24 weeks of gestation and was prescribed metoprolol SR 25 mg, with regular follow ups including ECGs and 2D echocardiograms until her delivery date. She consistently attended regular antenatal check-ups and serial ultra sound obstetric scans, maintaining follow-up with her obstetrician and physician as well until 36 weeks. At 36 weeks and 6 days of pregnancy, all standard investigations were conducted, and a cardiology opinion confirmed her cardiac status was stable, enabling the planning of surgery under mild cardiac risk. Two days post-admission, she was scheduled for a Elective Cesarean section and successfully delivered a live healthy male infant weighing 2.6 kg, with APGAR scores of 8 and 9 at one and five minutes, respectively. After the operation, her vital signs were closely monitored and remained stable throughout her recovery. Continuous ECG monitoring showed no irregularities. A cardiology consultation found no need for further cardiac interventions. The patient with stable vital signs was subsequently discharged.
ECG after Ablation
ECG with Short PR interval and Delta Waves
Wolf Parkinson-White syndrome was initially described by Kent in 1893 and has been recognized for over a century. This condition involves a bypass of the normal conduction pathways due to an anterograde accessory pathway. Consequently, this muscular connection within the heart predisposes individuals to ventricular preexcitation, which causes the initial segment of the QRS complex to widen (known as the delta wave). This creates a re-entry circuit between the normal and accessory pathways, potentially leading to antidromic or orthodromic atrioventricular nodal reentrant tachycardia and resulting in recurrent bouts of supraventricular tachycardia3.. In pregnant women with WPW syndrome, atrioventricular reciprocating tachycardia can cause hemodynamic distress that requires urgent intervention4. The overall prevalence of WPW syndrome is estimated at 0.1-0.3%, with a yearly risk of sudden death from severe arrhythmias ranging from 1% to 2% in these patients5 This syndrome can lead to dangerous arrhythmias that may result in sudden death. Patients with symptoms have an estimated risk of about 0.2% per year, or roughly 3% to 4% over their lifetime. The precise frequency of WPW syndrome during pregnancy remains unclear, although some studies suggest that pregnancy might trigger tachyarrhythmias in previously asymptomatic individuals with pre-excitation6,7 Various factors have been proposed to account for the increased occurrence of tachyarrhythmias in pregnant women with WPW syndrome. For instance, the maternal blood volume typically increases by around 40% compared to non-pregnant levels. Elevated plasma catecholamine levels, heightened sensitivity of adrenergic receptors, and increased end-diastolic volumes during pregnancy all contribute to a higher risk of arrhythmias. A rise in heart rate can lead to a unidirectional block in the re-entrant pathway, which may trigger reciprocating atrioventricular tachycardia Additionally, emotional stress, anxiety, and concerns about fetal well-being can activate the sympathetic nervous system, potentially leading to arrhythmia.9 Many patients are asymptomatic before pregnancy, but the condition can expose them to an increased risk of palpitations, shortness of breath, and dizziness. Throughout pregnancy, it is crucial to address any new symptoms, including palpitations, breathlessness, syncope, seizures, confusion, or significant intolerance. Differentiating between normal pregnancy symptoms and minor cardiac issues that require further assessment can be challenging.
Easiest diagnoses can be established using an electrocardiogram. choice of treatment is influenced by how well the patient tolerates arrhythmias, the presence of any underlying heart conditions, and the effects of antiarrhythmic medication. In cases of tachycardia associated with WPW, there is a risk of hemodynamic instability that could lead to sudden death for both mother and baby5
For patients, pre-conception counseling is important to discuss the risks of fetal cardiac anomalies. The likelihood of these anomalies is 2 to 5 times greater if the mother has a heart condition. This counseling helps in conducting a thorough maternal cardiac assessment to optimize her health, adjust medications for treatment during pregnancy, and address other comorbidities that could impact the pregnancy6
Certain lifestyle changes, dietary adjustments, and advice on adopting a lateral decubitus position are also recommended. The decision on the method of delivery primarily hinges on obstetric issues or existing comorbidities10,11
Most antiarrhythmic medications are considered potentially harmful to the fetus, so it's crucial to evaluate the risk-benefit ratio before initiating treatment. It is advisable to avoid antiarrhythmic drugs during the first trimester when possible.
Both adenosine and verapamil can extend the refractory period of the AV node and successfully stop 90% of acute attacks. In patients who are hemodynamically stable, vagal maneuvers can be attempted; if they fail, intravenous adenosine may be administered. Several studies have demonstrated adenosine's effectiveness and safety, but fetal cardiac activity must be monitored closely due to the risk of bradycardia6
Data on verapamil is limited, but there have been no reports of teratogenic effects or adverse maternal side effects. If these methods do not work, intravenous flecainide may be used to abort tachycardia7
In any stage of pregnancy, electrical cardioversion is advisable if there is hemodynamic instability or sustained supraventricular arrhythmia. Fetal monitoring is required, though electrical cardioversion itself is safe. If there are delays in cardioversion, drug therapy should be employed for 24 hours to assess its effectiveness, although this may prolong maternal tachycardia and increase the risks associated with antiarrhythmic medications.
Prophylactic treatment options for arrhythmias include beta-blockers and flecainide for those who cannot tolerate other medications. Catheter ablation is reserved for specific cases of uncontrolled or poorly tolerated arrhythmias12,13 It is ideal to defer ablation until the second trimester, after organ formation is complete. When using radiation doses under 50 mGy, there is no evidence linking them to congenital malformations or miscarriage. However, fluoroscopy should be minimized, using a protective X-ray shield on the abdomen to diminish fetal radiation exposure, or employing a zero-fluoroscopy approach as a preferable option. Using an electro-anatomical mapping system is also encouraged, as this has been shown to significantly lower the overall radiation dose during the procedure13
In our case, the patient had significant symptoms , prompting a consultation with a cardiologist. Under went radio frequency catheter ablation. Had regular follow ups with cardiologist and obstetrician, physician. till term.A lower segment cesarean section was performed with mild cardiac risk due to obstetric indications. The patient delivered a live term healthy boy weighing 2.6 kg, with Apgar scores of 8 and 9. Following delivery, a cardiology consultation was sought for the patient, and no cardiac interventions were deemed necessary.
WPW syndrome during pregnancy is considered a serious and uncommon condition that requires careful evaluation, as failing to diagnose it can pose significant life threatening risks to both the mother and the fetus. Consequently, close monitoring is essential. Patients who exhibit no symptoms or only mild ones, and have a structurally normal heart, can be reassured, while antiarrhythmics should be reserved for those who experience intolerable symptoms. The primary goal of treatment is to terminate complex arrhythmias, prevent their recurrence, and manage the ventricular rate. The selection of the appropriate antiarrhythmics should depend on the individual characteristics of the patient, the types of arrhythmias present, and the properties of the medications. Direct current cardio version is deemed acceptable at any stage of pregnancy, provided there is appropriate fetal monitoring. The management of WPW syndrome during pregnancy necessitates a precise diagnosis and effective treatment based on a multidisciplinary approach among obstetricians, cardiologists, and neonatologists.
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