Approach to therapy of fetal tachyarrhythmias

Gestational age	Rate (beats/minute)	Persistence	Hydrops	Therapy sequence
≥37 weeks	200 to 220	Low or Moderate	No	Observe Aim for term delivery
		Incessant	No	Maternal transfer to pediatric cardiac center
	>220 to 240	Low	No	Consider digoxin (outpatient regimen)
		Moderate or Incessant	No	Maternal referral to pediatric cardiac center Consider trial of flecainide
	>200	Any	Yes	Prompt referral to pediatric cardiac center Anticipate delivery
<37 weeks	200 to 220	Low or Moderate	No	Observe Aim for term delivery Trial of digoxin (outpatient regimen) reasonable Delivery at a pediatric cardiac center may be preferred
		Incessant	No	Referral to pediatric cardiac center Brief trial of digoxin reasonable May require flecainide/sotalol
	>220 to 240	Low	No	Consider digoxin (outpatient regimen) Incomplete control acceptable
		Moderate or Incessant	No	Referral to pediatric cardiac center Brief trial of digoxin reasonable May require flecainide/sotalol
	>200	Any	Yes	Prompt referral to pediatric cardiac center Brief or no trial of digoxin Flecainide or sotalol
		Any	Yes and preeclampsia	Delivery

Persistence refers to the amount of time that the fetus is in the arrhythmia: Low (<25%), moderate (25 to 50%), incessant (>50%).

Courtesy of Mark Alexander, MD, and Jami Levine, MD.

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