An Unusual Case of Ventricular Fibrillation Arrest During Pregnancy

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Journal of General Internal Medicine



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LEARNING OBJECTIVE #1: Evaluate potential causes of ventricular tachycardia in pregnancy. LEARNING OBJECTIVE #2: Identify appropriate indications for ICD placement. CASE: Patient is 23 yo G3P0112 female at 36 weeks’ gestation with history of tobacco use during pregnancy, prior meth use, and no known cardiac disease, who presented with ventricular fibrillation [VF] cardiac arrest after a syncopal event with no seizure activity. Per EMS, patient’s rhythm showed sustained monomorphic ventricular tachycardia prior to becoming VF; she was resuscitated after 10 minutes of life-saving measures. On arrival, she underwent emergent C-section with delivery of twins, one of whom later expired. Initial EKG showed sinus tachycardia with global ischemia and prolonged QT at 570 ms. Initial echocardiogram had reduced ejection fraction at 40%, with no wall motion or valvular abnormality; repeat echo later showed normal systolic function. QT interval on repeat EKG was normal at 360 ms. Stroke workup was negative. Due to unknown etiology of VF, patient underwent left heart catheterization, which showed no coronary artery disease, and implantable cardioverter-defibrillator placement. She was medically optimized and discharged with follow-up. IMPACT/DISCUSSION: Ventricular tachycardia [VT] in pregnancy is often seen in structural heart disease, including hypertrophic cardiomyopathy, congenital, or valvular heart disease—all negative in our patient, who had no personal or family history of cardiac disease or early death. Her recovered LV systolic function and normal RV also ruled out peripartum cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy, respectively. Finally, as left heart cath eliminated ischemia or spontaneous coronary artery dissection with reperfusion, our patient’s VF was thought to be due to primary electrical disease, including Brugada syndrome or catecholaminergic polymorphic ventricular tachycardia [CPVT]. Her initial QT of 570 ms suggested long QT syndrome as an etiology, but this later normalized. Patient lacked history of syncope prior to this event. In retrospective studies of women with Brugada syndrome (104 women) or CPVT (96 women), 6% and 5% of women, respectively, had recurrent syncope during pregnancy. While understudied, one of these electrical diseases may have precipitated her arrest. As an exact cause was unidentifiable, patient underwent ICD placement to prevent cardiac death. Also of note, patient was unwilling to share extent of prior meth use or tobacco use, however these substances likely contributed to her adverse outcomes. Animal studies have shown tobacco use to induce arrhythmia; meanwhile, meth is known to induce cardiomyopathy and a retrospective study showed that up to 72% of meth users have EKG abnormalities including arrhythmias and prolonged QT. CONCLUSION: In evaluating etiologies of VF, a detailed history remains crucial, even if not directly revealing as in our case. When no reversible cause of VT or VF is identified, ICD placement is indicated for secondary prevention of sudden cardiac death.


Cardiovascular System | Internal Medicine | Maternal and Child Health



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