A Case Report and Review of Postural Orthostatic Tachycardia Syndrome in Pregnancy

Abstract

Purpose Postural orthostatic tachycardia syndrome (POTS) is a form of orthostatic intolerance characterized by an increased heart rate upon transition from supine to standing, and head-up tilt without orthostatic hypotension. Its etiology is multifactorial, and no clear cause has been identified. Common symptoms include light-headedness, blurred vision, weakness, cognitive difficulties, and fatigue and are often accompanied by palpitations, shortness of breath, syncope, or gastrointestinal symptoms. Management includes volume expansion, physical counter maneuvers, and pharmacological agents such as fludrocortisone, midodrine, propranolol, and pyridostigmine. The course of POTS in pregnancy is variable and POTS has not been directly implicated in any adverse outcomes for the mother or fetus. Methods Two cases of POTS in pregnancy are presented, along with a review of the literature for reports of POTS in pregnancy. Results Along with our 2 cases, 10 other case reports were identified and included. Conclusion The course of POTS in pregnancy is variable, and not directly linked to increase perinatal morbidity or mortality. Women can safely undergo regional anesthesia, and vaginal delivery with close monitoring of hemodynamic changes.

Postural tachycardia syndrome and pregnancy

“…It is also possible that PoTS may present for the first time in pregnancy in which case diagnosis may be difficult, as pregnancy itself may induce similar symptoms . Diagnosis should be made based on a thorough and careful history and the presence of the normal criteria for PoTS for 6 months duration or longer . It should be noted that the tilt table test, an investigation commonly used in the diagnosis of PoTS, is generally contraindicated in pregnancy; a stand test may be undertaken instead.…”

“…The management of PoTS is challenging and requires a case‐by‐case approach. The general principles include initially treating reversible causes, blood volume expansion, physical manoeuvres, medication and cognitive behaviour therapy …”

“…Data from older studies of hypertension in which high doses were used throughout pregnancy show an association with intrauterine growth restriction, hypoglycaemia and fetal bradycardia . The effect appears to be dose dependent and low or standard doses of propranolol, as is recommended for PoTS, are not associated with adverse effects in pregnancy . However, the effect of lower maternal blood pressure may be the cause of fetal growth restriction …”

“…Given its vasoconstrictive properties it should be used with caution due to the increased risk for fetal vascular insults (e.g. gastroschisis) …”

“…The general principles include initially treating reversible causes, blood volume expansion, physical manoeuvres, medication and cognitive behaviour therapy. 19 The mainstay of conservative treatment for PoTS is increased fluid (2-3 l per day) and salt intake (up to 10-12 g per day), which is aimed at increasing circulating plasma volume and clinical symptom improvement. 3,20 Other conservative strategies include physical manoeuvres such as making a fist, bending forward, placing a foot on a chair and pumping calves before standing.…”