Case report :
A 22-year-old primigravida was referred for fetal echocardiography at 24 weeks gestation in view of suspicion of Fetal tachyarrhymia on screening. The 4-chamber view showed moderate pericardial effusion, hyperechoic endocardium, papillary muscles and both atrioventricular valve annuli. (Figure 1A&B) The heart was otherwise structurally normal. There was ventricular diastolic dysfunction as evident in the left ventricle inflow- outflow Doppler (Presystolic flow in ascending aorta) [Figure 2A&B] with no atrioventricular valve regurgitation.
Left ventricle inflow-outflow Doppler showed periods of fetal sinus bradycardia (Figure 3) alternating with frequent conducted atrial ectopics (Figure 4) triggering episodic atrial tachyarrhythmia.(Figure 5) . Left brachicephalic vein-aorta Doppler showed the beginning (Figure 6) and termination of the tachyarrhythmia(Figure 7). It was a 1:1 long VA tachyarrhythmia (VA interval 175ms ; AV interval 92ms) triggered by an atrial ectopic and spontaneously terminating with V. (Figure 8) Hence a diagnosis of tachy-bradycardia syndrome secondary to atrial, sinoatrial node and atrioventricular node disease with preserved conductivity was made. There was no evidence of atrioventricular block. Maternal serum SSA and SSB antibody levels were 145 U (normal <20) and 181 U (normal <20) respectively. In-utero course : Transplacental therapy with oral dexamethasone at a dose of 4mg/day was given initially for 7 days. Reassessment after one week showed absent pericardial effusion and improved ventricular diastolic function. However fetal bradycardia, conducted atrial ectopics and episodic atrial tachycardia persisted. Hence oral dexamethasone dose was increased to 8mg/day. Reassessment after a week showed no improvement. The parents decided for termination of pregnancy.