Ultrasound Obstet Gynecol 2006; 28: 117–119 Published online in Wiley InterScience (www.interscience.wiley.com). Letters to the Editor Flecainide treatment of fetal tachycardia and hydrops fetalis in a twin pregnancy Fetal supraventricular tachycardia (SVT) is a rare complication of pregnancy leading, in some cases, to cardiac failure and intrauterine fetal death. Digoxin is a safe and successful treatment for SVT and can be considered as the first-line choice in singleton and multiple pregnancies in which one of the fetuses presents with SVT 1,2 . Other well-known drugs used for this indication are flecainide 3 and amiodarone. Clinical and biochemical fetal hypothyroidism has been associated with the use of amiodarone 1 . In a multiple pregnancy, a triplet with two healthy fetuses and one affected fetus was successfully treated with digoxin and no adverse effects were reported, neither in the mother nor in the healthy fetuses 4 . No cases so far have been reported describing the treatment with flecainide in a multiple gestation. A 39-year-old patient, gravida 2 para 1, was admit- ted with a diagnosis of fetal tachycardia in one fetus of a dichorionic, diamniotic twin pregnancy at 21 weeks’ gestation. During a systematic fetal ultrasound examina- tion, tachycardia at a rate of 210–230 bpm with fetal hydrops was detected in one of the fetuses. With M-mode evaluation of the fetal heart a diagnosis of SVT was made. An initial treatment was started with digoxin 1000 μg intravenously in four doses over 24 h. Maternal biochem- ical parameters and electrocardiograms were monitored. The treatment was continued for 3 days but fetal car- dioversion was not achieved. The patient was then given oral flecainide, 300 mg daily divided in three doses. After 24 h the fetal heart rate was monitored and a sinus rhythm at a rate of 150 bpm was observed. The therapy was maintained until delivery and no other abnormali- ties of the cardiac rhythm were demonstrated. Hydrops resolved completely within 2 weeks of the cardioversion. Due to premature rupture of membranes and a breech pre- sentation, at 31 weeks’ gestation a Cesarean section was performed. No hydrops was detected and both newborns were healthy. The mother was discharged after 4 days and the neonates were followed in neonatal intensive care for 9 days. During this period, daily electrocardiograms (ECGs) were within normal limits as were subsequent ECGs performed intermittently for the first 2 years. Flecainide has been described as a highly effective medication even in hydropic fetuses, working quickly and efficiently because it crosses the placenta rapidly, reaching 80% of the maternal serum levels 5 . Fetal death with flecainide treatment has been reported and several concerns have been raised about the possible maternal drug-induced proarrhythmias 6 . We decided to administer flecainide, despite the possible serious side-effects for the fetus because we balanced this risk against the progressive cardiac insufficiency (manifested as hydrops) which would have led to intrauterine death. We did not consider administering flecainide with digoxin because of the high inotropic effect of the latter and the possible myocardial hypoxia, although successful treatment with digoxin and flecainide has been described in a single fetus affected at 13 weeks of gestation 7 . To our knowledge this is the first case describing the effective treatment with flecainide alone of a single hydropic fetus with SVT in a twin pregnancy. S. Gerli, G. Clerici, A. Mattei and G. C. Di Renzo Centre of Reproductive and Perinatal Medicine, Department of Medical-Surgical Specialties and Public Health, University of Perugia, Policlinico Monteluce, 06122 Perugia, Italy *Correspondence. (e-mail: gerber@unipg.it) DOI: 10.1002/uog.2808 Published online 30 May 2006 References 1. Cuneo BF, Strasburger JF. Management strategy for fetal tachycardia. Obstet Gynecol 2000; 96: 575–581. 2. Simpson JM, Sharland GK. Fetal tachycardias: management and outcome of 127 consecutive cases. Heart 1998; 79: 576–581. 3. Krapp M, Baschat AA, Gembruch U, Geipel A, Germer U. Flecainide in the intrauterine treatment of fetal supraventricular tachycardia. Ultrasound Obstet Gynecol 2002; 19: 158–164. 4. Jones LM, Garmel SH. Successful digoxin therapy of fetal supraventricular tachycardia in a triplet pregnancy. Obstet Gynecol 2001; 98: 921–923. 5. Allan LD, Chita SK, Sharland GK, Maxwell D, Priestley K. Flecainide in the treatment of fetal tachycardias. Br Heart J 1991; 65: 46–48. 6. Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL, Huther ML, Richardson DW, CAST Investigators. Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial. N Engl J Med 1991; 324: 781–788. 7. Porat S, Anteby EY, Hamani Y, Yagel S. Fetal supraventricular tachycardia diagnosed and treated at 13 weeks of gestation: a case report. Ultrasound Obstet Gynecol 2003; 21: 302–305. In-utero pericardiocentesis to treat fetal hydrops caused by X-linked chronic granulomatous disease A 17-year-old primigravid woman, with a previously uncomplicated pregnancy, presented to her local hospital with abdominal discomfort and was referred to our center at 33 weeks’ gestation with polyhydramnios and generalized fetal hydrops. She had recently been identified as an asymptomatic carrier of X-linked chronic Copyright  2006 ISUOG. Published by John Wiley & Sons, Ltd. LETTERS TO THE EDITOR