Introduction

Pregnancy entails a unique physiological state characterized by complex adaptations, including an accelerated maternal metabolism and an approximate 45% expansion in blood volume to meet the escalating demands of placental circulation.1 This augmented blood volume places considerable strain on the cardiovascular system, leading to an elevated heart rate and increased cardiac output.2 Consequently, cardiovascular disease (CVD) has become a primary cause of maternal mortality in Western nations during pregnancy.3 The United States has experienced a dramatic surge in maternal mortality, with rates escalating from 17.4 to 32.9 deaths per 100,000 live births between 2018 and 2021.4 Notably, this period also saw a parallel rise in pregnancy-associated arrhythmias, with an incidence of 67 cases per 100,000 pregnancies,5 suggesting that arrhythmias during pregnancy may be associated with adverse maternal and fetal outcomes.6,7

Arrhythmia, characterized by abnormal electrical activity in the heart, presents in diverse forms, such as excessively rapid, slow, irregular, or premature heartbeats.8 Clinical manifestations span from benign palpitations to severe symptoms like syncope, seizures, or sudden cardiac death.9 Common arrhythmias documented during pregnancy encompass atrial fibrillation, atrial flutter, supraventricular tachycardia, and sinus tachycardia.10,11 These conditions not only imperil maternal health but are also linked to adverse fetal outcomes, including intrauterine growth restriction, preterm birth, and stillbirth.10,12

Progress in diagnostic techniques and therapeutic interventions, alongside the trend of increasing maternal age, has led to a greater incidence of pregnancy-associated arrhythmias.13 Current research has pinpointed specific risk factors, for instance, mitral valve prolapse, which correlates with an increased likelihood of malignant ventricular arrhythmias during the perinatal phase compared to non-pregnant individuals.14,15 The rising occurrence of hereditary arrhythmias further emphasizes the necessity for specialized management approaches during pregnancy, as advancements in genetic testing and treatment options present new avenues for care.16 Despite these advancements, considerable knowledge deficits and inconsistencies in management strategies persist, calling for determining the current hotspots and future frontiers in this field, which can guide researchers in field to optimize identified outcomes in the future.17

Bibliometric analysis offers a potent methodological tool for the systematic assessment of research trends and patterns within a specific discipline. Through the application of mathematical and statistical methods, this type of analysis yields insights into research categories, which can help researchers identify current areas of concern and guide future research trends.18,19 Although such analysis has been conducted on cardiovascular disease (CVD) in gestational diabetes mellitus (GDM) patients,20 regarding arrhythmias in all pregnant women, the existing literature has not yet fully mapped the developmental course, research hotspots, and collaborative networks in this area. This study endeavors to conduct a bibliometric analysis of research on arrhythmias during pregnancy, concentrating on comprehending developmental paths, identifying principal research hotspots, and detecting emerging trends.

Materials and Methods Data Sources and Search Strategies

We performed a systematic literature search within the Web of Science Core Collection (WoSCC) due to its focus on high-quality, globally peer-reviewed academic publications, primarily traditional academic literature, including journal articles, conference proceedings, and books.21 Additionally, the WoSCC database is multidisciplinary and comprehensive, offering a complete citation network and key bibliometric indices (eg, Journal Citation Reports (JCR), impact factor (IF), and H-index).22 Therefore, we selected it to obtain global academic information for bibliometric analysis according to previous studies.23–25 The search query employed was: (TS=(Pregnan* OR gestational)26,27 AND TS=(Arrhythmia* OR Arrythmia OR “Cardiac Dysrhythmia”)).28 The inclusion criteria were: 1) English language; 2) published between January 1, 1996 (the earliest publication year in this field), to July 31, 2025; 3) articles related to arrhythmias during pregnancy meeting the search formula. Additionally, records such as reviews, editorial materials, letters, and meeting abstracts were excluded. To mitigate potential variations arising from database updates, the literature retrieval was conducted on a single day (July 31, 2025). All information was collected in text format, encompassing the number of publications and citations, titles, author information, institutions, countries/regions, keywords, and journals.

Statistical Analysis

Statistical analysis and data visualization were performed utilizing VOSviewer (version 1.6.20), CiteSpace (version 6.3.R1), and the R package “bibliometrix” (version 4.4.1). VOSviewer, a multifaceted software, was instrumental in constructing collaboration networks among institutions, authors, and publications,29 enabling the visualization and examination of intricate academic relationships, including co-authorship, co-citation, and keyword co-occurrence networks. CiteSpace served to identify emerging trends and keyword bursts.30 In the generated visualizations, node size corresponds to publication volume, line thickness signifies relationship strength, and node color indicates publication time, thus illuminating significant research developments chronologically. The “bibliometrix” R package was utilized for trend mapping and ranking analyses, aiding in the assessment of publication and citation patterns across authors, institutions, and countries.31 This package also supported the creation of trend charts and longitudinal examinations of the field’s evolution. Several bibliometric indices, such as the H-index, G-index, and M-index, were applied to gauge the academic influence of authors and journals.32 Furthermore, journals were classified using JCR according to their IF, which reflects the average citations per article, offering insight into their relative prominence in this field.33

Results The Publication Trends

An initial search yielded 1498 studies. Following the exclusion of reviews, meeting abstracts, early access articles, and other non-relevant document types 1042 studies were retained for detailed analysis (Figure 1). These publications involved 5667 authors from 1064 institutions spanning 76 countries and regions. The articles appeared in 400 journals and collectively cited 27,903 references (Figure 2A). A sustained increase was observed from 1996 to 2024, despite intermittent variations, with an annual growth rate of 4.9%. Specifically, publication volume remained relatively constant between 1996 and approximately 2007, with 10 to 25 articles annually. Post-2007, a notable surge occurred, reaching a peak of 78 publications in 2021. This pattern highlights escalating interest and consistent contributions to this research domain (Figure 2B).

Figure 1 Flowchart of data screening process.

Figure 2 (A) Comprehensive overview of arrhythmia in pregnant women. (B) Annual growth of publications on arrhythmia in pregnant women from 1996 to 2025.

Analysis of Leading Countries

As detailed in Table 1, the USA was at the forefront with 300 articles (28.8%), trailed by the United Kingdom (68 articles, 6.5%) and Canada (67 articles, 6.4%). The USA also recorded the highest total citations (TC) at 8919, followed by the United Kingdom (6212) and Germany (3247). United Kingdom distinguished itself with the highest average citations per article (91.4), while Germany and Netherlands also showed high averages (79.2 and 58.3 citations per article, respectively). International collaborations were also evident; the USA had the largest number of multiple-country publications (MCP, n=49), signifying considerable international cooperation, followed by the United Kingdom (n=24) and Canada (n=19) (Table 1 and Figure 3). Among the 69 countries participating in international collaborations, the USA contributed the most collaborative publications (n=269), succeeded by the United Kingdom (215) and the Netherlands (193) (Figure S1).

Table 1 Publication and Citation Profiles of Leading Countries

Figure 3 Distribution of corresponding authors’ publications by country in arrhythmia in pregnant women.

Analysis of Leading Institutions

Figure 4 displays the top 10 most prolific institutions. The University of Toronto headed the list with 95 publications, followed by the University of California system (n=94) and Imperial College London (n=68). A co-authorship analysis was performed to further examine inter-institutional collaboration. Among 91 institutions engaging in international collaborations with at least 6 articles, the University of Toronto demonstrated the highest number of collaborations (link strength=77), followed by Erasmus MC (link strength=60) and University of Amsterdam (link strength=55). This indicates extensive engagement across various countries, fostering knowledge and expertise exchange. The collaboration network also underscored the pivotal role of American and European institutions (Figure S2).

Figure 4 Top 10 institutions by article count and rank in arrhythmia in pregnant women.

Analysis of Authors

Table 2 summarizes that Roos-Hesselink JW was the leading author with 23 publications and an H-index of 19, ranking first in total publications (TP) and H-index. Silversides CK followed with 21 publications (H-index 16), and Pieper PG. with 17 publications (H-index 16). The highest TC were linked to Pieper PG. (6620 citations), followed by Roos-Hesselink JW (TC=3673) and Silversides CK (TC=2198). These researchers are pivotal to the field’s advancement, having made significant contributions to core study areas. Collaborative relationships among 66 researchers with a minimum of 4 articles are depicted in Figure S3. Circle size signifies publication count, and color denotes cluster affiliation. Close collaboration among numerous authors formed a total of 5 clusters. Joglar Jose A. exhibited the highest collaboration levels with other authors (link strength=98), followed by Mital Seema (link strength=97) and Burke Michael A. (link strength=95) (Figure S3).

Table 2 Publication and Citation Profiles of High-Impact Authors

Analysis of Journals

The analyzed articles were disseminated across 400 journals. The American Journal of Cardiology led with 25 total publications (IF = 2.1), followed by the International Journal of Cardiology (n = 22; IF = 3.2) and the Journal of the American College of Cardiology (n = 22; IF = 22.3). Regarding TC, Circulation had the highest count (2625 citations), followed by the Journal of the American College of Cardiology (n = 2085) and the American Journal of Cardiology (n = 1170) (Table 3). The journal co-occurrence network included 68 journals with at least four occurrences. The three journals with the greatest total link strength in this network were European Heart Journal (link strength = 303), Circulation (link strength = 270), and the Journal of the American College of Cardiology (link strength = 198) (Figure S4A). Similarly, the journal coupling network also comprised 68 journals with at least four couplings. In this network, the top three journals by total link strength were the Journal of the American College of Cardiology (link strength = 6803), European Heart Journal (link strength = 5999), and Circulation (link strength = 5286) (Figure S4B).

Table 3 Bibliometric Indicators of High-Impact Journals

Analysis of Keywords

Keyword analysis offers significant insights into research trends and focal areas within this discipline. Larger nodes, for instance “management” (125 occurrences, 364 total link strength), signify terms appearing frequently across numerous studies, emphasizing their core importance. The network also indicated that topics such as “risk” (116 occurrences, 326 total link strength) create interconnected clusters, implying their relevance across a wide array of studies. Color-coding within the network denotes the average publication year, with yellow nodes representing newer research areas. Topics like “outcomes” (86 occurrences, 260 total link strength) and “risk” (116 occurrences, 326 total link strength) have surfaced as more recent investigative focal points (Table 4 and Figure 5).

Table 4 Top 20 Keyword Co-Occurrence Network Analysis

Figure 5 Keyword co-occurrence overlay visualization in arrhythmia in pregnant women.

The keyword burst analysis, shown in Figure 6, pinpointed the top 20 keywords exhibiting the strongest citation bursts, indicative of emerging trends. “Arrhythmias” displayed the most significant citation burst (burst strength = 8.41, 1997–2007). Other keywords with notable citation bursts included “supraventricular tachycardia” (burst strength = 7.13, 1996–2010), “delivery” (burst strength = 5.53, 2016–2018), and “congenital heart disease” (burst strength = 5.35, 2009–2011). These bursts signal shifts in research priorities and the rise of evolving trends. More recent terms, namely “outcome” (burst strength = 5.2, 2019–2021), “long QT syndrome” (LQTS; burst strength = 4.82, 2022–2023), and “cardiovascular disease” (burst strength = 5.33, 2020–2025), have achieved prominence, pointing to significant ongoing advancements in these areas (Figure 6).

Figure 6 Citation burst analysis of keywords on arrhythmia in pregnant women.

Discussion Overall Findings

This bibliometric investigation mapped research trends concerning arrhythmia in pregnant women between 1996 and 2025, offering a panoramic view of publication and citation metrics, leading countries, institutions, journals, and principal research topics. The findings indicate a substantial upturn in academic interest over this period, evidenced by 1042 published documents and an annual growth rate of 4.9%. A notable surge occurred after 2007, suggesting a growing concern on higher risk of arrhythmias during pregnancy.34,35 The study underscored the paramount importance of pregnancy management in arrhythmia-related research, identifying significant contributions from a varied group of authors, institutions, and journals.

Authors, Countries, and Institutions

The data revealed that 5667 authors contributed to this specialty, with a mere 22 documents being single-authored, underscoring the highly collaborative character of this research area. The USA takes precedence in both publication volume and citations, marking its influential role in propelling research in this field. Since 1996, the Heart Rhythm Society (HRS) in the USA has formulated expert consensus documents that have steered clinical practice in managing cardiac arrhythmias. More recently, the newest HRS-led expert consensus statement was compiled in partnership with various authoritative bodies,17 suggesting its robust partnerships with other countries. Other influential countries include the United Kingdom and Canada, both also demonstrating robust international collaborative activities. Furthermore, institutions such as the University of Toronto, the University of California, and Imperial College London emerged as key contributors, are also from these leading countries. These findings highlighted that global and regional partnerships remain essential for advancing specialized research fields.

The examination of leading journals showed that Circulation and the Journal of the American College of Cardiology were the foremost publications, characterized by high impact factors and citation counts. These two journals, associated with the American Heart Association and the American College of Cardiology, respectively, function as crucial platforms for sharing vital findings on arrhythmias and present researchers with significant venues for future submissions.8,36

Keywords and Burst Terms

The analyses of keyword co-occurrence and burst detection provide vital insights into thematic evolution and research trends. “Management” was a frequently occurring term across multiple studies, indicating important gaps in knowledge and areas of uncertainty remain by recent guideline.17 Varied management strategies are warranted based on arrhythmia type. For atrial fibrillation and atrial flutter, rhythm control is generally preferred during pregnancy, often initiated with a beta-blocker.37 If a rate control approach is necessary, an oral beta-blocker is advised. Caution is urged with beta-blockers, class I antiarrhythmic drugs, and sotalol if systemic ventricular function is compromised.38 Concerning ventricular tachycardia, an implantable cardioverter-defibrillator is recommended if an indication arises during gestation.39 For patients with bradyarrhythmias, symptomatic bradycardia management includes repositioning the mother to a left lateral decubitus position. Persistent symptoms may necessitate a temporary pacemaker.38 Notably, the use of antiarrhythmic and anticoagulant therapies during pregnancy remains evidence-poor, largely relying on anecdotal experience due to the exclusion of pregnant populations from clinical trials. This underscores the need for dedicated studies focusing on pregnant patients through observational research, registry analyses, and systematic evidence synthesis, as highlighted by several recent expert consensuses.13,17,40

Citation burst terms over the past five years indicated emerging trends of this field, which were also the frontiers in the future. Keywords with potent citation bursts since 2020, such as “outcome”, “long QT syndrome”, and “cardiovascular disease”, merit specific consideration:

“Outcomes” (2019–2021) emphasized the adverse events of maternal and fetal in managing arrhythmias in pregnant individuals. While procainamide, adenosine, digoxin, and β-blockers are generally deemed safe for pregnant women, comprehensive evidence regarding fetal toxic effects is scarce for most agents.41 Ethical considerations often preclude clinical trials in pregnant women, resulting in a dearth of evidence on the clinical outcomes of these medications during pregnancy. For certain drugs, teratogenicity or other adverse effects are well-established; specifically, β-blocker therapy may potentially lead to fetal growth restriction.42 Consequently, given the typically benign and non-sustained nature of most pregnancy-related arrhythmias, drug therapy might be deferred to minimize adverse fetal outcomes, particularly during the first trimester.

Recent research has increasingly centered on “LQTS” (2022–2023), particularly due to the amplified risks of arrhythmias it presents to pregnant women. Women with inherited LQTS are highly susceptible to life-threatening arrhythmias like Torsades de Pointes, with risk escalating during the postpartum phase.43,44 In women with LQTS, treatment with β-blockers at appropriate doses is recommended throughout pregnancy and the high-risk postnatal period.45 However, data on fetal outcomes in such pregnancies remain limited. Moreover, recent studies indicate a higher incidence of fetal death in LQTS-complicated pregnancies compared to the general population.46 An elevated risk has been noted in maternal LQTS pregnancies versus paternal LQTS pregnancies, suggesting uteroplacental dysfunction secondary to the channelopathy, rather than fetal arrhythmias, as a potential underlying cause.46 While β-blockers are fundamental to LQTS treatment, prior studies suggest their use can result in lower birth weights compared to untreated women. Thus, rigorous monitoring via ultrasound, especially color Doppler assessments of uteroplacental circulation and fetal growth, is advised for pregnant women with LQTS.47

From 2020 to 2025, the term “cardiovascular disease” signifies a wider focus on heart conditions among pregnant women. The prevalence of CVD in this demographic is rising, attributable to better survival rates among women with congenital heart disease and the global trend of pregnancy at older ages.5 Cardiac disease is estimated to complicate about 1–2% of pregnancies.48 CVD is a significant contributor to morbidity and mortality during pregnancy and the postpartum period, responsible for up to 15% of maternal deaths.49 Accumulating evidence has identified distinct sex-specific risk factors associated with reproductive and pregnancy history. These factors are increasingly acknowledged in cardiovascular and obstetrical society guidelines; premature menopause and adverse pregnancy outcomes, in particular, are now recognized as risk-enhancing factors for CVD.38,50 These observations suggest that optimizing the management of cardiac diseases, not solely arrhythmias, is crucial for the health of pregnant women.

Notably, implementing guideline-based arrhythmia management in low-income countries faces significant barriers, including shortages of trained specialists, inadequate infrastructure, and limited access to device and ablative therapies.51 Several key interventions have been proposed by World Heart Federation for these regions: (1) capacity building for frontline healthcare workers in arrhythmia detection, (2) implementation of telemedicine solutions for diagnosis and management, (3) development of tailored training programs for both providers and patients at national levels, and (4) creation of simplified, context-appropriate arrhythmia management guidelines for pregnant women.52

Clinical Implications

Pregnant patients experiencing severe arrhythmias need a multidisciplinary care strategy, which should be in place outlining antepartum, intrapartum, and postpartum care. Notably, cardio-obstetrics is an emerging multidisciplinary subspecialty, with cardiology, maternal fetal medicine, pediatrics, and anesthesia, focused on optimizing outcomes in high-risk pregnancies. This collaborative approach emphasizes precise peripartum planning and communication to ensure optimal maternal and fetal outcomes.7,15

Preconception counseling is essential given that most pregnancy-related arrhythmias develop during the antenatal period.53 Three validated risk stratification systems are currently used to identify high-risk population, such as the CARPREG score (for cardiac disease in pregnancy), ZAHARA score (for congenital heart disease), and the modified WHO (mWHO) classification system.54 Moreover, integrating machine learning and artificial intelligence into diagnostic algorithms will enhance the identification of high-risk individuals during the antenatal period, enabling targeted monitoring.

The treatment of arrhythmias is guided by their etiology and clinical presentation. Patients with hemodynamically significant sustained arrhythmias should receive immediate stabilization with intravenous fluids, medications, or electrical cardioversion. Asymptomatic arrhythmias usually do not warrant therapy unless they pose a serious risk.40

Antiarrhythmic therapy in pregnancy presents multiple safety concerns. The first trimester (especially weeks 5–9) represents the highest risk window for teratogenic effects, making drug avoidance preferable during this phase.55 When drug treatment is essential, practitioners should prescribe the fewest possible medications from those with documented pregnancy safety data. The current evidence has established the side effect profiles of class I through IV antiarrhythmic drugs in pregnancy.40 Additionally, pregnancy-associated arrhythmia management lacks robust evidence, with available data restricted to small observational studies and registry reports (eg, ROPAC) that document existing practices. Systematic research expansion through prospective trials, comprehensive registries, and dedicated funding remains imperative.56

Significance and Limitations

This investigation offers a valuable resource for researchers by delineating key trends, prominent journals, and influential institutions. It facilitates the identification of research hotspots, leading publications, and collaborative opportunities, thereby guiding future research paths in arrhythmia and pregnancy. Furthermore, pinpointing emerging topics and mapping co-occurrence networks enables researchers to remain current with the latest advancements in this vital field.

Nevertheless, this study possesses several limitations. Firstly, like other bibliometric investigations, this study was limited to English-language publications indexed in the WoSCC, which may have introduced linguistic and database bias. As a result, relevant studies published in non-English languages or indexed in other bibliographic platforms may have been overlooked, potentially underrepresenting contributions from non-English-speaking countries. Future research could incorporate multilingual and multi-database strategies to broaden coverage and minimize regional bias. Secondly, exclusion of articles published before the time frame may affect the results, potentially restricting the comprehensiveness of research trends. Lastly, dependence on citation data does not capture the impact of recent studies that, while potentially influential, may not have yet accrued substantial citation counts.

Conclusion

This bibliometric study assessed and analyzed research trends related to arrhythmia in pregnant women through a combination of publication and citation metrics. The analysis illuminated key research domains, such as pregnancy management and clinical outcomes, while also identifying emergent topics like LQTS. This work furnishes valuable insights into the field, providing researchers with direction on potential research hotspots, influential authors, and key journals for subsequent investigation. From a clinical standpoint, the findings emphasize the necessity of refining management strategies for arrhythmias during pregnancy, with significant implications for both maternal and fetal health.

Data Sharing Statement

All data generated or analysed during this study are included in this published article.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Funding

This study was supported by the Natural Scientific Foundations of China (82160061, 82060269) and the Natural Scientific Foundations of Jiangxi (20202BABL216059).

Disclosure

The authors declare that they have no conflicts of interest related to this study.

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