Management of gestational supraventricular tachycardia with a ‘modified’ modified Valsalva manoeuvre

•The Valsalva manoeuvre can be optimised at baseline by including a period of supination &wirh with passive leg raise following forceful exhalation as described in the REVERT trial.•Supine positioning as described in the REVERT trial may be physiologically contraindicated in pregnancy due to the risk of uterine compression of the vena cava.•The modification of the REVERT technique to include left lateral pelvic tilt may be an effective means of adapting the procedure to fit the physiological challenges associated with pregnancy. A 36 year old woman with chest pain and palpitations at 34 weeks gestation (gravidity 2, parity 1) presented to the emergency department where she was found to be in supraventricular tachycardia (SVT). This patient had an earlier episode of SVT during the same pregnancy that was managed with intravenous adenosine. During both presentations a REVERT trial style ‘modified’ Valsalva manoeuvre (including supine positioning with passive leg raise) was attempted without success. Acknowledging the potential for vena caval compression in pregnant patients while in the Trendelenburg position, the same manoeuvre was attempted with the novel additional of 45 degree left pelvic tilt. This ‘modified’ modified Valsalva was successful in restoring sinus rhythm, suggesting this technique may warrant further investigation as a viable treatment for pregnant patients with hemodynamically stable SVT.