Peri-operative management of a pregnant patient with hereditary angioedema submitted to a cesarean-section: case report / Abordagem perioperatória de grávida com angioedema hereditário submetida a cesariana: relato de caso

Abstract Hereditary angioedema is an autosomal dominant disorder, presenting as sudden and recurring episodes of variable severity of subcutaneous and mucosa edema that may occur spontaneously or in response to triggers. There are three knwon types of hereditary angioedema. The disorder is caused by decrease in the plasma level or change in the functional capacity of C1 inhibitor, with increase in bradykinin and in vascular permeability, and consequent edema. Several measures are required in the perioperative period in order to avoid an acute attack. Prophylaxis should be carried out throughout pregnancy before any surgical procedure, before dental procedures, upon airway handling, on patients with previous episodes of angioedema, and when there are significant changes in volemia. The literature is scarce in regard to the association between hereditary angioedema and pregnancy. We describe a successful case of a pregnant patient with type I hereditary angioedema submitted to a C-section.

Resumo O angioedema hereditário é uma doença autossômica dominante, que se manifesta por crises súbitas, recorrentes e de gravidade variável de edema subcutâneo e submucoso, que podem ocorrer espontaneamente ou em resposta a gatilhos. São conhecidos três tipos de angioedema hereditário. A doença é condicionada por diminuição do nível plasmático ou alteração da capacidade funcional do inibidor de C1, com aumento da bradicinina e da permeabilidade vascular, com consequente edema. Várias medidas devem ser tomadas no período perioperatório de forma a evitar uma crise aguda. A profilaxia deverá ser realizada durante a gravidez antes de qualquer procedimento cirúrgico, antes de procedimentos dentários, quando existe manuseamento da via aérea, nos doentes com episódios prévios de angioedema e quando há alterações significativas da volemia. A literatura é escassa no que que diz respeito à associação de angioedema hereditário e gravidez. Descrevemos um caso de sucesso de uma grávida com angioedema hereditário tipo I submetida a cesariana.

Síndrome de Eisenmenger en una paciente embarazada de 21 años / Eisenmenger syndrome in 21-year pregnant patient

Resumen ANTECEDENTES El síndrome de Eisenmenger es la cardiopatía congénita con mayor riesgo de mortalidad de las embarazadas. CASO CLÍNICO: Paciente primigesta de 21 años, con síndrome de Eisenmenger e insuficiencia cardiaca grado III NYHA e hipertensión arterial sistémica. El embarazo se interrumpió mediante cesárea a las 30 semanas, con recién nacido vivo de 1000 g, Apgar 3-7, 32 semanas de gestación por Capurro. Seis días después de la cesárea la paciente falleció debido a choque cardiogénico. El neonato falleció de insuficiencia respiratoria el décimo segundo día de vida extrauterina. CONCLUSIONES El caso aquí descrito permite reflexionar acerca de las oportunidades de mejora en la atención de las pacientes con síndrome de Eisenmenger. En el primer nivel de atención es importante centrarse en la educación y consejería específicas que permitan comprender a la paciente y su pareja los riesgos implícitos de su afección, pues la alternativa más segura hubiera sido evitar el embarazo. En el segundo nivel de atención ha de favorecerse siempre la práctica basada en evidencia y correcta coordinación en los equipos de salud que, en este caso particular, hubiera permitido que la paciente desde la semana 14 hubiera sido referida para atención altamente especializada que hubiese podido incrementar las probabilidades de supervivencia de ella y el neonato.

Abstract BACKGROUND Eisenmenger syndrome is congenital heart disease with a higher risk of mortality for pregnant women. CLINICAL CASE 21-years women with Eisenmenger syndrome, whose pregnancy was accompanied by class III NYHA heart failure and systemic arterial hypertension. Pregnancy was interrupted at 30 weeks by caesarean section. Six days after the caesarean section, the patient died due to cardiogenic shock. CONCLUSIONS The case described here allows us to reflect on the opportunities for improvement in the care of patients with Eisenmenger syndrome. At the first level of care, it is important to focus on specific education and counseling that allows the patient and her partner to understand the implicit risks of their condition, since the safest alternative would have been to avoid pregnancy. At the second level of care, the practice based on evidence and correct coordination in the health teams should always be favored, which in this particular case would have allowed the patient, since week 14, to have been referred for highly specialized care could increase the chances of survival of her and the neonate.

Pregnancy is a unique time in a woman’s life and is characterized by complex physiological changes affecting general oral health. Pregnancy is also an opportune time to educate women about preventing dental caries in young children, a common childhood problem. This article reviews physiological changes associated with pregnancy and general considerations for the dental treatment of pregnant dental patients as well as for pregnant dental professionals. The limitations and uses of drugs are also discussed.

Pregnancy is a unique time in a woman’s life and is characterized by complex physiological changes affecting general oral health. Pregnancy is also an opportune time to educate women about preventing dental caries in young children, a common childhood problem. This article reviews physiological changes associated with pregnancy and general considerations for the dental treatment of pregnant dental patients as well as for pregnant dental professionals. The limitations and uses of drugs are also discussed.

Pitfalls and Red Flags in Common Clinical Syndromes

Awareness of pitfalls in common clinical symptoms is important. Not all patients with ACS presents with chest pains (beware of patients presenting with syncope, diaphoresis, dyspnoea, pain upper back, etc.). In a breathless patient, anxiety and other psychiatric conditions should only be considered as the diagnosis after careful exclusion of other life threatening causes: metabolic acidosis, partially occluded upper airway, bronchospasm, and pulmonary embolism. In a patient with headaches, intracranial haemorrhage, meningitis/ encephalitis, and brain mass lesion need to be considered in the differential diagnosis. The elderly patient presenting with acute abdominal pain will require FPs to maintain a high index of suspicion for potential life threatening causes. Possible causes of serious backache are ACS, AD, AAA, and spinal cord compression. In the wounded patient, there is a need to determine the medical condition that may have resulted in the patient’s injury, and patient’s risk profile is as important as the wound profile for correct management. In the pregnant patient, dyspnea can be due to pulmonary embolism, or heart failure; placenta abruption from abdominal injury may not have the classical triad of pain, tenderness or vaginal bleeding.

Pitfalls and Red Flags in Common Clinical Syndromes

Awareness of pitfalls in common clinical symptoms is important. Not all patients with ACS presents with chest pains (beware of patients presenting with syncope, diaphoresis, dyspnoea, pain upper back, etc.). In a breathless patient, anxiety and other psychiatric conditions should only be considered as the diagnosis after careful exclusion of other life threatening causes: metabolic acidosis, partially occluded upper airway, bronchospasm, and pulmonary embolism. In a patient with headaches, intracranial haemorrhage, meningitis/ encephalitis, and brain mass lesion need to be considered in the differential diagnosis. The elderly patient presenting with acute abdominal pain will require FPs to maintain a high index of suspicion for potential life threatening causes. Possible causes of serious backache are ACS, AD, AAA, and spinal cord compression. In the wounded patient, there is a need to determine the medical condition that may have resulted in the patient’s injury, and patient’s risk profile is as important as the wound profile for correct management. In the pregnant patient, dyspnea can be due to pulmonary embolism, or heart failure; placenta abruption from abdominal injury may not have the classical triad of pain, tenderness or vaginal bleeding.

Sistema on-line para o cálculo de doses fetais de pacientes e trabalhadoras ocupacionalmente expostas em radiologia diagnóstica / On-line software for the estimation of fetal radiation dose to patients and staff members in diagnostic radiology

Neste trabalho descrevemos um sistema on-line, chamado “Dose Fetal Web”, que calcula a dose fetal e os riscos radiológicos devido a exposições clínicas ou ocupacionais de gestantes. O sistema utiliza a metodologia matemática onde são usados coeficientes de conversão de dose uterina para dose fetal, gerados por meio de simulações pelo método de Monte Carlo. Para exposição médica de uma paciente gestante, uma base de dados de informações de operação de equipamentos acompanhados por um programa de garantia de qualidade e parâmetros fetais e maternos coletados durante exames de ultrassonografia obstétrica são incorporados na estimativa da dose fetal. No caso de dose fetal de uma trabalhadora gestante sujeita à exposição ocupacional (IOE),informações de uma base de dados de monitoração pessoal como dose ocupacional e carga de trabalho são usadas nos cálculos. No primeiro caso, considerando-se uma paciente gestante de 26 semanas submetida a um procedimento abdominal AP (tensão aplicada ao tubo de 70 kVp e filtração total de 3 mmAl), a dose fetal calculada pelo sistema foi 4,61 mGy e os riscos radiológicos obtidos foram 5,0·10-4 e 0,14 para a probabilidade de indução de retardamento mental e declínio de pontos de QI, respectivamente. No segundo caso, considerando-se uma IOE gestante, e assumindo-se que ela utilize um avental de proteção de 0,5 mm de equivalência em chumbo durante cada procedimento de radiologia intervencionista, e que a leitura pessoal de um dosímetro TLD portado fora do avental foi de 2 mGy/mês, a dose fetal calculada pelo sistema foi 0,02 mSv/mês.

In this paper we describe an online software, named “Dose Fetal Web”, which calculates the dose of the fetus and the radiological risks from both medical and occupational exposures of pregnant women. The software uses a mathematical methodology where coefficients for converting uterus to fetal dose, NUD, have been calculated by using Monte Carlo simulation. In the fetal dose from diagnostic medical examination of the pregnant patient, database information regarding output and other equipment related parameters from the QA database, maternal and fetal parameters collected by ultrasound procedures were used for the fetal dose estimation. In the case of fetal dose of the pregnant staff member the database information regarding routine individual monitoring dosimetry, such as occupational dose and workload, were used for the estimation. In the first case, suppose a 26 weeks pregnant patient had to undergo a single AP Abdomen procedure (70 kVp peak tube voltage and total filtration 3 mmAl), the fetal dose calculated by the software was 4.61 mGy and the radiological risks would be 5.0·10-4 and 0.14 to the probability of mental retardation induction and decline in the IQ score, respectively. In the second case,considering that the staff member can be pregnant, and assuming that she wore a 0.5 mm lead equivalent apron during every interventional radiology procedure and a personal dosimetry reading of 2 mGyTLD/month measured with the TLDs outside the apron, the fetal dose calculated by the software was 0.02 mSv/month.