Miocardiopatía periparto: revisión de la literatura / Peripartum Cardiomyopathy

Resumen: La Miocardiopatía Periparto es una patología que se presenta como una insuficiencia cardíaca aguda que aparece en el último mes del embarazo o los primeros 5 meses post parto, en ausencia de otra causa identificable. A pesar de ser más frecuente en países Afrodescendientes, el efecto migratorio ha provocado un aumento en su incidencia en los países de América latina, influyendo en la morbimortalidad materna. Si bien su etiología aún no está claramente definida, se han propuesto algunos mecanismos como el aumento del estrés oxidativo, el desequilibrio de la angiogénesis y las reacciones inflamatorias que, en un organismo genéticamente predispuesto, podrían ser los desencadenantes de esta enfermedad. Su manejo aún se considera de soporte, pero se sigue investigando en alternativas terapéuticas que puedan mejorar los resultados a largo plazo. Así, el motivo de esta revisión es evaluar la evidencia disponible hasta el momento, para el enfrentamiento del equipo tratante de estas pacientes.

Abstract: Peripartum Cardiomyopathy is a diseae presenting as acute heart failure that appears in the last month of pregnancy or within 5 months postpartum, in the absence of other identifiable cause. Despite being more frequent in Afro-descendant populations, the migratory effect has caused an increase in its incidence in Latin American countries, influencing maternal morbidity and mortality. Although its etiology is not yet defined, some mechanisms have been proposed such as increased oxidative stress, angiogénesis imbalance and inflammatory reactions that in a genetically predisposed organism, could be the triggers of this disease. Supportive therapy is still the initial management. Therapeutical alternatives that are still being investigated. The main purpose of this review is to evaluate the evidence available to improve the prognosis of the disease.

Conocimiento de los médicos generales sobre complicaciones obstétricas asociadas a riesgo cardiovascular subsecuente / General practitioners’ knowledge about pregnancy complications associated with long-term cardiovascular risk

Resumen Introducción: La enfermedad cardiovascular (ECV) constituye la principal causa de mortalidad en mujeres; la preeclampsia (PE) y la diabetes mellitus gestacional (DMG) están asociadas a incremento en el riesgo de ECV. Objetivo: Evaluar el conocimiento de los médicos generales (MG) sobre complicaciones obstétricas asociadas a ECV. Métodos: Se envió a los MG un cuestionario electrónico anónimo basado en casos, diseñado para evaluar el entendimiento de la influencia de la historia obstétrica en el riesgo cardiovascular a largo plazo y el conocimiento general sobre riesgo de ECV. Resultados: La tasa de respuesta fue de 35 % (161/465). Los participantes reconocieron que la PE y la DMG son factores de riesgo para ECV (98 y 83 %, respectivamente) y reportaron las siguientes estrategias de tamizaje de ECV en mujeres con historial de PE y DMG: monitoreo de presión arterial (PE 100 %, DMG 46 %), cálculo de índice de masa corporal (PE 68 %, DMG 57 %), evaluación del perfil de lípidos (PE 71 %, DMG 57 %), hemoglobina glucosilada (PE 26 %, DMG 92 %) y glucosa en ayuno (PE 28 %, DMG 91 %). Conclusión: Las estrategias de tamizaje para identificar ECV en mujeres con antecedentes de PE y DMG reportadas por los MG fueron variables.

Abstract Introduction: Cardiovascular disease (CVD) is the leading cause of mortality in women; preeclampsia (PE) and gestational diabetes mellitus (GDM) are associated with an increased risk of CVD. Objective: To evaluate general practitioners (GP) knowledge about complicated pregnancies and their association with CVD. Methods: An anonymous case-based electronic questionnaire designed to assess the level of understanding on the influence of a history of pregnancy complications on long-term cardiovascular risk and general knowledge about CVD risk was sent to GPs. Results: The response rate was 35 % (161/465). The participants recognized that PE and GDM are risk factors for CVD (98 and 83 %, respectively), and reported the following CVD screening strategies in women with a history of PE and GDM: blood pressure monitoring (PE 100 %, GDM 46 %), body mass index calculation (PE 68 %, GDM 57 %), lipid profile evaluation (PE 71 %, GDM 57 %), glycated hemoglobin (PE 26 %, GDM 92 %), and fasting glucose (PE 28 %, GDM 91 %). Conclusion: GP-reported screening strategies to identify CVD in women with a history of PE and GDM were variable.

Enfermedades cardio-metabólicas en el embarazo: revisión sobre diagnóstico, tratamiento y proyección del riesgo cardiovascular a largo plazo / Cardio-metabolic diseases in pregnancy: a review on diagnosis, treatment and projection of long-term cardiovascular risk

Las enfermedades cardiovasculares representan la mayor causa de morbimortalidad a nivel mundial. Si bien presenta un descenso en la población general, en las mujeres tiende a mantenerse estable la prevalencia de enfermedad coronaria. Varios factores propios de la mujer predisponen a que esto ocurra, incluyendo el embarazo, mediado tanto por los cambios hematológicos y cardiovasculares característicos de la gestación; como por patologías asociadas, principalmente trastornos hipertensivos del embarazo y diabetes gestacional. Su presencia se ha asociado fuertemente a la aparición a futuro de otras patologías de alto riesgo cardiovascular como hipertensión crónica, dislipidemia y diabetes mellitus. Dado el impacto que esto representa, se hace imperante la identificación de grupos de alto riesgo y la implementación de medidas preventivas, así como de diagnóstico precoz y tratamientos adecuados con el fin de disminuir complicaciones materno-fetales en las etapas perinatal y posparto.

Cardiovascular disease is the leading cause of morbidity and mortality worldwide. Although there is a decrease in general population, the prevalence of coronary heart disease remains stable in women. Several factors typical of womenkind predispose to cardiovascular disease, including pregnancy, mediated by hematological and cardiovascular changes characteristic of it; and by associated pathologies, mainly hypertensive disorders and diabetes. The presence of these diseases has been strongly associated with future presence of other conditions of high cardiovascular risk such as chronic hypertension, dyslipidemia and diabetes mellitus. Given this impact, the identification of high-risk groups and the implementation of preventive measures, as well as early diagnosis and adequate treatment in order to reduce both maternal and fetal complications in perinatal and postpartum stages becomes imperative.

Pregnancy in Women with Complex Congenital Heart Disease. A Constant Challenge / Gravidez em Portadoras de Cardiopatias Congênitas Complexas: Um Constante Desafio

Abstract Background: The improvement in surgical techniques has contributed to an increasing number of childbearing women with complex congenital heart disease (CCC). However, adequate counseling about pregnancy in this situation is uncertain, due to a wide variety of residual cardiac lesions. Objectives: To evaluate fetal and maternal outcomes in pregnant women with CCC and to analyze the predictive variables of prognosis. Methods: During 10 years we followed 435 consecutive pregnancies in patients (pts) with congenital heart disease. Among of them, we selected 42 pregnancies in 40 (mean age of 25.5 ± 4.5 years) pts with CCC, who had been advised against pregnancy. The distribution of underlying cardiac lesions were: D-Transposition of the great arteries, pulmonary atresia, tricuspid atresia, single ventricle, double-outlet ventricle and truncus arteriosus. The surgical procedures performed before gestation were: Fontan, Jatene, Rastelli, Senning, Mustard and other surgical techniques, including Blalock, Taussing, and Glenn. Eight (20,0%) pts did not have previous surgery. Nineteen 19 (47.5%) pts had hypoxemia. The clinical follow-up protocol included oxygen saturation recording, hemoglobin and hematocrit values; medication adjustment to pregnancy, anticoagulation use, when necessary, and hospitalization from 28 weeks, in severe cases. The statistical significance level considered was p < 0.05. Results: Only seventeen (40.5%) pregnancies had maternal and fetal uneventful courses. There were 13 (30.9%) maternal complications, two (4.7%) maternal deaths due to hemorrhage pos-partum and severe pre-eclampsia, both of them in women with hypoxemia. There were 7 (16.6%) stillbirths and 17 (40.5%) premature babies. Congenital heart disease was identified in two (4.1%) infants. Maternal and fetal complications were higher (p < 0.05) in women with hypoxemia. Conclusions: Pregnancy in women with CCC was associated to high maternal and offspring risks. Hypoxemia was a predictive variable of poor maternal and fetal outcomes. Women with CCC should be advised against pregnancy, even when treated in specialized care centers.

Resumo Fundamento: A contínua habilidade na conduta das cardiopatias congênitas complexas (CCC) tem permitido o alcance da idade fértil. Contudo, a heterogeneidade das lesões cardíacas na idade adulta limita a estimativa do prognóstico da gravidez. Objetivo: Estudar a evolução materno-fetal das gestantes portadoras de CCC e analisar as variáveis presumíveis de prognóstico. Método: No período de 10 anos, 435 gestantes portadoras de cardiopatias congênitas foram consecutivamente incluídas no Registro do Instituto do Coração (Registro-InCor). Dentre elas, foram selecionadas 42 gestações em 40 mulheres com CCC (24,5 ± 3,4 anos) que haviam sido desaconselhadas a engravidar. As cardiopatias de base distribuíram-se em: transposição das grandes artérias, atresia pulmonar, atresia tricúspide, ventrículo único, dupla via de saída de ventrículo direito, dupla via de entrada de ventrículo esquerdo e outras lesões estruturais. As cirurgias realizadas foram Rastelli, Fontan, Jatene, Senning, Mustard e outros procedimentos combinados, como tunelização, Blalock Taussing e Glenn. Oito pacientes (20%) não haviam sido operadas, e 19 (47,5%) apresentavam hipoxemia. O protocolo de atendimento incluiu: registro da saturação de oxigênio, hemoglobina sérica, hematócrito, ajuste das medicações, anticoagulação individualizada e hospitalização a partir de 28 semanas de gestação, em face da gravidade do quadro clínico e obstétrico. Na análise estatística, o nível de significância adotado foi de 0,05. Resultado: Somente 17 gestações (40,5%) não tiveram complicações maternas nem fetais. Houve 13 problemas maternos (30,9%) e 2 mortes (4,7%) causadas por hemorragia pós-parto e pré-eclâmpsia grave, ambas em pacientes que apresentavam hipoxemia. Houve 7 perdas fetais (16,6%), 17 bebês prematuros (40,5%) e 2 recém-nascidos (4,7%) com cardiopatia congênita. As complicações materno-fetais foram significativamente maiores em pacientes que apresentavam hipoxemia (p < 0,05). Conclusão: O alcance da idade reprodutiva em pacientes com CCC é crescente; contudo, a má evolução materno-fetal desaconselha a gravidez, particularmente nas pacientes que apresentam hipoxemia.

Ruptured renal artery aneurysm in a pregnant woman: case report and literature review / Ruptura de aneurisma de artéria renal em gestante: relato de caso e revisão da literatura

Abstract Renal artery aneurysms (RAAs) are rare and usually asymptomatic; ~ 90% of them are unilateral. Once diagnosed during pregnancy, they may rupture, presenting a high maternal-fetal risk. The present study reports the case of a 32-year-old pregnant woman with a 30-week gestational age and a ruptured unilateral RAA.

Resumo Os aneurismas de artéria renal (AAR) são raros, normalmente assintomáticos, e ~ 90% dos casos são unilaterais. Uma vez diagnosticados durante a gestação, estes podem se tornar predisponentes a rotura e apresentar elevado risco materno-fetal. O presente artigo relata o caso de uma gestante de 32 anos, com idade gestacional de 30 semanas e quadro de AAR unilateral roto.

Manejo terapéutico y diagnóstico en equipo multidisciplinario y resultados obtenidos en gestantes con cardiopatía orgánica / Diagnostic and therapeutic management and clinical outcome by a multidisciplinary team in pregnant women with heart disease

Las enfermedades cardiovasculares afectan aproximadamente al 2% de las mujeres embarazadas, por lo que suponen un aumento del riesgo tanto para la madre como para el feto. El embarazo y el parto producen cambios fisiológicos sustanciales que requieren de una adecuada adaptación del sistema cardiovascular. Estos cambios fisiológicos que son muy bien tolerados en las gestantes sin cardiopatía, exponen a la mujer con enfermedad cardiovascular a eventos clínicos significativos. Este es un trabajo descriptivo, retrospectivo, de casos consecutivos de pacientes que acudieron a la División de Medicina Cardiovascular, del Hospital de Clínicas en un período comprendido entre Agosto de 2013 a Junio de 2014. Incluye a 5 pacientes embarazas y portadoras de cardiopatías conocidas o desconocidas. La edad promedio fue de 27 años, rango etario de 17 a 36 años. La edad gestacional al momento de la consulta fue de 34 semanas por fecha de última menstruación, menor edad gestacional 30 semanas y mayor edad gestacional 38 semanas. El síntoma principal de consulta fue la disnea (100%), edema de miembros inferiores en 3 pacientes (60%), y palpitaciones en 2 pacientes (40%). El manejo diagnóstico y terapéutico conjunto con un seguimiento detallado y adecuado por un equipo multidisciplinario de cardiólogos, clínicos, ginecólogos, anestesiólogos y cirujanos cardiovasculares facilitan una buena evolución clínica y un desenlace exitoso del embarazo y parto de la gestante con la cardiopatía orgánica. Como resultado de este manejo multidisciplinario todos los recién nacidos tuvieron buena evolución durante su permanencia en la unidad de cuidados intensivos sin inconvenientes(AU)

Heart diseases affect approximately 2% of pregnant women increasing the risk of the mother and the child. The pregnancy and the delivery produce substantial physiological changes requiring an adequate adaptation of the cardiovascular system. These changes, which are well tolerated by pregnant women without heart disease, expose the pregnant women with heart disease to significant clinical events. This is a descriptive, retrospective study of consecutive cases in the Division of Cardiovascular Medicine of the Hospital de Clínicas between August 2013 and June 2014. It includes five pregnant women with known or unknown heart disease at the time of consultation. The average age was 27 years old (17 to 36 years old). The average gestational age was 34 weeks (30 to 38 weeks). The main symptom at consultation was dyspnea (100%), edema of inferior limbs (60%), and palpitations (40%). The joint diagnostic and therapeutic management with a detailed and adequate follow-up by a multidisciplinary team of cardiologists, physicians, gynecologists, anesthesiologists, and cardiac surgeons facilitated a good clinical outcome and a successful completion of the pregnancy and delivery of the pregnant women with heart disease. As a result of the work of this multidisciplinary team, all the newborns had good evolution during their stay at the intensive care unit without any difficulties(AU)

Hypotension and bradycardia before spinal anesthesia / Hipotensão e bradicardia antes da raquianestesia

Abstract I report a case of hypotension and bradycardia before spinal anesthesia in a pregnant woman with mild to moderate hypertension treated with nifedipine and methyldopa, scheduled for an elective cesarean delivery. She had the history of neurally-mediated syncopes. Two main factors (increased vagal tone and adverse effects of antihypertensive drugs) could explain the hypotension and bradycardia before spinal anesthesia. Monitoring allowed recognizing the problem and corrected it. Thus, it was avoided a disaster in anesthesia, as hemodynamic changes after spinal anesthesia, they would have joined to previous hypotension and bradycardia, which would have caused even a cardiac arrest.

Resumo Relato de um caso de hipotensão e bradicardia antes da raquianestesia em uma mulher grávida com hipertensão leve a moderada tratada com nifedipina e metildopa, programada para parto cesáreo eletivo. A paciente apresentava história de síncopes neuralmente mediadas. Dois fatores principais (aumento do tônus vagal e efeitos adversos de medicamentos anti-hipertensivos) poderiam explicar a hipotensão e bradicardia antes da raquianestesia. O monitoramento permitiu reconhecer o problema e corrigi-lo. Dessa forma, foi evitado um desastre em anestesia; assim como as alterações hemodinâmicas após a raquianestesia, esses fatores teriam se juntado à hipotensão e bradicardia anterior, o que poderia até ter causado uma parada cardíaca.

Eisenmenger syndrome in pregnancy

Abstract Eisenmenger syndrome is very rare in pregnant women. Debates remain concerning the management of Eisenmenger syndrome in this patient population and the prognosis is unclear in terms of maternal and fetoneonatal outcomes. Epidural analgesia is preferred for Cesarean section as it alleviates perioperative pain and reduces the pulmonary and systemic vascular resistances. Maternal mortality in the presence of Eisenmenger syndrome is reported as 30-50% and even up to 65% in those with Cesarean section. The major causes of death could be hypovolemia, thromboembolism and preeclampsia. Pregnancy should ideally be avoided in a woman with Eisenmenger syndrome concerning the high maternal mortality rate and probable poor prognosis of the baby. A short labour and an atraumatic delivery under epidural block are preferred in the women with a strong desire of pregnancy. The purpose of this article is to discuss the debates of Eisenmenger syndrome in pregnancy and the possible resolutions.

Mitral valve prolapse in pregnancy

Abstract Mitral valve prolapse is a benign condition. Mitral regurgitation is only complicated in patients with severe mitral valve prolapse. Women with mitral valve prolapse in the absence of other cardiovascular disorders tolerate pregnancy well and do not develop remarkable cardiac complications. Nevertheless, serious complications of mitral valve prolapse, including arrhythmia, infective endocarditis and cerebral ischemic events, can be present in pregnancy. Debates remain with regard to the use of prophylactic antibiotics and β-blockers in the pregnant women with mitral valve prolapse. The prognosis of the pregnant patients might be closely related to the pathological and (or) functional changes of the mitral valve. Non-myxomatous mitral valve prolapse poses no or little obstetric risks in terms of pregnancy, labor and neonatal complications; whereas myxomatous mitral valve prolapse is a major etiology of valvular heart disease in women of childbearing age. In the pregnant patients with mitral valve prolapse progressing into major complications, surgical interventions are considered. Medicinal treatment of such patients with β-blockers should be a concern for the fetal safety.

Cardiac myxoma in pregnancy: a comprehensive review / Mixoma cardíaco na gravidez: revisão abrangente

AbstractObjective:Cardiac myxoma in pregnancy is rare and the clinical characteristics of this entity have been insufficiently elucidated. This article aims to describe the treatment options and the risk factors responsible for the maternal and feto-neonatal prognoses.Methods:A comprehensive search of the literature of cardiac myxoma in pregnancy was conducted and 44 articles with 51 patients were included in the present review.Results:Transthoracic echocardiography was the most common diagnostic tool for the diagnosis of cardiac myxoma during pregnancy. Cardiac myxoma resection was performed in 95.9% (47/49); while no surgical resection was performed in 4.1% (2/49) patients (P=0.000). More patients had an isolated cardiac myxoma resection in comparison to those with a concurrent or staged additional cardiac operation [87.2% (41/47) vs. 12.8% (6/47), P=0.000]. A voluntary termination of the pregnancy was done in 7 (13.7%) cases. In the remaining 31 (60.8%) pregnant patients, cesarean section was the most common delivery mode representing 61.3% and vaginal delivery was more common accounting for 19.4%. Cardiac surgery was performed in the first, second and third trimester in 5 (13.9%), 14 (38.9%) and 17 (47.2%) patients, respectively. No patients died. In the delivery group, 20 (76.9%) neonates were event-free survivals, 4 (15.4%) were complicated and 2 (7.7%) died. Neonatal prognoses did not differ between the delivery modes, treatment options, timing of cardiac surgery and sequence of cardiac myxoma resection in relation to delivery.Conclusion:The diagnosis of cardiac myxoma in pregnancy is important. Surgical treatment of cardiac myxoma in the pregnant patients has brought about favorable maternal and feto-neonatal outcomes in the delivery group, which might be attributable to the shorter operation duration and non-emergency nature of the surgical intervention. Proper timing of cardiac surgery and improved cardiopulmonary bypass conditions may result in even better maternal and feto-neonatal survivals.

ResumoObjetivo:Mixoma cardíaco durante a gravidez é raro e as características clínicas dessa entidade não foram suficientemente esclarecidas. Este artigo tem como objetivo descrever as opções de tratamento e os fatores de risco responsáveis pelo prognóstico materno e fetal-neonatal.Métodos:Foi realizada uma pesquisa abrangente na literatura sobre mixoma cardíaco durante a gravidez e 44 artigos com 51 pacientes foram incluídos na presente revisão.Resultados:Ecocardiografia transtorácica foi a ferramenta de diagnóstico mais comum para o diagnóstico de mixoma cardíaco durante a gravidez. Ressecção do mixoma cardíaco foi realizada em 95,9% (47/49); enquanto não foi realizada ressecção cirúrgica em 4,1% (2/49) dos pacientes (P=0,000). Mais pacientes tiveram ressecção isolada do mixoma cardíaco em comparação com aqueles com operação cardíaca concomitante ou adicional [87,2% (41/47) vs. 12,8% (6/47), P=0,000]. A interrupção voluntária da gravidez foi feita em 7 (13,7%) casos. Nas restantes 31 (60,8%) pacientes grávidas, a cesariana foi o modo de parto mais comum, representando 61,3% e parto vaginal contabilizou 19,4%. A cirurgia cardíaca foi realizada no primeiro, segundo e terceiro trimestre em 5 (13,9%), 14 (38,9%) e 17 (47,2%) pacientes, respectivamente. Nenhuma paciente morreu. No grupo de parto, 20 (76,9%) recém-nascidos sobreviveram livres de eventos, 4 (15,4%) tiveram complicações e 2 (7,7%) morreram. Os prognósticos neonatais não diferiram entre os modos de parto, opções de tratamento, tempo de cirurgia cardíaca e sequência de ressecção mixoma cardíaco em relação ao parto.Conclusão:O diagnóstico de mixoma cardíaco durante a gravidez é importante. Tratamento cirúrgico de mixoma cardíaco em pacientes grávidas trouxe resultados favoráveis para as mães e os neonatos no grupo de parto, o que pode ser atribuído à duração mais curta da operação e à natureza não emergencial da intervenção cirúrgica. O momento adequado da cirurgia cardíaca e melhoria das condições de circulação extracorpórea podem resultar em sobrevivência materna e do feto-neonato ainda melhor.

Hipertensión portal en el embarazo: presentación de un caso / Portal hypertension in pregnancy: report of a case

La coexistencia de embarazo y enfermedad hepática representa una situación clínica compleja. Durante el embarazo se desarrolla un estado hipervolémico debido a un flujo esplácnico incrementado, que contribuye a mayor presión portal transmitida a las venas colaterales que incrementan el riesgo de hemorragia varicosa en este grupo de pacientes. Se reporta el caso de una paciente de 39 años en el sexto embarazo y sin ningún antecedente médico previo que presenta hipertensión portal pre-sinusoidal y que gracias al manejo multidisciplinario adecuado, tuvo un parto sin complicaciones. Se revisa la literatura pertinente al caso.

The coexistence of pregnancy and liver disease represents a complex clinical situation. Pregnancy develops hypervolemic state due to increased splachnic blood flow, which contributes to increased portal pressure transmitted to collateral veins that increase the risk of variceal bleeding in these patients. We report the case of a 39 years old patient in the sixth pregnancy and without any previous medical history that presented pre-sinusoidal portal hypertension, and thanks to appropriate multidisciplinary management had an uncomplicated delivery. We review the literature relevant to the case.

Resultado perinatal em mulheres portadoras de hipertensão arterial crônica: revisão integrativa da literatura / Perinatal outcome in women suffering from chronic hypertension: literature integrative review / Resultado perinatal en mujeres que sufren de hipertensión crónica: revisión integradora de la literatura

Objetivou-se identificar as principais complicações relativas à Hipertensão Arterial Crônica observadas em mulheres gestantes e conhecer a evolução nos padrões de riscos dos resultados perinatais em duas décadas. Realizou-se uma revisão integrativa da literatura com abrangência temporal entre os anos de 1990 e 2010, nas bases de dados LILACS, SciELO e MEDLINE. Entre os resultados, observou-se que gestantes hipertensas crônicas apresentaram pré-eclâmpsia sobreposta (20% a 78%), restrição do crescimento fetal (8,5% a 30,7%), prematuridade (32,4% a 86,4%), cesárea (69,2%), descolamento prematuro da placenta (3,75% a 8,4%), óbito fetal (9,5% a 27,2%), complicações cardiovasculares, renais e pulmonares maternas. Conclui-se que a associação entre hipertensão crônica e gestação mostra forte risco para complicações maternas e perinatais, principalmente quando associados à severidade e etiologia da hipertensão, não mostrando evolução no decorrer das duas décadas pesquisadas sobre o resultado perinatal.

The study aimed to identify patterns in the evolution of risk of perinatal outcomes of pregnant women with chronic hypertension in order to compare the results of the pregnancy outcome. It was held an integrative literature with time span between the years 1990 and 2010, in the databases LILACS, SciELO and MEDLINE. As results, it was observed that pregnant women had chronic hypertensive superimposed preeclampsia (20% to 78%), fetal growth restriction (8.5% to 30.7%), prematurity (32.4% to 86.4%), cesarean section (69 2%), placental abruption (3.75% to 8.4%), fetal death (9.5% to 27.2%), cardiovascular complications, maternal kidney and lung. We conclude that the association of chronic hypertension and pregnancy shows strong risk for maternal and perinatal complications, especially when associated with the severity and etiology of hypertension, showing no trend during the two decades studied on perinatal outcome.

Objetivó-se identificar los patrones en la evolución del riesgo de resultados perinatales de las mujeres embarazadas con hipertensión crónica con el fin de comparar los resultados de la evolución del embarazo. Realizó-se una revisión integradora de la literatura, con lapso de tiempo entre los años 1990 y 2010, en las databases LILACS, SciELO y MEDLINE. En los resultados, fue observado que las mujeres embarazadas con hipertensión crónica apresentaran preeclampsia superpuesta (20% a 78%), restricción del crecimiento fetal (8,5% a 30,7%), prematuridad (32,4% a 86,4%), cesárea (69 2%), desprendimiento abrupto de la placenta (3,75% a 8,4%), muerte fetal (9,5% a 27,2%), complicaciones cardiovasculares, renales y pulmonares materna. Concluye-se que la asociación de hipertensión crónica y embarazo presenta riesgo importante para complicaciones maternas y perinatales, especialmente cuando se asocia con la gravedad y etiología de la hipertensión, sin mostrar tendencia a evolución, durante las dos décadas estudiadas, en el resultado perinatal.

Marfan's syndrome: pre-pubertal aortic rupture with left coronary artery aneurysms and fistulas / Síndrome de Marfan: ruptura aórtica prepubertal con fístulas y aneurismas de la arteria coronaria izquierda

Aortic dissection and rupture occur in 20-40% of patients with Marfan's syndrome. This occurs predominantly in the third and fourth decade of life, contributing to the increased morbidity and mortality of this specific group of patients. This is the first known documented case report of pre-pubertal left coronary sinus rupture with left coronary artery aneurysms with fistulous communication to both the superior vena cava and right superior pulmonary vein, presenting with a continuous murmur.

La disección y ruptura aórticas ocurren en 20-40% de los pacientes con el síndrome de Marfan. Esto ocurre predominantemente en la tercera y cuarta décadas de la vida, contribuyendo al aumento de la morbilidad y la mortalidad de este grupo específico de pacientes. Éste es el primer reporte de un caso documentado conocido de ruptura prepubertal del seno coronario izquierdo con aneurisma de la arteria coronaria izquierda, y comunicación fistulosa tanto con la vena cava superior como con la vena pulmonar superior derecha, acompañada de un soplo continuo.

Idiopathic spontaneous hemoperitoneum in pregnancy: a case report with review of literature

Spontaneous hemoperitoneum in pregnancy is a rare cause of acute abdomen. Often in these cases the diagnosis made is obstetric emergencies like abruption, placentae or the commoner surgical emergencies in pregnancy. The causes of spontaneous hemoperitoneum include obstetric emergencies like ovarian cyst rupture, ectopic pregnancies which present in early pregnancy and uterine rupture and hepatic rupture in cases of HELLP syndrome which present in late pregnancy. Pregnancy may also predispose rarely to splenic rupture, rupture of visceral arteries like splenic and uterine and rupture of utero-ovarian veins. However in certain cases of spontaneous hemoperitoneum the site of bleeding may not be identified at surgical exploration. Even with recent advances in angiography there are cases where the site of bleeding is not identified. These cases of idiopathic spontaneous hemoperitoneum were historically termed as abdominal apoplexy. The first case of idiopathic spontaneous hemoperitoneum was reported in 1909. We report a case of idiopathic spontaneous hemoperitoneum at 32 weeks of pregnancy. Early operative intervention was done in the case which led to good maternal outcome. The fetal prognosis usually depends on the degree of prematurity. In our case the baby was premature and was discharged well after a 17-day NICU stay

Prinzmetal's angina in a pregnant woman: a case report

Acute myocardial infarction [MI] during pregnancy is rare and MI due to Prinzmetal's angina is much rarer. We present a 35-year-old, obese, multigravida, and pre-eclamptic woman, who developed acute anterior wall MI at the 30th week of gestation. On coronary angiography, the second obtuse marginal branch was totally occluded and the right coronary artery [RCA] was normal. Three days later, she had chest pain and ST elevation in the inferior leads. On second angiography, there was narrowing in the RCA, while the obtuse marginal branch was patent. We presume that this discrepancy between the first and second electrocardiograms and angiographic findings was due to Prinzmetal's angina

Anomalía de Ebstein y embarazo: presentación de 2 casos / Ebstein anomaly and pregnancy: two cases report

La enfermedad de Ebstein es una rara malformación cardiaca descrita por Wilhelm Ebstein en 1866 de la cual existen pocos reportes, se caracteriza por el desplazamiento apical de las valvas septal y posterior de la válvula tricúspide hacia el interior del ventrículo derecho, estas alteraciones determinan la auriculización de la porción basal del ventrículo derecho. Se presentan dos casos de embarazadas con esta malformación y la manifestación de insuficiencia cardiaca las llevó al departamento de Eco cardiografía del Centro Médico Diagnóstico de alta Tecnología José Martí, de la misión Barrio Adentro II, en la ciudad de Barcelona, estado Anzoátegui, República de Venezuela.

Ebstein's anomaly is a rare cardiac malformation described by Wilhelm Ebstein in 1866 of which there are few reports, is characterized by apical displacement of septal and psterior leaflets of the tricuspid valve into the right ventricle, these alterations determine atrialization basal portion of the right ventricle. Two cases of pregnant women with this malformation are presented and the manifestation of heart failure led them to the echocardiography Department of Diagnostic Medical Center High Technology José Martí, Mission Barrio Adentro II, in Barcelona city, Anzoátegui state, Republic of Venezuela.

Brainstem cavernous malformations: a review with two case reports / Malformações cavernosas do tronco cerebral: uma revisão com relato de dois casos

Central nervous system (CNS) cavernous malformations (CMs) are developmental malformations of the vascular bed with a highly variable clinical course due to their dynamic nature. We present one case of "de novo" brainstem cavernous malformation after radiation therapy adding to the increasing number of reported cases in the medical literature, and the case of a pregnant patient with symptomatic intracranial hemorrhage related to brainstem CMs to illustrate the complex nature in management of these patients, followed by a review of clinical and radiographic characteristics. CMs account for 8-15 percent of all intracranial and intraspinal vascular malformations. Although traditionally thought to be congenital in origin, CMs may present as acquired lesions particularly after intracranial radiation therapy. Clinical manifestations are protean and surgical treatment should be considered for patients with progressive neurologic deficits.

Malformações cavernosas (MFC) do sistema nervoso central são malformações do desenvolvimento do leito vascular com múltiplas apresentações clínicas devido a sua natureza dinâmica. Apresentamos dois casos de malformações cavernosas do tronco cerebral: o primeiro após radioterapia e o segundo em paciente grávida com hemorragia intracraniana sintomática. MFC são responsáveis por cerca de 8-15 por cento de todas as malformações vasculares. Embora tradicionalmente sejam genéticas, as MFC podem também ser adquiridas, particularmente após radioterapia. As manifestações clínicas são variáveis e o tratamento cirúrgico deve ser considerado para pacientes com quadros neurológicos progressivos.

Trombosis de la vena ovárica: Factores de riesgo, diagnóstico y tratamiento / Ovarian vein thrombosis: risk factors, diagnosis and treatment

La trombosis de la vena ovárica es una complicación muy poco frecuente (0.002-0.05%), que se observa en mujeres que presentan un incremento en los factores de coagulación. La principal situación en la que es posible detectar esta complicación es el embarazo, aunque no es la única. Se describe el caso de una mujer de 31 años de edad, gestante de 16 semanas, que presenta un aborto espontáneo séptico complicado con una trombosis de la vena ovárica. Se aprovecha el caso clínico para revisar en la literatura los factores de riesgo, el diagnóstico y el tratamiento de esta inusual patología.

Ovarian vein thrombosis is an uncommon complication (0.002-0.05%) related to hypercoagulated status of women. The most frequent condition associated to ovarian vein thrombosis is pregnancy, but there are other possible causes. We present a case of a 31 year old pregnant woman at 16th week of gestation who had spontaneuos septic abortion complicated with an ovarian vein thrombosis. A discussion of risk factors, diagnostic and treatment options of ovarian vein thrombosis are presented.