Multidisciplinary approach for the management of term pregnancy complicated by Eisenmenger syndrome / 浙江大学学报（英文版）（B辑：生物医学和生物技术）

Pregnancy in patients with Eisenmenger syndrome (ES) is associated with high maternal mortality rates of 30%‒50%, or even up to 65% in the case of a cesarean section (Yuan, 2016). Here, we report a case of term pregnancy complicated with ES and severe pulmonary artery hypertension (PAH), which was managed by a multidisciplinary team (MDT) and resulted in an uncomplicated delivery via elective cesarean section. The goal of this study is to emphasize the importance of multidisciplinary approach in the management of pregnancy with ES, which can profoundly improve maternal and infant outcomes.

Efeitos do tratamento manipulativo osteopático na hemodinâmica e na qualidade de vida de gestantes no terceiro trimestre: coorte prospectiva / Effects of osteopathic manipulative treatment on the hemodynamics and quality of life of pregnant women in the third trimester: prospective cohort

Na gestação várias mudanças pelas quais as mulheres passam são capazes de intervir no seu estado de saúde. Estudos relatam que a incapacidade do corpo de algumas gestantes de acomodarem o crescimento uterino estaria na raiz de problemas na hemodinâmica materno-fetal. A busca por terapêuticas não medicamentosas vem crescendo dentro da área da saúde nos últimos anos. O tratamento manipulativo osteopático é uma terapêutica integrativa complementar de saúde reconhecida pela organização mundial de saúde e aceita pelo sistema único de saúde brasileiro. Método: Trata-se de uma coorte prospectiva realizada com 80 pacientes do ambulatório de pré-natal e da enfermaria de gestantes do Instituto Fernandes Figueira/Fiocruz entre julho de 2021 e setembro de 2022. Foram realizados dois estudos, um estudo transversal com 51 grávidas para avaliar os efeitos hemodinâmicos materno-fetais após o tratamento manipulativo osteopático através da dopplervelocimetria nas gestantes e um estudo prospectivo com 64 gestantes para avaliar a influência do tratamento manipulativo osteopático sobre a intensidade das dores lombar e pélvica, assim como mudanças na sua qualidade de vida. População: foram investigadas gestantes no terceiro trimestre de gestação, acima de 18 anos, e excluídas as gestantes com ruptura prematura de membrana, com malformações fetais, com fetos múltiplos e trabalho de parto ativo. Resultados: Os resultados do estudo transversal após o tratamento manipulativo não foram significantes estatisticamente. No estudo prospectivo, as gestantes foram divididas em dois grupos ≤ 3 e ≥ 4. Observou-se uma melhora significante estatisticamente na intensidade das dores lombar e pélvica em ambos os grupos. Houve melhora nos dois grupos nos índices de qualidade de vida, sendo que no grupo≥ 4 atendimentos todos os resultados foram estatisticamente significativos. Conclusão: a análise dos dados do estudo considerou que o tratamento manipulativo osteopático é seguro para o feto e para gestantes portadoras de comorbidades, não afetando os sinais vitais maternos e nem a circulação uteroplacentária e feto-placentária. Os dados também apontaram que o tratamento osteopático foi eficaz na redução da intensidade da dor lombar e pélvica e efetivo na melhora da qualidade de vida das gestantes.

During pregnancy, several changes women undergo can affect their health status. Studies related to the inability of the body of some pregnant women to accommodate uterine growth would be at the root of problems in maternal-fetal hemodynamics. The search for non-drug treatments has grown in the health area recently. Manipulative osteopathic treatment is a complementary, integrative health therapy recognized by the world health organization and accepted by the Brazilian single health system. Method: This prospective cohort study was carried out with 80 patients from the prenatal clinic and the pregnant women's ward of Instituto Fernandes Figueira/Fiocruz between July 2021 and September 2022. Two studies were carried out, a cross-sectional study with 51 pregnant women to evaluate the maternal-fetal hemodynamic effects after osteopathic manipulative treatment through Doppler velocimetry in pregnant women and a prospective study with 64 pregnant women to evaluate the influence of osteopathic manipulative treatment on the intensity of lumbar and pelvic pain, as well as changes in their quality of life. Population: pregnant women in the third trimester of pregnancy, over 18 years old, were investigated, and pregnant women with premature membrane rupture, fetal malformations, multiple fetuses, and active labor were excluded. Results: The results of the cross-sectional study after manipulative treatment were not statistically significant. Pregnant women were divided into two groups ≤ 3 and ≥ 4 in the prospective study. There was a statistically significant improvement in lumbar and pelvic pain intensity in both groups. There was an improvement in both groups in the quality-of-life indices, and in the group≥ four consultations, all results were statistically achieved. Conclusion: an analysis of the study data found that osteopathic manipulative treatment is safe for the fetus and pregnant women with comorbidities, not affecting maternal signs or uteroplacental and fetal-placental circulation. The data also showed that osteopathic treatment effectively reduced the intensity of lumbar and pelvic pain and improved the quality of life of pregnant women.

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.

Paro cardiorrespiratorio en la embarazada y cesárea perimortem / Maternal cardiac arrest and perimortem cesarean delivery

Resumen El paro cardiorrespiratorio (PCR) en la mujer embarazada es una situación infrecuente, grave y de manejo multidisciplinario. La reanimación cardiopulmonar requiere consideraciones y particularidades propias de la embarazada, centradas en la fisiología y la anatomía, teniendo especial consideración la compresión aortocava, la intubación-ventilación difícil, la presencia de estómago lleno y el hecho que hay dos vidas involucradas. Las principales causas de PCR son las hemorrágicas, seguidas de las embólicas, cardiovasculares, anestésicas e infecciosas. Las principales acciones incluyen activación del código azul obstétrico con respuesta rápida para una eventual realización de histerotomía de emergencia oportuna en el mismo sitio evitando el traslado al quirófano, compresiones torácicas de buena calidad, desviación manual uterina a la izquierda, intubación endotraqueal y manejo avanzado de la vía aérea, todo esto con el fin de mejorar la sobrevida materno-fetal. La cesárea perimortem es un pilar en el manejo, favoreciendo el desenlace materno y eventualmente el fetal. Se debe realizar a los 4 minutos de una reanimación cardiopulmonar no exitosa. Sin embargo, aún hay retardo a la hora de indicarla, por lo que se debe incentivar el entrenamiento, la simulación en resucitación cardiopulmonar materna y las guías clínicas para todo el personal involucrado en la atención de pacientes obstétricas.

Abstract Cardiopulmonary arrest is a rare event during pregnancy and labor. It involves many subspecialties and allied health providers. Besides it requires knowledge of maternal physiology as it relates to resuscitation, particularly aortocaval compression, difficult airway, full stomach and the fact that there are two lives involved. The most frequent causes of cardiac arrest during pregnancy include bleeding, followed by embolism, infection, anesthesia complications and heart failure. The main steps required are: obstetric code activation with appropriate response for performing timely emergent hysterotomy in the same place avoiding the transfer to operating room; good-quality chest compressions; manual uterine displacement to the left, advanced pharmacological and airway management; and optimal care after resuscitation to improve maternal and fetal outcomes. Although current recommendations for maternal resuscitation include the performance of perimortem cesarean section after four minutes of unsuccessful cardiopulmonary resuscitation, deficits in knowledge about this procedure are common. Therefore, training and available evidence-based guidelines should be put in place for all obstetric caregivers.

The REBECGA brazilian registry of pregnancy and heart disease: rationale and design

BACKGROUND: Maternal mortality rates in Brazil remain above the goals established by the United Nations Sustainable Development Goals. Heart disease is estimated to affect 4% of all pregnancies and remains by itself the main indirect obstetric cause of maternal death. In the last decades, a significant improvement in the prognosis of heart diseases has made pregnancy possible in women with heart disease and provided better maternal and fetal outcomes. OBJECTIVES: To establish a multicenter Brazilian Registry of pregnant women with heart disease; to study the causes of immediate and late maternal mortality; and to assess the prevalence of heart disease in the country's macro-regions. METHODS: This is an observational study, with retrospective and prospective stages, of the clinical and obstetric progression of pregnant women with heart disease. These women consecutively received care during pregnancy and will be followed up for up to a year after delivery at public and private hospitals with infrastructure for the execution of this project, a principal investigator, and approval by Ethics and Research Committees. RESULTS: Our results will be presented after data collection and statistical analysis, aiming to demonstrate immediate and late maternal mortality rates, as well as the prevalence of heart disease in the country and its cardiovascular and obstetric complications during pregnancy. CONCLUSIONS: REBECGA will be the Brazilian Registry of heart disease and pregnancy and it will contribute to planning preventive measures, raising financial resources for the improvement of high-risk prenatal care, and reducing immediate and late maternal mortality due to heart disease.

Síndrome de Eisenmenger y embarazo - reporte de 2 casos / Eisenmenger's and pregnancy syndrome - 2 case report

RESUMEN El síndrome de Eisenmenger es una patología del sistema vascular pulmonar, que se caracteriza por un incremento de las resistencias en los vasos sanguíneos pulmonares, en pacientes con antecedentes de cardiopatía con comunicación entre la circulación pulmonar y circulación sistémica. Este síndrome en la mujer embarazada representa un alto índice de morbilidad y mortalidad tanto para la madre como para el feto; los síntomas que presentan surgen como consecuencia de los cambios fisiológicos en el sistema cardiovascular y hematopoyético. Es un desafío para el obstetra el manejo de estas pacientes idealmente debe ofrecerse asesoría preconcepcional, y valoración por cardiología; si no es posible, se realizará evaluación del riesgo desde el primer control prenatal. El mejor tratamiento consiste en oxigenoterapia, medicamentos vasodilatadores, y anticoagulantes, logrando disminuir el porcentaje de pobres desenlaces materno-fetales. Es de vital importancia definir el momento del nacimiento con el fin de tomar las medidas terapéuticas necesarias para evitar complicaciones, además se requiere de un manejo multidisciplinario, incluido el apoyo por una unidad de cuidado intensivo dado la alta probabilidad de complicaciones asociadas a esta patología.

ABSTRACT Eisenmenger syndrome is a pathology of the pulmonary vascular system, which is characterized by an increase in resistance of the pulmonary blood vessels in patients with a history of heart disease with communication between the pulmonary circulation and the systemic circulation. This syndrome in pregnant women represents a high morbidity and mortality rate for both the mother and the fetus. The symptoms that arise are a consequence of the physiological changes in the cardiovascular and hematopoietic system. The management of these patients is a challenge for the obstetrician; ideally, preconception counseling and cardiology assessment should be offered and if this is not possible, risk assessment should be carried out from the first prenatal control. The best treatment consists of oxygen therapy, vasodilating agents, and anticoagulant medications with the goal of reducing the percentage of poor maternal-fetal outcomes. It is vitally important to define the time of birth in order to take the necessary therapeutic measures to avoid complications. In addition, multidisciplinary management and an intensive care unit are required due to the high probability of complications associated with this pathology.

Daño cardiovascular en la COVID-19: Una extensión de la enfermedad pulmonar / Cardiovascular injury in COVID-19: An extension of pulmonary disease

RESUMEN Ante la ocurrencia de un brote de neumonía en 59 pacientes sospechosos en un mercado local de mariscos en Wuhan, China, el 1 de diciembre de 2019 fue confirmado por el laboratorio el primer caso de un nuevo coronavirus, hasta entonces desconocido. El 7 de enero de 2020 fue identificado un nuevo tipo de virus de la familia Coronaviridae denominado SARS-CoV-2, agente causal de la enfermedad conocida como COVID-19. Los escasos informes iniciales limitaban la afectación al tracto respiratorio inferior. Con el progreso de la enfermedad y el cúmulo de evidencia científica, se demostró el papel fundamental que desempeña la afectación cardiovascular en el desarrollo y pronóstico de la infección. La edad es un predictor independiente de mortalidad y se ha demostrado una asociación entre la enfermedad cardiovascular preexistente y las formas graves de la enfermedad. La afectación cardiovascular puede ser directa o indirecta, se destacan el daño miocárdico agudo, la miocarditis, el infarto agudo de miocardio, la insuficiencia cardíaca, las arritmias y los eventos tromboembólicos venosos. Se añaden los efectos adversos del tratamiento de las complicaciones cardíacas y el ensayo con fármacos en los protocolos terapéuticos. En esta monografía se revisa el daño cardiovascular por la COVID-19.

ABSTRACT Faced with a pneumonia outbreak in 59 suspected patients at a local seafood market in Wuhan, China, the first case of a novel coronavirus was laboratory-confirmed on December 1, 2019. On January 7, 2020, a new type of virus of the family Coronaviridae called SARS-CoV-2 -causative agent of COVID-19- was identified. The few initial reports restricted involvement to the lower respiratory tract. Both, disease progression and build-up of scientific evidence, proved the crucial role played by cardiovascular involvement in the development and prognosis of the infection. Age is an independent predictor of mortality and an association between pre-existing cardiovascular disease and severe forms of the disease has been demonstrated. Cardiovascular involvement may be either direct or indirect; acute myocardial injury, myocarditis, acute myocardial infarction, heart failure, arrhythmias and venous embolic events stand out among others. Adverse effects of treatment for cardiac complications and drug testing in therapeutic protocols may be contributing aspects. This paper addresses cardiovascular involvement due to COVID-19.

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.

Mechanical heart valve thrombosis during pregnancy under non / 中南大学学报(医学版)

Anticoagulation drugs should be used for patients with mechanical heart valve (MHV) in case of potential risk of thrombosis. Pregnant women with MHV have to change therapies due to teratogenic effect of some anti-coagulation drugs. European Society of Cardiology clinical guidelines for the management of cardiovascular diseases during pregnancy gives specific suggestions for anticoagulation therapy.We have treated 2 patients with mechanical heart valve thrombosis (MVT) during pregnancy: One received low molecular weight heparin (LMWH) throughout the pregnancy and developed MVT at the third trimester of pregnancy; one developed MVT at the first trimester when replacing vitamin K antagonists (VKA) with LMWH. These patients raised secondary reflection on the balance between clinical guideline and personalized medicine. During LMWH therapy, we should dynamically monitor patients' anti-activated factor X (anti-Xa) level to evaluate coagulation function during pregnancy. When a pregnant woman with MHV develops symptoms of acute heart failure, stuck mechanical valve should be paid attention to and surgery should be promptly performed if necessary.

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.

Risk factors for cardiac, obstetric, and neonatal complications in patients with heart disease during pregnancy / Factores de riesgo para complicaciones cardíacas, obstétricas y neonatales en pacientes con enfermedad cardíaca durante el embarazo

Abstract Objective: Heart disease in pregnancy can cause clinical deterioration and maternal-fetal death. It is essential to evaluate risk factors related to complications. Methodology: This was a observational, analytical retrospective cohort study with a non-probabilistic convenience sample of pregnant women with congenital or acquired heart disease, corrected or not, or arrhythmias requiring urgent intervention. Patients with mild or moderate valvular regurgitation, mild valvular stenosis, patients without echocardiography or without delivery information were excluded from the study. The outcome was a composite of cardiac, obstetric, and neonatal events. Univariate and multivariate analyzes were performed with logistic regression model and discriminatory capacity with area under the curve and independent analysis of the modified World Health Organization (mWHO) risk classification (mWHO). Results: A total of 104 patients with an average age of 25 ± 6.5 years presented cardiac events in 13.5%, obstetric in 14.42%, and neonatal in 28.85%. The univariate analysis found an association with New York Heart Association functional status, hypertensive disorders of pregnancy, cesarean delivery, gestational age < 27 weeks, hypoxemia, and mWHO risk. In multivariate only cesarean delivery (odds ratio [OR], 2.68; 95% confidence interval [CI], 1.05-6.86) and gestational age at delivery (OR, 0.39; 95% CI, 0.22-0.67) maintain association with outcomes. The area under the curve for the mWHO risk is 0.75. Conclusions: There is a high rate of adverse events in patients with heart disease during pregnancy. Gestational age and cesarean delivery behaved as predictors of adverse maternal-fetal outcomes. The mWHO risk classification had an acceptable prediction of adverse outcomes.

Resumen Objetivo: La enfermedad cardíaca en el embarazo puede ocasionar deterioro clínico y muerte maternofetal. Es indispensable evaluar factores de riesgo relacionados con complicaciones. Método: Estudio observacional y analítico de cohorte retrospectivo con muestra no probabilística por conveniencia de embarazadas con cardiopatía congénita o adquirida, corregida o no, o arritmias que requerían intervención urgente. Se excluyó a pacientes con insuficiencias valvulares leves o moderadas, estenosis valvulares leves, pacientes sin ecocardiografía o sin información del parto. El desenlace fue un compuesto de episodios cardíacos, obstétricos y neonatales. Se realizó análisis univariado y multivariado con modelo de regresión logística y capacidad diferenciadora con área bajo la curva y análisis independiente de la clasificación de riesgo de la OMS modificada (OMSm). Resultados: 104 pacientes con edad promedio de 25 ± 6.5 años presentaron episodios cardíacos en 13.5%, obstétricos en 14.42% y neonatales en 28.85%. El análisis univariado encontró una relación con el estado funcional de la NYHA, trastornos hipertensivos del embarazo, parto por cesárea, edad gestacional < 27 semanas, hipoxemia y riesgo de la OMSm. En el multivariado sólo el parto por cesárea (OR, 2.68; IC 95%, 1.05-6.86) y la edad gestacional al momento del parto (OR, 0.39; IC 95%, 0.22-0.67) mantienen nexo con los desenlaces. El área bajo la curva para el riesgo de la OMSm es de 0.75. Conclusiones: Hay una elevada tasa de efectos adversos en pacientes con enfermedad cardíaca durante el embarazo. La edad gestacional y el parto por cesárea se comportaron como predictores de resultados adversos maternofetales. La clasificación de riesgo de la OMSm tuvo una predicción aceptable de desenlaces adversos.

Congenital complete atrioventricular heart block in a pregnant woman with sjögren syndrome: prenatal care follow-up and the challenge of intrauterine treatment / Bloqueio atrioventricular completo congênito em uma mulher grávida com síndrome de Sjögren: seguimento pré-natal e desafio do tratamento intrauterino

Abstract The present report describes a case of complete atrioventricular block (CAVB) diagnosed at 25 weeks of gestation in a pregnant woman with Sjögren's syndrome and positive anti-Ro/SSA antibodies. Fluorinated steroids (dexamethasone and betamethasone) and terbuline were used to increase the fetal heart rate, but the fetal heart block was not reversible, and the administration of drugs was discontinued due to maternal collateral effects. Follow-up fetal echocardiograms were performed, and the fetus evolved with pericardial effusion, presence of fibroelastosis in the right ventricle, and ventricular dysfunction. Interruption of pregnancy by cesarean section was indicated at 34 weeks of gestation, and a cardiac pacemaker was implanted in the male newborn immediately after birth. Therapy for fetuses with CAVB is controversial mainly regarding the use or not of corticosteroids; however, monitoring of the atrioventricular interval by fetal echocardiography should be performed in fetuses from pregnant women with positive autoantibodies anti-Ro/SSA and/or anti-La/SSB to prevent the progression to CAVB.

Resumo Este relato descreve um caso de bloqueio atrioventricular completo (BAVC) diagnosticado com 25 semanas de gestação em uma mulher com síndrome de Sjögren e anticorpos anti-Ro/SSA positivos. Esteroides fluoretados (dexametasona e betametasona) e terbulina foram utilizados para aumentar a frequência cardíaca fetal, mas o bloqueio cardíaco fetal não foi reversível, e a administração dos medicamentos foi interrompida devido a efeitos colaterais maternos. Ecocardiogramas fetais de acompanhamento foram realizados, e o feto evoluiu com derrame pericárdico, presença de fibroelastose no ventrículo direito, e disfunção ventricular. A interrupção da gravidez por cesariana foi indicada com 34 semanas, e um marca-passo cardíaco foi implantado no recém-nascido do sexo masculino imediatamente após o nascimento. A terapia para fetos com BAVC é controversa, principalmente no que diz respeito ao uso ou não de corticosteroides; no entanto, o monitoramento do intervalo atrioventricular pela ecocardiografia fetal deve ser feito em fetos de mulheres grávidas com autoanticorpos positivos anti-Ro/SSA e/ou anti-La/SSB para impedir a progressão para o BAVC.

Preeclampsia y enfermedad cardiovascular: un enfoque integral para detectar las fases subclínicas de complicaciones obstétricas y cardiovasculares / Preeclampsia and cardiovascular disease: an integrated approach to detect the subclinical stages of obstetrical and cardiovascular complications

Desde 1995 hasta la fecha la asociación entre patologías derivadas los embarazos hipertensivos y las enfermedades cardiovasculares ha generado un gran volumen de potentes evidencias epidemiológicas y clínicas. Los propósitos de esta revisión son varios. Mostrar la consistencia y magnitud de la evidencia científica. Integrar los riesgos/enfermedades cardiovasculares y los problemas obstétricos a través de la disfunción endotelial. Preconizar el seguimiento postparto de la hipertensa embarazada, como una ventana de oportunidad para beneficiar la salud de las mujeres y sus hijos. Incluir la historia obstétrica como factor de riesgo de enfermedad coronaria. Proponer cuestionarios adaptables a las prácticas locales para facilitar la pronta incorporación de los índices de riesgo obstétrico y cardiovascular en dos etapas de la vida de una mujer. Ha llegado el momento para que los equipos obstétricos, cardiológicos y las pacientes jueguen un rol en la prevención de los riesgos y enfermedades cardiovasculares.

From 1995 onwards the association between hypertensive pregnancies and cardiovascular disease has generated a great volume of epidemiologic and clinical evidence. The purposes of this review are several. To demonstrate the consistence and weight of the scientific evidence. To integrate cardiovascular risks/diseases and obstetric complications through the link of endothelial dysfunction. To advocate postpartum follow-up after a hypertensive pregnancy as a window of opportunity to benefit the health of mothers and offsprings. To include the obstetrical history as a risk factor for coronary disease. To propose questionnaires adaptable to local practices to incorporate cardiovascular and obstetrical indexes in two stages of a woman's lifetime. The time has come for obstetrical teams, cardiologists and patients to play a preventive role regarding cardiovascular risks and diseases.

Pregnancy in teenagers with heart disease / Embarazo en pacientes adolescentes con cardiopatía

Abstract The prevalence of pregnancy in adolescent women is high in Mexico and represents a public health problem. The pregnant teenager with heart disease has a high probability of complications during pregnancy and the delivery, which carries a risk of death of both the mother and the product. In many cases the pregnancy should have been avoided, planned or interrupted, however the majority at this age is vulnerable and although certain cases must be interrupted by their high risk of maternal-fetal death, prevention and legal aspects should be considered. In some cases the woman wants a pregnancy although her health condition does not allow it, but there are options of adoption or recourse to a surrogate belly. In response to this growing social problem, the National Cardiology Institute Ignacio Chávez and National Institute of Perinatology, with the coordination of Ministry of Health in Mexico, started a pregnancy prevention module within a clinic of follow-up of cardiopathy and pregnancy. This review raises the global problem in our country that occupies the first place in pregnancies in adolescents, with more than 400,000 pregnancies a year and the form of immediate response in a multidisciplinary way.

Resumen La prevalencia de embarazo en mujeres adolescentes es muy alta en México, y representa un problema de salud pública. La adolescente embarazada con cardiopatía tiene altas posibilidades de complicaciones durante el embarazo y su resolución, lo que pone en riesgo la vida tanto de la madre como del producto. En muchos casos el embarazo debió ser evitado, planeado o interrumpido, sin embargo la mayoría a esta edad es vulnerable y si bien ciertos casos deben ser interrumpidos por su alto riesgo de muerte materno-fetal, es fundamental considerar la prevención y los aspectos legales. En algunos casos la mujer desea un embarazo aunque su condición de salud no se lo permite, pero existen opciones de adopción o recurrir a un vientre subrogado. Atendiendo este problema social cada vez más creciente, el Instituto Nacional de Cardiología Ignacio Chávez, en coordinación con la Comisión Coordinadora de la Secretaría de Salud y el Instituto Nacional de Perinatología, echaron a andar un módulo de prevención de embarazo dentro de una clínica de seguimiento de cardiopatía y embarazo. Esta revisión plantea el problema global en nuestro país, que ocupa el primer lugar en embarazos en adolescentes, con más de 400 mil embarazos al año y la forma de dar respuesta inmediata de manera multidisciplinaria.

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.