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.

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.

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.

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.

Avaliação de alterações urinárias e função renal em gestantes com hipertensão arterial crônica / Urinary abnormalities and renal function in pregnant women with chronic hypertension

Resumo Introdução: O acometimento renal em gestantes portadoras de hipertensão arterial crônica (HAC) não é amplamente conhecido. Objetivos: 1- Descrever o perfil epidemiológico de pacientes com HAC; 2- Avaliar a ocorrência de alterações urinárias e de função renal (por meio de determinação sérica de creatinina, cistatina C e ritmo de filtração glomerular estimada - RFGe); 3- Avaliar o desfecho das gestações em HAC. Métodos: Foram submetidas a avaliações clínicas e laboratoriais 103 gestantes com HAC (pressão arterial acima de 140/90 mmHg, identificada previamente à gestação ou até a 20ª semana). Resultados: As gestantes tinham 21-45 (média: 34) anos; 12,6% eram primigestas, 64,1% tiveram múltiplas gestações. A relação proteinúria/creatininúria em amostra isolada estava alterada em 5,2% casos (0-6,44 g/g), creatinina sérica estava elevada em 19,6% e cistatina C em 14,7%. Na avaliação das características da gestação em pacientes com HAC e seus recém-nascidos (RN) (vs. frequências nos casos com CKD-EPI cistatina C < 60 ml/min/1,73 m2), observou-se: 20,5% (33,3%) de nascidos pré-termo < 37 sem, 17,5% (22,2%) de RN com peso < 2500 g e 17,5% (22,2%) de RN pequeno para a idade gestacional (PIG); sobreposição de DHEG ocorreu em 24,7% (22,2%) dos casos. Conclusão: Alterações renais foram identificadas por proteinúria, creatinina e cistatina C séricas em 5,2%, 19,6 e 14,7% das gestantes. Os resultados sugerem que as fórmulas do CKD-EPI e MDRD também podem ter aplicabilidade nessa avaliação em gestantes. Detectou-se alta frequência de RN pré-termo ou com menos de 2500 g ao nascer ou PIG, assim como de sobreposição de DHEG (24,7%) em gestantes com HAC.

Abstract Introduction: Renal involvement in pregnant women with chronic hypertension is not widely known. Objectives: 1- To describe the epidemiological profile of pregnant women with chronic hypertension; 2- To evaluate urinary abnormalities (by urinalysis), renal function (serum creatinine and cystatin C, and estimated glomerular filtration rate (eGFR); 3- To evaluate the pregnancy outcome in chronic hypertension. Methods: 103 pregnant women with chronic hypertension (blood pressure over 140/90 mmHg, detected previously to pregnancy or until the 20th week) were submitted to clinical and laboratorial evaluation. Results: Pregnant women were 21-45 (mean: 34) years-old. Protein/creatinine ratio in random urine was elevated in 5.2% (0.0-6.4g/g), serum creatinine in 19.6% and cystatin C in 14.7% of them. It was observed that characteristics of pregnant patients and their newborns (vs. frequencies of the cases with CKD-EPI cystatin C < 60 ml/min/1.73 m2) were: 20.5% (33.3%) of preterm birth < 37 weeks, 17.5% (22.2%) of birth weight < 2500g and 17.5% (22.2%) of small for gestational age; superimposed preeclampsia-eclampsia occurred in 24.7% (22.2%) of the cases. Conclusions: Renal abnormalities were detected by proteinuria, determinations of serum creatinine and cystatin C in 5.2, 19.6 and 14.7% of the cases. The results suggest that the formulas CKD-EPI and MDRD can have applicability in assessing renal function in pregnant women. It was also shown a high frequency of preterm birth or with < 2500g at birth or small for gestational age, as well as of superimposed preeclampsia-eclampsia (24.7%) in pregnant women with chronic hypertension.

Taquicardia ventricular del tracto de salida del ventrículo derecho durante el embarazo / Right ventricular outflow tachycardia during pregnancy

Durante el embarazo aumentan el metabolismo basal, el consumo de O2, la frecuencia cardíaca, el volumen sistólico, el volumen minuto y la volemia y disminuyen la tensión arterial y la resistencia periférica. Diferentes estudios han demostrado que durante este período la posibilidad de que ocurra una arritmia cardíaca o se produzca la exacerbación de una arritmia preexistente es mayor. No obstante, en su enorme mayoría carecen de importancia pronóstica tanto para la madre como para el feto. La taquicardia ventricular del tracto de salida del ventrículo derecho es una arritmia poco frecuente y su aparición se ha correlacionado con el aumento del tono adrenérgico. Se presentan los casos de dos pacientes que mostraron en el curso de la gestación reiterados episodios de taquicardia ventricular del tracto de salida del ventrículo derecho. Se analiza la asociación del embarazo con la ocurrencia de trastornos del ritmo cardíaco.

During pregnancy, there is an increase in metabolism, oxygen consumption, heart rate, stroke volume, cardiac output, blood volume and a decrease in blood pressure and peripheral resistance. Studies have shown that during this period the occurrence of cardiac arrhythmias is not uncommon. Fortunately, malignant arrhythmias are rare. Herein we report two young patients who presented with symptomatic right ventricular outflow tachycardia during pregnancy that required antiarrhythmic therapy. Possible pathophysiologic mechanisms are discussed.

Síndrome de Eisenmenger y embarazo / The Eisenmenger's syndrome and the pregnancy

El síndrome de Eisenmenger se define como una enfermedad vascular pulmonar de tipo obstructivo que se desarrolla a partir de la existencia previa de una comunicación entre la circulación sistémica y pulmonar, con desviación de la corriente sanguínea de izquierda a derecha. Durante el embarazo conlleva una mortalidad fetal y materna superior al 50 por ciento. El objetivo de este trabajo es describir un caso clínico de una paciente con síndrome de Eisenmenger asociado al embarazo. Se presenta el caso clínico de una paciente de 16 años de edad, primigesta, con antecedentes de síndrome de Eisenmenger que acude al servicio de Cardiopatía y embarazo con una gestación de 20 sem. Se mantiene hospitalizada con evaluación de la calidad de vida fetal por sospecha de retardo del crecimiento y se utilizan inductores de la madurez pulmonar fetal en las sem 30 y 33 de gestación. A las 34,4 sem se le practica una cesárea electiva y esterilización quirúrgica. Se obtiene un recién nacido masculino, peso 1 958 g, apgar 9/9 sin incidentes anestÚsicos ni quirúrgicos durante el procedimiento. La evolución del puerperio inmediato y mediato es satisfactoria y egresa a los 36 días. El síndrome de Eisenmenger implica un alto riesgo de morbilidad y mortalidad materno-perinatal y el manejo multidisciplinario optimiza los resultados

Eisenmenger's syndrome is defined as a obstructive pulmonary vascular disease developed from the previous existence of a communication between the systemic and the pulmonary circulation with a deviation of blood stream from left to right. During pregnancy entails a mother and fetus mortality higher than 50 percent. The objective of present paper is to describe a clinical case of a patient presenting with Eisenmenger's syndrome seen in the Heart Disease service and a 20 weeks pregnancy. Remains admitted with an evaluation of the fetal quality of life due to suspicion of growth retardation using inductors of the fetal pulmonary maturity at 30 and 33 weeks of pregnancy. At 34.4 weeks she undergoes an elective cesarean section and surgical sterilization. She give birth a male newborn weighing 1 958 g, Apgar 9/9 without surgical and anesthetic backgrounds during procedure. Immediate puerperium evolution is satisfactory and is discharged at 36 days. The Eisenmenger's syndrome entails a high risk of morbidity and mortality for mother and for fetus, and the multidisciplinary management optimizes the results

Áscaris lumbricoides en el corazón de una gestante / Presence of Ascaris lumbricoides in the heart of a pregnant woman

El áscaris es el nematodo de mayor tamaño que parasita al hombre; es un helminto dioico (sexos separados). Su prevalencia se debe fundamentalmente a la contaminación fecal del suelo y a la capacidad de supervivencia de los huevos. Los adultos de áscaris lumbricoides se localizan en el intestino delgado, aunque algunas veces puede haber migraciones erráticas de parásitos adultos a lugares como el hígado, peritoneo, riñones, etc. Describir la forma de presentación del parasitismo intestinal por áscaris lumbricoides en una embarazada, actualizar e informar sobre el parasitismo intestinal, mostrar la experiencia en el manejo de un caso de difícil diagnóstico y transmitir conocimientos, contribuir a la docencia médica, son los objetivos de esta presentación. Se realizó una revisión bibliográfica sobre el parasitismo intestinal, específicamente del áscaris lumbricoides partiendo de la existencia de un caso obstétrico portadora de manifestaciones cardiovasculares importantes y de difícil manejo, por lo que se revisó exhaustivamente la historia clínica de dicha paciente en los 2 hospitales en los cuales estuvo ingresada. Paciente portadora de una gestación de 12 sem que acude con manifestaciones respiratorias y cardiovasculares, la primera impresión diagnóstica fue de una miocarditis o miocardiopatías, después de concluir estudios pertinentes se concluye como portadora de áscaris lumbricoides en corazón derecho y además se complica con un tromboembolismo pulmonar. A pesar de ser infrecuente en nuestros días, debemos pensar en el parasitismo como una explicación a ciertas sintomatologías de extraña presentación clínica

The ascaris is the higher nematode to parasitizes the man; it is dioecious helminths (having separate sexes). Its prevalence is due mainly to soil fecal contamination and to survival ability of eggs. The adult Ascaris lumbricoides are located in the small bowel, although some times may be erratic migrations of adult parasites to places like the liver, peritoneum, kidneys, etc. The aim of present paper is to describe the presentation way of intestinal parasitism by Ascaris lumbricoides in a pregnant woman, to update and to inform on the intestinal parasitism, to show the experience in the management of a case of difficult diagnosis and to transmit the knowledges, and to contribute to medical teaching. A bibliographic review on the intestinal parasitism was made, specifically of Ascaris lumbricoides from the existence of a obstetric case carrier of significant cardiovascular manifestations and of a difficult management, thus we made an exhaustive review of medical record of this patient in the two hospitals where she was admitted. A patient with 12 weeks pregnancy to come to consultation due to respiratory and cardiovascular manifestations, the first diagnostic impression was a myocarditis or myocardiopathies. After conclude the pertinent studies she is classified as a Ascaris lumbricoides carrier in right heart and that also it is complicated with a pulmonary thromboembolism. Despite this condition is infrequent nowadays, we must to think about the parasitism like an explanation for some symptomatology of a rare clinical presentation

Effect of physiological overload on pregnancy in women with mitral regurgitation

OBJECTIVES: to evaluate the structural and functional heart abnormalities in women with mitral regurgitation during pregnancy. INTRODUCTION: Women with mitral regurgitation progress well during pregnancy. However, the effects on the heart of the association between pregnancy and mitral regurgitation are not well established. METHODS: This is a case-control, longitudinal prospective study. Echocardiograms were performed in 18 women with mitral regurgitation at the 12th and 36th week of pregnancy and on the 45th day of the puerperium. Twelve age-matched healthy and pregnant women were included as controls and underwent the same evaluation as the study group. RESULTS: Compared with controls, women with mitral regurgitation presented increased left cardiac chambers in all evaluations. Increasing left atrium during pregnancy occurred only in the mitral regurgitation group. At the end of the puerperium, women with mitral regurgitation showed persistent enlargement of the left atrium compared with the beginning of pregnancy (5.0 ± 1.1 cm vs 4.6 ± 0.9 cm; p<0.05). Reduced left ventricular relative wall thickness (0.13 ± 0.02 vs 0.16 ± 0.02; p<0.05) and an increased peak of afterload (278 ± 55 g/cm² vs 207 ± 28 g/cm²;p<0.05) was still observed on the 45th day after delivery in the mitral regurgitation group compared with controls. CONCLUSIONS: Pregnancy causes unfavorable structural alterations in women with mitral regurgitation that are associated with an aggravation of the hemodynamic overload.

Fatores preditores para o óbito neonatal em gestações com diástole zero ou reversa na doplervelocimetria da artéria umbilical / Predictor parameters of neonatal death in gestations with absent or reverse end-diastolic flow in the umbilical artery doppler velocimetry

OBJETIVO: avaliar os fatores de risco antenatais e pós-natais para o óbito neonatal em gestações com diástole zero (DZ) ou reversa (DR) na doplervelocimetria da artéria umbilical. MÉTODOS: estudo transversal, retrospectivo, inferencial, a partir de 48 prontuários de gestações únicas com DZ ou DR, idade gestacional entre 24 e 34 semanas, em uma maternidade no Nordeste do Brasil. A média de idade foi de 27,3 anos (DP: 7,9). Vinte (41,7 por cento) eram primigestas. Síndromes hipertensivas foram observadas em 44 (91,7 por cento) casos. Trinta e cinco (72,9 por cento) apresentavam DZ e 13 (27,1 por cento) DR. Procedeu-se inicialmente à análise univariada (teste t de Student e teste Exato de Fisher), relacionando os parâmetros com o desfecho avaliado (óbito neonatal). As variáveis que apresentaram associação significativa foram incluídas no modelo de regressão logística (Estatística de Wald). O nível de significância utilizado foi de 5 por cento. RESULTADOS: a mortalidade perinatal foi de 64,6 por cento (31/48). Ocorreram cinco óbitos fetais e 26 neonatais. A média de idade gestacional no momento do diagnóstico foi de 27,9 (DP: 2,8) semanas. A resolução da gestação antes de 24 horas após o diagnóstico ocorreu em 52,1 por cento dos casos. Parto abdominal foi realizado em 85,4 por cento dos casos. Os recém-nascidos pesaram em média 975,9 g (DP: 457,5). Vinte e quatro (57,1 por cento) apresentaram Apgar menor que 7 no primeiro minuto e 21,4 por cento, no quinto. A idade gestacional no momento do diagnóstico, o peso ao nascer e o Apgar de primeiro minuto revelaram-se variáveis significativamente relacionadas com o óbito neonatal (valores de p foram, respectivamente, 0,008; 0,004 e 0,020). As razões de chance foi de 6,6; 25,3 e 13,8 para o óbito neonatal, quando o diagnóstico foi estabelecido até a 28ª semana, peso <1000 g e Apgar < 7, respectivamente. CONCLUSÕES: idade gestacional no momento do diagnóstico, peso ao nascer e Apgar de primeiro minuto foram fatores capazes de predizer o óbito neonatal em gestações com DZ ou DR na doplervelocimetria da artéria umbilical.

PURPOSE: to evaluate the antenatal and postnatal risk factors of neonatal death in pregnancies with absent (DZ) or reverse (DR) end-diastolic flow in the umbilical artery. METHODS: a cross-sectional retrospective study based on data from 48 medical records of singleton pregnancies with DZ or DR, and gestational age of 24 to 34 weeks, at a maternity in the Brazilian Northeast. Mean age was 27.3 (SD: 7.9) years. Twenty (41.7 percent) patients were primiparas. Hypertensive disorders were found in 44 (91.7 percent) cases. Thirty-five women (72.9 percent) had DZ and 13 (27.1 percent) had DR. Univariate analysis was firstly done (Student's t-test and Fisher's exact test) correlating the parameters with the assessed outcome (neonatal death). Variables that showed significant association were included in the logistic regression model (Wald statistics). The level of significance was set at 5 percent. RESULTS: The perinatal mortality rate was 64.6 percent (31/48). There were five stillbirths and 26 neonatal deaths. The mean gestational age at diagnosis was 27.9 (SD: 2.8) weeks. Deliveries before 24 hours after diagnosis occurred in 52.1 percent of the cases. Cesarean section was performed in 85.4 percent of the sample. The newborns weighed 975.9 g on average (SD: 457.5). Twenty-four (57.1 percent) presented Apgar scores below 7 in the first minute and 21.4 percent in the fifth minute. Gestational age at diagnosis, birth weight and Apgar of the first minute proved to be variables significantly related to neonatal death (p values were: 0.008, 0.004, and 0.020, respectively). The Odds Ratio was 6.6, 25.3 and 13.8 for neonatal death, when the diagnosis was established at the 28th week, weight was <1000 g and first minute Apgar score was <7, respectively. CONCLUSIONS: gestational age at diagnosis, birth weight and Apgar score at the first minute were factors that could predict neonatal death in pregnancies with DV or DR determined by umbilical artery Doppler velocimetry.

Pregnancy and non-valvular heart disease - Anesthetic considerations.

Non-valvular heart disease is an important cause of cardiac disease in pregnancy and presents a unique challenge to the anesthesiologist during labor and delivery. A keen understanding of the underlying pathophysiology, in addition to the altered physiology of pregnancy, is the key to managing such patients. Disease-specific goals of management may help preserve the hemodynamic and ventilatory parameters within an acceptable limit and a successful conduct of labor and postpartum period..

Anestesia para gestante cardiopata / Anaesthesia for pregnant cardiac disease

Gestantes com doença cardíaca habitualmente possuem prognóstico favorável tanto materno quanto fetal. Com exceção das pacientes com a síndrome de Eisenmenger, hipertensão pulmonar primária e síndrome de Marfan com aortopatia, morte materna durante a gravidez em pacientes cardiopatas é rara. A gravidez por si só impõe modificações hemodinâmicas significativas, colocando à prova o sistema cardiovascular. Doença cardíaca reumática é a mais frequente nas gestantes, e o edema agudo pulmonar, a complicação mais comum. Defeito do septo atrial é a cardiopatia congênita acianótica mais prevalente na população adulta, enquanto que a Tetralogia de Fallot é a mais frequente das cardiopatias congênitas cianóticas. Gravidez e cardiopatia são uma associação de grandes desafios para o anestesiologista. Para evitar complicações decorrentes da morbidade ou mortalidade materno-fetal, o anestesiologista deve conhecer a evolução da doença durante a gravidez. Aqui são discutidas a fisiopatologia, apresentação clínica e a condução anestésica das doenças cardíacas valvulares adquiridas, das doenças cardíacas congênitas, da doença isquêmica do miocárdio e das miocardiopatias na gravidez.

Pregnancy in most women with heart disease has a favorable maternal and fetal outcome. With the exception of patients with Eisenmenger syndrome, pulmonary hypertension primary, and Marfan syndrome with aortopathy, maternal death during pregnancy in women with heart disease is rare. Pregnancy per se imposes significant hemodynamic changes placing a major burden on the cardiovascular system. Rheumatic heart disease remains the most frequent heart disease in the pregnant population and the pulmonary edema is the most frequent complication. Atrial septal defect is the most frequent congenital acianotic heart disease in the adult population, whereas tetralogy of Fallot is the most common cyanotic congenital heart disease. Pregnancy and heart disease present a unique challenge to the anesthesiologist. To avoid untoward complications resulting in significant maternal and/or fetal morbidity or mortality, the anesthesiologist must be familiar about the progression of heart disease during pregnancy. In this article, we review the pathophysiology, clinical presentation, and anesthetic management of valvular, congenital, vascular and ischemic heart disease, and cardiomyopathy in pregnancy.

Resultados maternos e perinatais em pacientes com disfunção sistólica grave / Maternal and perinatal outcome in patients with severe systolic dysfunction

OBJETIVO: O objetivo deste trabalho é avaliar os resultados maternos e perinatais em gestantes com disfunção sistólica grave de ventrículo esquerdo acompanhadas em hospital terciário durante a gestação, parto e puerpério imediato. MÉTODOS: Doze pacientes com disfunção ventricular grave, definida por fração de ejeção <40 por cento em ecocardiograma realizado durante a gestação, foram avaliadas retrospectivamente. Os dados incluíram ocorrência de complicações clínicas e obstétricas, características do parto e resultados neonatais. As complicações clínicas consideradas foram aparecimento ou piora da dispnéia, arritmia, acidente vascular cerebral, tromboembolismo pulmonar, edema agudo de pulmão, parada cardíaca e morte. RESULTADOS: A média da fração de ejeção das pacientes foi 28,9+-6,47 por cento (mediana: 30 por cento). Quatro pacientes iniciaram o pré-natal em classe funcional III e oito com classe I ou II. Dez pacientes apresentaram piora da dispnéia durante a gravidez. A complicação clínica mais comum foi edema agudo de pulmão (Três pacientes). Três das quatro pacientes que iniciaram o pré-natal em classe funcional III apresentaram boa evolução da gravidez; a outra apresentou parto prematuro devido à piora dos sintomas. Houve dois partos vaginais e 10 cesáreas. Dez dos 13 recém-nascidos foram pequenos para idade gestacional. Uma paciente, que já tinha indicação de transplante cardíaco antes da gestação, apresentou descompensação clínica durante a gravidez e evoluiu para edema agudo de pulmão e choque cardiogênico, realizando o transplante dois meses após o parto. Não houve morte materna ou neonatal. CONCLUSÕES: Embora o número de gestações avaliadas tenha sido pequeno, deve-se rever a indicação de abortamento terapêutico em gestantes com disfunção ventricular esquerda grave, uma vez que todas as gestações evoluíram até a viabilidade. Os recém-nascidos destas mães apresentaram grande incidência de restrição do crescimento intra-uterino...

OBJECTIVE: The objective of this study was to evaluate maternal and fetal outcome in patients with severe left ventricle systolic dysfunction followed in a terciary-care hospital. METHODS: We retrospectively evaluated 12 pregnant women with severe systolic dysfunction, defined as a ejection fraction <40 percent. Follow-up data included functional class evaluation, ocurrency of cardiac and obstetric events, labor data and neonatal outcome. Cardiac events were defined as new onset of arrhythmias, stroke, pulmonary thrombosis, pulmonary edema, cardiac arrest, and death. RESULTS: The mean ejection fraction was 28,9±6,47 percent. Four patients were in the NYHA class III, and 8 in class I or II on presentation. Ten patients had deteriorated during pregnancy. The most common cardiac event was pulmonary edema (3 patients). Three of the four patients with class III on presentation had a good evolution during pregnancy, and the other one had preterm delivery due to worsening symptons. There were 2 vaginal espontaneous deliveries and 10 cesarean sections. Small-for-gestational-age birthweigth ocurred in 10 pregnancies. There was no maternal or neonatal death. CONCLUSIONS: Pregnancy in patients with severe left ventricle systolic dysfunction increases the risk of maternal complications and compromises fetal growth. It is important to follow this women in a tertiary-care hospital.

Outcomes of Pregnancy in Women with Congenital Heart Disease: A Single Center Experience in Korea

Pregnancy outcomes in patients with congenital heart disease have not been fully assessed in Korea. Forty-nine pregnancies that occurred in 34 women with congenital heart disease who registered at our hospital between September 1995 and April 2006 were reviewed. Spontaneous abortions occurred in two pregnancies at 6+1 and 7 weeks, and another two underwent elective pregnancy termination. One maternal death in puerperium occurred in a woman with Eisenmenger syndrome. Maternal cardiac complications were noted in 18.4%, pulmonary edema in 16.3%, symptomatic arrhythmia in 6.1%, deterioration of New York Heart Association (NYHA) functional class by > or =2 in 2.0%, and cardiac death in 2.0%. Independent predictors of adverse maternal cardiac events were an NYHA functional class of > or =3 (odds ratio [OR], 20.3), right ventricular dilation (OR, 21.2), and pulmonary hypertension (OR, 21.8). Neonatal complications occurred in 22.4% of pregnancies and included preterm delivery (16.3%), small for gestational age (12.2%), and neonatal death (2.0%). Independent predictors of adverse neonatal events were pulmonary hypertension (OR, 6.8) and NYHA functional class > or =3 (OR, 23.0). Pregnancy in women with congenital heart disease was found to be significantly associated with maternal cardiac and neonatal complications. Pre-pregnancy counseling and multidisciplinary care involving cardiologists and obstetricians are recommended for women with congenital heart disease contemplating pregnancy.

Heart diseases during pregnancy

Improvements in health care services in recent decades have permitted more frequent identification of pregnant women with congenital and acquired heart disease. Normal pregnancy and the peripartum period are associated with considerable cardiocirculatory changes, which are usually well tolerated by the mother. However, the increased cardiac demands imposed by those changes may at times unmask cardiac disease in presumably normal women or increase morbidity and mortality in women with established heart disease. A recognition and understanding of these changes is essential for providing optimal care to obstetrical patients with cardiac disorders. This article offers a brief review of those cardiocirculatory changes during pregnancy and of the main features of various congenital and valvular heart disorders frequently referred for advice to our cardiology practice, along with recommendations for their management and follow up.

Effects of L-arginine oral supplements in pregnant spontaneously hypertensive rats

OBJETIVO: Avaliar os efeitos da oferta oral de L-arginina em ratas prenhas espontaneamente hipertensivas (SHR).MÉTODOS: 30 SHR e 10 Wistar-EPM-1 ratas virgens foram utilizadas no estudo. Antes da distribuição, as fêmeas foram acasaladas com machos da mesma linhagem (3:1); a prenhez foi confirmada pela presença de espermatozóides no esfregaço vaginal. As ratas Wistar-EPM-1 foram utilizadas como controles. As ratas SHR foram aleatoriamente distribuídas em 4 grupos (n=10): Grupo Controle-2, não-tratado; Grupo L-Arginina, tratado com L-arginina; Grupo Alfa-metildopa, tratado com alfa-metildopa; Grupo L-Arginina+Alfa-metildopa, tratado com arginina+Alfa-metildopa. L-arginina (2%) foi oferecida ad libitum na água de beber e a Alfa-metildopa (33 mg/Kg) foi administrada por gavagem, duas vezes ao dia, durante toda a prenhez (20 dias). Aferição da pressão arterial (PA) foi realizada por pletismografia da cauda, nos dias 0 e 20 e dos pesos nos dias 0-10-20. Resultados foram expressos como média±DP (Desvio Padrão). Testes estatísticos apropriados (ANOVA unidirecional/Tukey ou Kruskal-Walli/Dunn) foram utilizados para comparações intergrupais. P<0,05 foi considerado significante.RESULTADOS: Não houve ganho de peso significante nas ratas tratadas com L-arginina. A PA média diminuiu no Grupo L-Arginina comparado ao Grupo Controle-2. CONCLUSÃO: A oferta oral de L-arginina reduz a PA em ratas SBP durante a prenhez.

Estudo da reatividade vascular induzida pelo estresse mental na gravidez de mulheres portadoras de estenose mitral / Vascular reactivity response to mental stress in pregnant women with mitral stenosis

OBJETIVO: Estudar a reatividade vascular mediante a análise do fluxo sangüíneo e da resistência vascular periférica em repouso e estresse mental na gravidez de mulheres com estenose mitral. MÉTODOS: Foram estudadas 22 mulheres portadoras de estenose mitral, 13 grávidas (GE) e 9 não-grávidas (EM), e 9 gestantes saudáveis voluntárias (GN). Na gestação, 9 (GEB) das 13 do GE necessitaram de betabloqueador e 4 restantes (GESB) evoluíram sem medicação. A plestimografia em repouso e sob estresse mental analisou o fluxo sangüíneo muscular, resistência vascular periférica (RVP), pressão arterial média (PAM) e freqüência cardíaca (FC) na gestação e no puerpério. RESULTADOS: Na gestação do GESB, os valores do fluxo sangüíneo muscular e da FC foram maiores em 1,6 por cento e 20,5 por cento (p = 0,05), e os da RVP e da PAM foram menores em 19,3 por cento e 4,4 por cento, respectivamente, em comparação ao puerpério; no estresse mental, o fluxo sangüíneo muscular aumentou em 55,9 por cento, a FC reduziu em 30,2 por cento e houve semelhança da RVP e PAM. No GEB, os valores do fluxo e da FC foram maiores em 5,9 por cento e 14,9 por cento (p = 0,001) e os da PAM e da RVP menores em 10,3 por cento e 9,1 por cento, respectivamente, quando comparados ao puerpério; no estresse mental o fluxo e a PAM aumentaram em 69,8 por cento e 174,1 por cento, respectivamente, a FC foi semelhante e a RVP reduziu em 53,7 por cento. O estudo comparativo mostrou que no grupo GN o fluxo sangüíneo muscular foi maior, a RVP menor e houve semelhança na PAM e FC em relação ao grupo GE e que os grupos GE, GN, EM apresentaram semelhança na resposta ao estresse mental. CONCLUSÕES: A reatividade vascular na gestação de mulheres com estenose mitral foi preservada e a análise das medidas mostrou valores menores de fluxo sangüíneo muscular e maiores da RVP quando comparados às gestantes saudáveis.

Vascular change in the placenta of diabetic mothers and hypertensive diabetic mothers.

Pregnancy complicated by diabetes and/or hypertension is a significant medical problem not only affecting maternal health, but also jeopardizing fetal normalcy. The placenta being the bridge between maternal fetal activity, this structure is considered as a window through which understanding of maternal dysfunctions as well as of their impacts on fetal wellbeing can be obtained. And as it is an almost all-vessel organ, its functional status depends primarily on the structural status of its vessels. To observe vascular changes in the placenta, a study was carried out on 44 placentas.19 from overt diabetic mothers having no hypertension and 5 from hypertensive diabetic mothers, and 20 from control group having no hypertension or diabetes. These were collected just after delivery though caesarian section. Macroscopic findings of the study was that there was a trend of increase weight, volume and number of cotyledons in overt diabetes group, where as the in the hypertensive diabetes group was the opposite. But none of these levels has reached a significant level. For all these variables, the hypertensive diabetes group had smaller values than the overt diabetes group, significantly so for the number of cotyledons. The placental diameter was non-significantly larger in the overt diabetes group than in the control group, but a smaller than control value was found in the hypertensive diabetes group. Although neonatal weight did not show any significant change in either group, but in overt diabetes group, it showed a significant positive correlation with placental weight.