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.

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.

Perinatal outcome of hypertensive pregnant women is related to the severity of preeclampsia

Introduction: Hypertension in pregnancy plays a key role in perinatal morbidity and mortality. This study aims to analyze maternal and perinatal outcomes associated with hypertension in pregnant women. Methods: A prospective longitudinal study was conducted at the University Hospital of Santa Maria, RS, Brazil, involving hypertensive pregnant women admitted for delivery. The results were analyzed using the chi-square test and the Mann-Whitney test. Results: Of the 162 hypertensive pregnant women studied, 61.1% were diagnosed with preeclampsia. Cesarean section was the most frequent mode of delivery (79.6%). Overall, 46.2% of newborns were premature; of these, 23.4% required intensive neonatal care. Preeclampsia and severe preeclampsia were associated with prematurity in 56.2% of cases (p = 0.011) and 75.7% of cases (p = 0.004), respectively. Severe preeclampsia was associated with neonatal complications (45.9%), and no neonatal complications were associated with mild preeclampsia in 78% (p = 0.014) and gestational hypertension in 96% (p = 0.001). Neonatal deaths occurred in 11.1% of cases admitted to the neonatal intensive care unit, corresponding to a neonatal mortality rate of 24 per 1,000 live births. Conclusions: The association of severe preeclampsia with prematurity and adverse perinatal outcomes corroborates the need . (AU)

Guía de práctica clínica para la prevención de eventos tromboembólicos venosos durante la gestación, el parto o el puerperio / Clinical practice guideline for the prevention of venous thromboembolic events during pregnancy, childbirth or postpartum period

RESUMEN Objetivo: reducir la variabilidad injustificada y apoyar a los profesionales de la salud con la mejor evidencia en torno a la efectividad y seguridad de las intervenciones disponibles para la prevención de eventos tromboembólicos venosos durante la gestación, el parto o el puerperio, y generar indicadores de implementación para la guía. Materiales y métodos: se configuró el grupo desarrollador en el que participaron profesionales de la salud y un representante de los pacientes. Se formularon preguntas clínicas contestables, se graduaron los desenlaces y se realizó la búsqueda sistemática de guías de práctica clínica. Estas fueron analizadas en términos de su rigor metodológico, y dado que ninguna de ellas fue susceptible de adaptación, se procedió al desarrollo de Novo. Se realizó la búsqueda de revisiones sistemáticas, ensayos clínicos y estudios observacionales en Medline vía PudMed, Embase y Central. La calidad de la evidencia, al igual que la dirección y la fortaleza de las recomendaciones, fueron establecidas según la metodología GRADE (Grading of Recommendations Assessment, Development and Evaluation). Resultados: se presenta la versión corta de la guía de práctica clínica para "la prevención de eventos tromboembólicos venosos durante la gestación, el parto o el puerperio", con sus respectivas recomendaciones, evidencia de soporte y criterios de auditoría. Conclusión: como recomendación central para la implementación se propone el uso de un instrumento para graduar el riesgo y el uso de intervenciones no farmacológicas y farmacológicas para la prevención primaria. La Guía deberá actualizarse en tres años.

ABSTRACT Objective: To reduce unwarranted variability and support healthcare professionals with the best available evidence regarding effectiveness and safety of the interventions used for the prevention of venous thromboembolic events during pregnancy, childbirth or the postpartum period, and to develop guideline implementation indicators. Materials and methods: The team of developers consisted of healthcare professionals and one patient representative. Answerable clinical questions were asked, outcomes were graded, and a systematic search of clinical practice guidelines was performed. The latter were analysed for methodological quality and when it was found that none of them could be adapted, a de novo development was undertaken. A search was conducted of systematic reviews, clinical trials and observational studies in PubMed, EMBASE and Central. The GRADE methodology (Grading of Recommendations Assessment, Development and Evaluation) was used to graduate the quality of the evidence as well as the direction and strength of the recommendations. Results: The abridged version of the clinical practice guideline for the "prevention of venous thromboembolic events during pregnancy, childbirth or the postpartum period" is presented together with the respective recommendations, supporting evidence and audit criteria. Conclusion: The core recommendation for implementation is the use of a tool to assess risk, as well as pharmacological and non-pharmacological interventions for primary prevention. The Guideline must be updated in three years.

Cesación de tabaquismo en embarazo / Smoking cessation in pregnancy

Resumen En Chile, las mujeres en edad fértil y las embarazadas presentan una alta prevalencia de tabaquismo. El consumo de tabaco durante el embarazo tiene efectos prenatales (por ejemplo, aborto espontáneo, mortinatalidad) y es un factor de riesgo de morbilidad y mortalidad infantil. Todas las mujeres en edad fértil deben ser alentadas a dejar de fumar, y las mujeres que ya están embarazadas deben ser alentadas a dejar de fumar continuamente durante todo el embarazo, desde el momento más precoz posible hasta el período posterior al parto. Se presenta un conjunto de antecedentes y recomendaciones para la cesación de tabaquismo en embarazadas, basadas en guías internacionales sobre este tema.

In Chile, women of childbearing age and pregnant women have a high prevalence of smoking. Tobacco use during pregnancy has antenatal effects (spontaneous abortion, stillbirth) and it is a risk factor for infant morbidity and mortality. All women of childbearing age should be encouraged to quit smoking, and women who are already pregnant should be encouraged to stop smoking continuously throughout the pregnancy, from the earliest possible moment to the postpartum period. We present a set of background information and recommendations for smoking cessation in pregnant women, based on international guidelines on this topic.

Repercusión del embarazo en gestantes con diagnóstico de cardiopatía congénita / Repercussion of pregnancy in women diagnosed with congenital heart disease

Introducción: Las mujeres cardiópatas estuvieron "condenadas" durante muchos años a no poder asumir la maternidad debido al riesgo incrementado de mortalidad materna que el embarazo representaba para ellas, actualmente el 85 porciento o más de estas pacientes sobreviven la edad de 18 años, y muchas, dependiendo del tipo específico de la afectación cardiaca y el grado de corrección que se le pueda realizar, pueden tener una expectativa de vida similar a la población general. Objetivo: describir los resultados perinatales obtenidos en las pacientes embarazadas con diagnóstico de cardiopatía congénita, a partir de la aplicación de un protocolo de trabajo realizado por un grupo multidisciplinario de especialistas. Métodos: se realizó un estudio descriptivo prospectivo transversal, en el que se analizaron factores clínicos y perinatológicos asociados a las gestantes con cardiopatías congénitas, atendidas en el Servicio de Cardiopatía y Embarazo del Hospital Ramón González Coro, en el municipio Plaza, provincia La Habana, en el periodo correspondiente entre el 1ro. de enero de 2000 y el de 31 de diciembre de 2010. Resultados: el 75 porciento, de las pacientes se embarazó antes de los 30 años de edad. El 10,4 porciento, presentó morbilidad de causa obstétrica y entre ellas prevaleció la diabetes gestacional. Hubo agravamiento de la clasificación funcional I al inicio del embarazo a II y III al momento del parto. No hubo recién nacido con diagnóstico de cardiopatía congénita. Conclusión: Con la aplicación del Protocolo de Atención a la Gestante Cardiópata se han logrado resultados perinatales alentadores en la gestante con cardiopatía congénita

Introduction: for many years, the women presenting with heart disease were condemned to not to get pregnant due to the increased risk of maternal mortality caused by it, nowadays the 85 percent or more of these patients survives the 18 years old, and many of them, depending on the type specific of cardiac affection and the degree of a potential correction, may to have a life expectancy similar to general population. Objective: to describe the perinatal results obtained in pregnant patient diagnosed with congenital heart disease, from the implementation of a work protocol conducted by a multidisciplinary group of specialists. Methods: a cross-sectional, prospective and descriptive study was conducted to analyze the clinical and perinatology factors associated with congenital heart diseases seen in the Heart Disease and Pregnancy Service of the Ramón González Coro Hospital of the Plaza municipality of La Habana from January 1, 2000 to December, 31 2010. Results: the 75 percent of patients got pregnants at 30 years old. The 10.4 percent had a morbidity of obstetric cause and among them prevailed the gestational diabetes. There was worsening of functional I classification at onset of pregnancy at II and III at delivery. There was not newborn diagnosed with congenital heart disease. Conclusion: with the implementation of the Protocol of Care to Heart Disease Patient it has been possible to achieve encouraging perinatal results in pregnant presenting with congenital hart disease

Caracterización del riesgo cardiovascular y del síndrome metabólico en gestantes con riesgo de preeclampsia/eclampsia / Characterization of cardiovascular risk and metabolic syndrome in pregnant women at risk of preeclampsia / eclampsia

Entre los factores de riesgo de preeclampsia eclampsia se incluye el riesgo cardiovascular y del síndrome metabólico. Objetivos: identificar factores de riesgo cardiovascular y del síndrome metabólico en una población de gestantes con riesgo de preeclampsia eclampsia. Método: estudio descriptivo de corte transversal en el Municipio de Santa Clara, Villa Clara, en el año 2011. La muestra se conformó con 181 gestantes con al menos dos factores de riesgo...

Avaliação de implementação das ações de controle da gestação de alto risco: cuidados à gestante com doença hipertensiva específica da gravidez e aos seus conceptos / Evaluation of implementation of actions to control high-risk pregnancies, care for pregnant women with hypertensive disorders of pregnancy and their fetuses

A iniciativa deste estudo nasceu da necessidade de avaliar a qualidade das ações de controle da assistência à gestação de alto risco, mais especificamente nos cuidados prestados à gestante com doença hipertensiva específica da gravidez (DHEG) e aos seus conceptos. Objetivou esta pesquisa no grau de implementação, identificar os fatores facilitadores do contexto institucional e verificar a conformidade como desfecho de sucesso de implementação com o padrão ouro. Nesta análise, com foco no processo, optou-se pela avaliação formativa e como estratégia o estudo de caso único. No contexto desta avaliação foi abordada a dimensão qualidade técnico-científica aqui considerada conformidade às normas e critérios preconizados pelo Ministério da Saúde, entendida nas subdimensões: disponibilidade, oportunidade e acomodação. O desenho metodológico deste estudo envolveu a análise de prontuários de gestantes com DHEG; aplicação de questionários com o gestor e profissionais de saúde; observação direta na assistência ao pré-parto, parto e pós-parto; roteiro de verificação do laboratório e da farmácia e análise documental...

The initiative of this study came from the need of evaluating the quality of the control actions of the assistance to the high risk pregnancy, more specifically in the assistance given to the patients with Hipertensive Illness Specific from Pregnancy (DHEG in Portuguese) and to her newborns. This research aimed at, in the implementation degree, identifying the facilitating factors of the institutional context and verifying the conformity as ending of implementation success with the gold pattern. In this analysis, the formative evaluation and the single-case study strategy were chosen, focusing on the process. In the context of this evaluation the scientific-technical quality dimension was mentioned, considered here according to the standards and criteria recommended by the Ministry of Health, understood in the sub dimensions: availability, opportunity and accommodation. The methodological drawing of this study involved the analysis of the pregnant women’s (with DHEG) records; administration of questionnaires with the manager and health professionals; direct observation in the assistance to the prenatal, birth and post-partum; script of verification of the laboratory and the drugstore and the documental analysis...

Impacto de la creación de un programa de educación para la salud de los trastornos hipertensivos de la gestación / Creation impact of a health education program related to pregnancy hypertensive disorders

INTRODUCCIÓN: la hipertensión arterial inducida por el embarazo o hipertensión gestacional representa una de las afecciones más temidas por el obstetra, debido a que su aparición puede ser súbita, su presentación clínica variable, y su evolución rápida. OBJETIVO: demostrar el impacto en el nivel de conocimiento sobre estos trastornos, a partir de la creación de una escuela de promoción de salud acerca de los trastornos hipertensivos de la gestación y sus factores de riesgo. MÉTODOS: estudio experimental (cuasi experimental) de tipo intervención comunitaria en fase confirmatoria, que consistió en un programa de educación para la salud. Para ello se utilizó un universo de estudio de 25 gestantes con trastornos hipertensivos, y 17 gestantes aparentemente sanas. RESULTADOS: hubo un cambio en el nivel de conocimientos para la mayoría de los factores de riesgo, que se incrementó después de la intervención comunitaria. Durante la pesquisa activa de factores de riesgo para los trastornos hipertensivos de la gestación en las 17 gestantes aparentemente sanas, los que más incidieron fueron los antecedentes familiares de hipertensión arterial, la presencia de enfermedades crónicas, y las condiciones socioeconómicas regulares y malas. CONCLUSIÓN: se demostró el favorable impacto de la propuesta de intervención comunitaria relacionado con los factores de riesgo modificables de los trastornos hipertensivos de la gestación al incrementarse el nivel de conocimientos relacionados con este tema...

INTRODUCTION: pregnancy-induced arterial hypertension or gestational hypertension is one of the more feared by obstetrician due to that its appearance could be sudden, the variation in its clinical presentation, and quickly course. AIM: to demonstrate the impact at level of knowledge on these disorders, from the creation of a health promotion school related to pregnancy hypertensive disorders and its risk factors. METHODS: an experimental (quasi experimental) of community intervention type in confirmatory phase consisting of a health education program including a cohort of 25 pregnant women presenting with hypertensive disorders, and 17 apparently health pregnant women. RESULTS: there was a change in knowledge level for most of risk factors increasing after community intervention. During active investigation of risk factors for pregnancy hypertensive disorders in the 17 apparently health pregnants, the great incidence was in the family backgrounds related to arterial hypertension, presence of chronic diseases, and the regular and poor social-economic conditions. CONCLUSIONS: the favorable impact of community intervention proposal was demonstrated related to modifiable risk factors of pregnancy hypertensive disorders at increase the knowledge level related to this matter...

Anticoagulation for pregnant patients with mechanical heart valves.

Management of a pregnant patient with mechanical heart valve is a complex issue for all health care providers involved in the care of such patients. Complications may arise at any stage due to the increased haemodynamic load imposed by pregnancy or because of impaired cardiac performance often seen in these patients. In addition, the use of various cardiovascular drugs in pregnancy (especially anticoagulants) may lead tofoetal loss or teratogenic complications. Additionally, the risk of thrombo-embolic complications in the mother is increased by the hypercoagulable state of pregnancy. In this review, we have attempted to draw inferences to guide management of such patients based on the available literature. It seems that in pregnant women with mechanical heart valves, recent data support warfarin use throughout pregnancy, followed by a switch to heparin and planned induction of labour. However, the complexity of this situation demands a cafeteria approach where the patient herself can choose from the available options that are supported by evidence-based information. Unfortunately there is no consensus on such data. An overview of the available literature forms the basis of this review. In conclusion, a guideline comprising pragmatic considerations is preffered.

Maternal mortality due to arterial hypertension in São Paulo City (1995-1999)

AIM: To describe the case profile of maternal death resulting from hypertensive disorders in pregnancy and to propose measures for its reduction. METHODS: The Committee on Maternal Mortality of São Paulo City has identified 609 cases of obstetric maternal death between 1995 and 1999 with an underreporting rate of 52.2 percent and a maternal mortality rate of 56.7/100,000 live births. Arterial hypertension was the main cause of maternal death, corresponding to 142 (23.3 percent) cases. RESULTS: Ninety-five (66.9 percent) of the deaths occurred during the puerperal period and 34 (23.9 percent) occurred during pregnancy. The time of death was not reported in 13 (9.2 percent) cases. Seizures were observed in 41 cases and magnesium sulfate was used in four of them. The causes of death were ruled to be cerebrovascular accident (44.4 percent), acute pulmonary edema (24.6 percent), and coagulopathies (14.1 percent). Cesarean section was performed in 85 (59.9 percent) cases and vaginal delivery in 15 (16.0 percent). CONCLUSION: Complications of arterial hypertension are responsible for the high rates of pregnancy-related maternal death in São Paulo City. Quality prenatal care and appropriate monitoring of the hypertensive pregnant patient during and after delivery are important measures for better control of this condition and are essential to reduce disorders in pregnancy.

OBJETIVO: Descrever o perfil dos casos de morte materna decorrente de complicações da hipertensão arterial e propor medidas para sua redução. MÉTODOS: De 1995 a 1999 o Comitê de Mortalidade Materna da Cidade de São Paulo identificou 609 casos de morte materna obstétrica, com uma subnotificação de 52,2 por cento e um CMM=56,7/100.000 Nascidos Vivos. A hipertensão arterial foi a principal causa de óbito materno, correspondendo a 142 (23,3 por cento) casos. RESULTADOS: Ocorreram 95 (66,9 por cento) de óbitos no puerpério e 34 (23,9 por cento) durante a gestação. Em 13 (9,2 por cento) casos não se teve referência ao momento do óbito. Houve relato de crises convulsivas em 41 casos com a utilização de sulfato de magnésio em quatro deles. As principais causas determinantes do óbito foram: o acidente vascular cerebral (44,4 por cento), o edema agudo de pulmão (24,6 por cento) e as coagulopatias (14,1 por cento). A cesárea foi realizada em 85 (59,9 por cento) casos e o parto vaginal em 15 (16,0 por cento). Em 28 (19,7 por cento) casos não foi realizada nenhuma conduta para interromper a gravidez e em 14 (9,8 por cento) não se obteve relato do procedimento. CONCLUSÃO: As complicações da hipertensão arterial no ciclo gravídico-puerperal determinam altos índices de mortalidade materna na cidade de São Paulo. A realização de um pré-natal de qualidade e o atendimento apropriado da gestante hipertensa no parto e no pós-parto são medidas de fundamental importância para um melhor controle desse evento, sendo primordial para a redução dessas ocorrências.

Anticoagulación y embarazo / Anticoagulation and pregnancy

Se comentan los aspectos clínicos del tratamiento anticoagulante en la paciente embarazada.

Predicao da acidose no nascimento em gestacao com diastole zero ou reversa a dopplervelocimetria das arterias umbilicais / Predicting acidosis at birth in pregnancies with absent or reverse end-diastolic flow velocity diagnosed through dopplervelocimetry of the umbilical arteries

A diastole zero e a diastole reversa demonstram grave insuficiencia placentaria, merecendo intensiva vigilancia do bem estar fetal. O conhecimento de um teste de avaliacao da vitalidade fetal de predicao da acidose no nascimento em casos de diastole zero ou diastole reversa a dopplervelocimetria das arterias umbilicais pode facilitar a escolha do melhor momento para interrupcao da gestacao diminuindo assim a mortalidade e a morbidade perinatal nestes casos

Efeito do atendimento fisioterapico no puerperio imediato para pacientes portadoras de hipertensao arterial induzida pela gravidez / Physical therapy effects on patients who have developed induced pregnancy hipertension in postpartum stage

Esta pesquisa tem como objetivo avaliar o comportamento pressorico das puerperas portadoras de HAIG quando submetidas a um protocolo de tratamento fisioterapico no Puerperico imediato. Foram selecionadas 33 puerperas e submetidas ao...

Fatores geneticos na pre-eclampsia / Genetics factors in preeclampsia

A pre-eclampsia e uma patologia sistemica da gravidez bastante frequente e muitas vezes perigosa, caracterizada por hipertensao e proteinuria, sendo ainda a maior causa de mortalidade materna em nosso meio. Neste artigo enfatizamos a correlacao entre a pre-eclampsia e os aspectos geneticos e imunologicos, e sua relacao com possiveis fatores etiologicos. Abordamos aspectos familiares (antecedentes), fatores paternos, fatores fetais (cromossomopatias e malformacoes), fatores genicos e fatores imunologicos para compreendermos melhor possiveis desencadeantes desta patologia e atuarmos de maneira adequada na sua prevencao

Profilaxis de la hipertensión arterial tipo III con el uso de la aspirina / Prophylaxis of type III arterial hypertension with the use of aspirin

Se realiza un estudio, en el período comprendido entre enero de 1994 hasta enero de 1995, con 104 gestantes diagnosticadas como hipertensas crónicas en la consulta externa del hospital docente ginecoobstétrico de Matanzas. Del total de la muestra, 54 fueron tratadas con dosis bajas en aspirina y en 50 no se aplicó este tratamiento. Las gestantes que utilizaron bajas dosis de aspirina, no desarrollaron hipertensión arterial tipo III (HTA III), ni se presentaron en las mismas complicaciones materno-fetales