Cardiomiopatia periparto / Peripartum cardiomyopathy

A cardiomiopatia periparto (CMPP) é uma forma de cardiomiopatia dilatada, caracterizada pelo desenvolvimento de insuficiência cardíaca sistólica no período entre o último mês da gravidez e os cinco meses pós-parto. A incidência estimada varia entre 1/1.300 a 1/15.000 gestações. Admitem-se como fatores de risco para CMPP a idade materna avançada, multiparidade, raça negra, gestação gemelar, obesidade, pré-eclâmpsia e doença hipertensiva gestacional. A etiologia da CMPP permanece incerta, mas possíveis causas têm sido propostas, incluindo miocardite, resposta imune anormal a gravidez, má resposta adaptativa hemodinâmica à gestação, citocinas ativadas pelo stress, infecção viral, uso prolongado de tocolíticos, hereditariedade, déficits nutricionais e distúrbios hormonais. Os sinais e sintomas presentes na CMPP são semelhantes aos que aparecem em pacientes com insuficiência cardíaca de outras causas. O diagnóstico é confirmado pelo ecocardiograma, que mostra objetivamente a presença de disfunção ventricular esquerda. O tratamento é semelhante ao da insuficiência cardíaca de outras etiologias, sendo os inibidores da enzima de conversão da angiotensina e os bloqueadores dos receptores da angiotensina II evitados durante a gravidez (devido aos efeitos tóxicos para o feto), porém indicados no período puerperal, não interferindo na lactação. O papel dos imunossupressores no tratamento da CMPP ainda é controverso. Estudos bem desenhados são fundamentais para que se descubra a etiologia, que poderá orientar um tratamento específico, levando a uma melhor evolução dos pacientes com essa doença.

Peripartum cardiomyopathy (PPCM) is a disorder of dilated cardiomyopathy and left ventricular dysfunction occurring in the last month of pregnancy of within five months postpartum. Incidence of PPCM ranges from 1/1.300 to 1/15.000 pregnancies. Risk factors for PPCM include advanced maternal age, multiparity, African race, twin pregnancies, obesity, preeclampsia and gestacional hypertension. The etiology of PPCM is unknown, but many hypotheses have been proposed including myocarditis, abnormal immune response to pregnancy, maladaptative response to the hemodynamic stresses of pregnancy, stress activated cytokines, viral infection, prolonged tocolysis, heredity, nutritional and hormonal disorders. Symptons and signs of PPCM are similar to the one of those patients with heart failure of other causes. The diagnosis is confirmed with the echocardiographic identification of left ventricular systolic dysfunction. The treatment of PPCM is similar to medical therapy for other forms of cardiac failure. In spite of that, the use of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker is contraindicated because of the potencial toxic effects on the fetus; they can be used in puerperal period and during lactation. Further researches are needed to discover the peripartum cardiomyopathy's etiology; they will be able to guide a specific treatment and a better prognostic for the patients with this disease.

Nevirapine-induced side effects in pregnant women: experience of a brazilian university hospital

Nevirapine-based therapy is associated with increased frequency of adverse events among HIV-infected pregnant women. The aim of this article was to evaluate the incidence of adverse effects in HIV-infected women who started nevirapine during pregnancy. A retrospective study was performed in our center between January 2003 and December 2006 analyzing all women prescribed nevirapine during pregnancy. Women presenting any risk factor for hepatotoxicity were excluded from the analysis. Patients were divided into two groups according to the presence or absence of adverse effects, and a correlation to CD4 counts was performed. Liver function abnormality was graded according to the Division of AIDS toxicity guidelines. A total of 170 women initiated nevirapine during pregnancy, but only 133 were included in the study. Twenty-seven women (20.3 percent) presented adverse effects, skin rash accounting for 77.8 percent (21/27 women) and liver function abnormalities for 22.2 percent (6/27) of the cases. Baseline CD4 counts, viral loads and transaminases were similar in both groups. All nevirapine side effects were developed in less than seven weeks. Four of 31 women with CD4 counts <250 cells/µL (12.9 percent) and 23 of 102 women with CD4 counts ≥250 cells/µL (22.5 percent) developed adverse events. All patients who experienced hepatotoxicity had pretreatment CD4 counts >250cells/µL. The incidence of adverse events with nevirapine in our study was high, but most of them were cutaneous. There was no correlation between high CD4 counts and adverse events when analyzing both cutaneous and hepatic reactions; nevertheless, hepatotoxicity occurred only in pregnant women with CD4 counts ≥250cells/µL.