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.

Impacts of Obesity on Maternal and Fetal Outcomes in Women with Singleton Pregnancy at a Nigerian Clinical Setting.

Background: Obesity, an emerging public health concern in maternity care with increasing prevalence even in developing countries is associated with maternal and perinatal complications. This study sought to evaluate the impact of maternal obesity on pregnancy outcomes in a cohort of Nigerian women. Study Design: A prospective cohort study. Place and Duration of Study: Department of Obstetrics and Gynaecology, Bingham University Teaching Hospital Jos, between January 2013 and September 2014. Methodology: A study of matched 324 obese [Body mass index (BMI) ≥ 30 Kg/m2] and 324 non-obese women (BMI 18.5 – 24.9 Kg/m2) with singleton pregnancies recruited at the antenatal clinic during their first trimester. They were followed-up to the postpartum period to ascertain development of antenatal, intra-partum, postpartum and fetal complications. Chi square or Fisher’s Exact test and student t-test were done to ascertain any relationship between obesity and the outcome variables using SPSS version 16 (SPSS Inc., Chicago, IL, USA) and P value < 0.05 was considered statistically significant. Results: In comparison with pregnant women with normal BMI, obese women faced higher risk of developing antenatal complications (P = 0.001, Odds Ratio (OR) 5.32, 95% Confidence Interval (CI) 1.90 – 14.94) especially gestational hypertension and pre-eclampsia (P = 0.002, OR 4.66, 95% CI 1.65 – 13.19), having caesarean section (P = 0.043, OR 0.48, 95% CI 0.23 – 0.99) and macrosomic baby (P = 0.005, OR 3.40, 95% CI 1.41 – 8.19). However, no statistical difference with respect to risk of spontaneous miscarriage (P = 0.313, OR 3.08, 95% CI 0.31 – 30.22), preterm delivery (P = 0.167, OR 3.16, 95% CI 0.62 – 16.15), genital tract injury (P = 0.407, OR 0.76, 95% CI 0.40 – 1.46), postpartum haemorrhage (P = 0.199, OR 1.75, 95% CI 0.74 – 4.13), low birth weight babies (P = 0.732, OR 1.27, 95% CI 0.33 – 4.90) and stillbirth (P = 0.080, OR 0.96, 95% CI 0.92 – 1.01). Conclusion: Maternal obesity is associated with elevated risk of hypertensive disorders, caesarean delivery and fetal macrosomia. It is imperative to implement a policy of identifying these women as high risk group at this clinical setting so as to institute appropriate materno-fetal surveillance and management strategies aim at enhancing their pregnancy outcomes.