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.

Pregnancy in Women with Complex Congenital Heart Disease. A Constant Challenge.

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.

Contents of conjugated linoleic acid isomers in ruminant-derived foods and estimation of their contribution to daily intake in Portugal.

The present study provides a detailed overview of the contents of conjugated linoleic acid (CLA) isomers in the most consumed Portuguese CLA-rich foods (milk, butter, yoghurt, cheese, beef and lamb meat), by using silver ion-HPLC. In addition, the contribution of these ruminant-derived foods to the daily intake of CLA isomers was estimated based on Portuguese consumption habits. The total CLA concentration in milk and dairy products ranged from 4.00 mg/g fat in yoghurt to 7.22 mg/g fat in butter, and, regarding meats, from 4.45 mg/g fat in intensively produced beef to 11.29 mg/g fat in lamb meat. The predominant CLA isomers identified in these products were cis-9, trans-11 (59.89-79.21 %) and trans-7, cis-9 (8.04-20.20 %). The average estimated total CLA intake for the Portuguese population was 73.70 mg/d. Milk and cheese are probably the two products with the highest contribution to the final CLA intake, as a result of their high fat content and consumption values. The results also suggested that cis-9, trans-11 and trans-7, cis-9 are the isomers most represented, with, respectively, 76.10 and 12.56 % of the total CLA intake. Being the first detailed report on the contents of total and individual CLA isomers in Portuguese commercial ruminant-derived foods, we further discuss the implication of the results for diet characteristics and human health.

Synthesis, surface active and antimicrobial properties of new alkyl 2,6-dideoxy-L-arabino-hexopyranosides.

Synthesis of alkyl 2,6-dideoxy-L-arabino-hexopyranosides was accomplished by the reaction of 1,5-anhydro-2,6-dideoxy-L-arabino-hex-1-enitol with fatty alcohols in dichloromethane, catalyzed by triphenylphosphine hydrobromide. Reaction with octanol and dodecanol gave the corresponding alpha-glycosides in 50% and 42% yield, the beta-glycosides in 20% and 21% yield and the alpha-anomer of the Ferrier product in 10% and 9% yield, respectively. Deacetylation of the alpha-/beta-glycosides with sodium methoxide in methanol afforded the amphiphilic L-arabino-hexopyranosides in 94-99% yield. The surface tension at the air-water interface of the octyl L-glycosides and of the dodecyl alpha-L-glycoside aqueous solutions at 35 degrees C was measured with a du Noüy ring tensiometer and surface properties such as critical micelle concentration (CMC), relative surface excess, molecular area at the interface and Gibbs micellization free energy were evaluated. The stereochemistry of the hexopyranoside ring in unimers and aggregates is correlated to the hydrophobicity and packing efficiency on the air-water interface. The antibacterial and antifungal activities of the surface-active glycosides were evaluated using the paper disk diffusion method. The dodecyl alpha-L-arabino-hexopyranoside was quite active over Bacillus cereus and Bacillus subtilis, while low activity was found for this glycoside over Enterococcus faecalis and Listeria monocytogenes. The octyl glycosides tested showed low activity over almost all the above-mentioned bacteria, and also over the fungus Candida albicans. No inhibition of Salmonella enteritidis and of the filamentous fungus Aspergillus niger was detected for any of the compounds tested.

Vantagens do aleitamento materno nos bebês nos seis primeiros meses de vida no município de ivaté no ano 2001 / Advantages of maternal breast feeding of babies during the first six months of life in the city of Ivaté during the year of 2001

O presente trabalho busca dar sua contribuição para o incentivo ao Aleitamento Materno, demonstrando suas vantagens através de pesquisa realizada no Município de Ivaté, no período de setembro a outubro de 2001. Esta experiência tem como objetivo comparar a importância do aleitamento materno, demonstrar o crescimento e o desenvolvimento do bebê em aleitamento materno exclusivo, os benefícios emocionais que a lactação proporciona à mãe e ao recém nascido, analisa a oferta de orientações pró-aleitamento que o serviço de saúde proporciona e as principais causas do desmame precoce. Foi utilizado como instrumento de pesquisa, um questionário estruturado, sendo entrevistadas 10 mulheres em período de lactação, cujos filhos não ultrapassam a faixa etária de seis meses. Na análise dos resultados percebe-se que 80 por cento receberam acompanhamento do serviço de saúde, 90 por cento relataram um ótimo desenvolvimento do bebê aleitado exclusivamente e por isto o lactante apresenta um comportamento tranqüilo segundo relato de 80 por cento das nutrizes. A unanimidade das mães compreende como a principal vantagem do aleitamento materno, a proteção total ao bebê contra doenças infecto-contagiosas. Este estudo impulsiona para uma maior conscientização e sensibilização da importância e dos benefícios que o aleitamento materno exclusivo oferece, especialmente alertando os profissionais de saúde ao compromisso e a responsabilidade de acompanhar e orientar as nutrizes durante o período de pré-natal e lactação, privilegiando mães e bebês e reduzindo os coeficientes de morbi mortalidade infantil