Maria Rita de Figueiredo Lemos Bortolotto

Influência da gestação na evolução clínica materno-fetal de portadoras de cardiomiopatia hipertrófica

OBJECTIVES To study clinical evolution of women with HCM during pregnancy; the influencing factors of gestation on natural course of HCM and the frequency of HCM in their children in early childhood. METHODS A prospective study was conducted in 35 women with HCM; there were 23 pregnant women (PG group) and 12 nonpregnant control patients (NP group), matched for age and functional class (FC). Clinical monthly evaluations were carried out and electrocardiogram and transthoracic echocardiography tests were performed. The offspring endpoints included stillbirth and prematurity rates and investigation of HCM during childhood. RESULTS No deaths occurred in either group. Cardiac arrhythmias were significantly (p< 0.05) more frequent in the NP group (33.3% vs. 13.4%), and no differences were observed between the groups (p>0.05) in heart failure (30.3% vs. 16.6%) or ischemic stroke (4.3% vs. 8.3%) rates. In the PG group, required hospitalization for treatment of cardiac complication was more frequent (p=0.05) in patients with family history of HCM (71.4% vs. 25.0%). Cesarean section was performed in 12 (52%) patients, for obstetrical reasons; there were 7 (30.4%) premature babies and 1 (4.3%) neonatal death. One child was clinically diagnosed as having HCM, and his genetic study identified a mutation in the beta myosin heavy chain gene, located on chromosome 14. CONCLUSION Heart failure is a frequent cardiac complication in women with HCM during pregnancy, particularly in patients with family history of the disease, but this did not influence the natural course of HCM. In one child, clinical examination allowed HCM identification during early childhood.

Use of a Minimally Invasive Uncalibrated Cardiac Output Monitor in Patients Undergoing Cesarean Section under Spinal Anesthesia: Report of Four Cases

BACKGROUND AND OBJECTIVES Hemodynamic changes are observed during cesarean section under spinal anesthesia. Non-invasive blood pressure (BP) and heart rate (HR) measurements are performed to diagnose these changes, but they are delayed and inaccurate. Other monitors such as filling pressure and cardiac output (CO) catheters with external calibration are very invasive or inaccurate. The objective of the present study was to report the cardiac output measurements obtained with a minimally invasive uncalibrated monitor (LiDCO rapid) in patients undergoing cesarean section under spinal anesthesia. CASE REPORT After approval by the Ethics Commission, four patients agreed to participate in this study. They underwent cesarean section under spinal anesthesia while at the same time being connected to the LiDCO rapid by a radial artery line. Cardiac output, HR, and BP were recorded at baseline, after spinal anesthesia, after fetal and placental extraction, and after the infusion of oxytocin and metaraminol. We observed a fall in BP with an increase of HR and CO after spinal anesthesia and oxytocin infusion; and an increase in BP with a fall in HR and CO after bolus of the vasopressor. CONCLUSIONS Although this monitor had not been calibrated, it showed a tendency for consistent hemodynamic data in obstetric patients and it may be used as a therapeutic guide or experimental tool.

Maternal-fetal outcome and prognosis of cardiac surgery during pregnancy

BACKGROUND Cardiac surgery improves the maternal prognosis in cases refractory to medical therapy. However, it is associated with risks to the fetus when performed during pregnancy. OBJECTIVE To analyze maternal-fetal outcome and prognosis related to cardiac surgery performed during pregnancy and puerperium. METHODS The outcome of 41 gestations of women undergoing cardiac surgery during pregnancy and puerperium was studied. Fetal cardiotocography was performed throughout the procedure in patients with gestational age above 20 weeks. RESULTS Mean maternal age was 27.8 +/- 7.6 years; there was a predominance of patients with rheumatic valve disease (87.8%), of whom 15 (41.6%) underwent reoperation due to prosthetic valve dysfunction. Mean extracorporeal circulation time was 87.4+/- 43.6 min and hypothermia was used in 27 (67.5%) cases. Thirteen (31.7%) mothers experienced no events and gave birth to live healthy newborns. Postoperative outcome of the remaining 28 (68.3%) pregnancies showed: 17 (41.5%) maternal complications and three (7.3%) deaths; 12 (29.2%) fetal losses, and four (10%) cases of neurological malformation, two of which progressed to late death. One patient was lost to follow-up after surgery. Nine (21.9%) patients underwent emergency surgery, and this variable was correlated with maternal prognosis (p<0.001) CONCLUSION Cardiac surgery during pregnancy allowed survival of 92.7% of the mothers, and 56.0% of the patients who presented cardiac complications refractory to medical therapy gave birth to healthy children. Worse maternal prognosis was correlated with emergency surgery.FUNDAMENTO: A cirurgia cardiaca favorece o prognostico materno em casos refratarios a terapeutica clinica, contudo associa-se a riscos ao concepto quando realizada durante a gravidez. OBJETIVO: Analisar a evolucao e o prognostico materno-fetal de gestantes submetidas a cirurgia cardiaca no ciclo gravidico-puerperal. METODOS: Estudou-se a evolucao de 41 gestacoes de mulheres que tiveram indicacao de cirurgia cardiaca no ciclo gravidico puerperal. A cardiotocografia fetal foi mantida durante o procedimento nas pacientes com idade gestacional acima de 20 semanas. RESULTADOS: A media da idade materna foi de 27,8 ± 7,6 anos, houve predominio da valvopatia reumatica (87,8%), e 15 dessas (41,6%) foram submetidas a reoperacao, devido a disfuncao de protese valvar. A media do tempo de circulacao extracorporea foi de 87,4 ± 43,6 min, e a hipotermia foi utilizada em 27 casos (67,5%). Treze maes (31,7%) nao apresentaram intercorrencias e tiveram seus recem-nascidos vivos e saudaveis. A evolucao pos-operatoria das demais 28 gestacoes (68,3%) mostrou: 17 complicacoes maternas (41,5%); tres obitos (7,3%); 12 perdas fetais (29,2%) e quatro casos de malformacao neurologica (10%), dois dos quais evoluiram para obito tardio. Houve uma perda de seguimento apos a cirurgia. Nove pacientes (21,9%) foram operadas em carater de emergencia, situacao que influenciou (p < 0.001) o prognostico materno. CONCLUSAO: A cirurgia cardiaca durante a gravidez permitiu sobrevida materna em 92,7% e nascimento de criancas saudaveis em 56,0% das pacientes que apresentaram complicacoes cardiacas refratarias a terapeutica clinica. O pior prognostico materno teve correlacao com a cirurgia em carater de emergencia.

Resultados maternos e perinatais em pacientes com disfunção sistólica grave

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%. 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%. 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.

Sepsis and septic shock during pregnancy: clinical management

Sepsis is one of the main causes of maternal death, being related to infections from obstetric origin (infected abortion, chorioamnionitis, puerperal infection) or non-obstetric (resulting from infections which occur in other areas). This review aims at describing the mechanisms involved in the physiopathology of this entity and at updating the clinical approach to sepsis, recommended in international guidelines (early goal-directed therapy--precocious resuscitation, or precocious treatment guided by goals), as well as at calling attention to the influence of pregnancy both in the clinical manifestation and in the therapeutic management of septic conditions.

Case 4/2011 - agranulocytosis and puerperal sepsis in women after the use of ceftriaxone

Editor de la Sección: Alfredo José Mansur (ajmansur@incor.usp.br) Editores asociados: Desidério Favarato (dclfavarato@incor.usp.br) Vera Demarchi Aiello (anpvera@incor.usp.br) Mujer de 34 años de edad fue internada en la sala de obstetricia en la 34a semana de gestación, con queja de disnea progresiva hasta ocurrir en el decúbito hace dos días y edema de miembros inferiores. La historia obstétrica de la paciente incluía un aborto espontáneo cuatro años antes y un parto hacía dos años. Hacía control prenatal en Unidad Básica de Salud, en uso de suplementación vitamínica. La paciente sabía ser portadora de soplo cardíaco. Hacía tres días, había recibido ceftriaxona por vía intramuscular para tratamiento de pielonefritis. El examen físico reveló paciente coloreada, hidratada, disneica, peso de 56 kg, altura de 1,70 m, frecuencia cardíaca de 116 latidos por minuto, presión arterial de 110/70 mm Hg. El examen de los pulmones reveló murmullo vesicular presente bilateralmente, sin ruidos adventicios. El examen del corazón reveló ruidos rítmicos, soplo sistólico ++/6 y ruflar diastólico en área mitral. Había edema en miembros inferiores ++/4. El examen obstétrico reveló taquicardia fetal (170 lpm) y reducción del líquido amniótico (oligoamnios). Los exámenes serológicos para diagnóstico de infección por HIV, hepatitis y enfermedad de Chagas fueron negativos. El hemograma reveló leucocitosis de 18.360 células/mm3. El electrocardiograma reveló ritmo sinusal, frecuencia de 70 latidos por minuto, eje eléctrico de QRS a +120°, componente final de onda P negativa en V1, entallada y bífida en II, onda S profunda en V1, V2 y V3, alteraciones del segmento ST y de la onda T en V2,V3 y V4. (Figura 1) La radiografía de tórax demostró área cardíaca aumentada ++/4 y señales de congestión pulmonar en ambos pulmones (Figura 2). El ecocardiograma evidenció aorta de 26 mm, atrio izquierdo de 56 mm, ventrículo izquierdo de 44 mm (diástole) y 33 mm (sístole), fracción de eyección del ventrículo izquierdo a 63%. La válvula mitral estaba espesada con fusión comisural. El gradiente transvalvular máximo fue evaluado en 32 mm Hg, y el gradiente medio fue estimado en 19 mm Hg. El área valvular fue estimada en 1,05 cm2. No había insuficiencia mitral. Las válvulas aórtica y tricúspide mostraban reflujo discreto. La presión sistólica de arteria pulmonar fue estimada en 93 mm Hg.

Evolução e prognóstico materno-fetal da cirurgia cardíaca durante a gravidez

BACKGROUND Cardiac surgery improves the maternal prognosis in cases refractory to medical therapy. However, it is associated with risks to the fetus when performed during pregnancy. OBJECTIVE To analyze maternal-fetal outcome and prognosis related to cardiac surgery performed during pregnancy and puerperium. METHODS The outcome of 41 gestations of women undergoing cardiac surgery during pregnancy and puerperium was studied. Fetal cardiotocography was performed throughout the procedure in patients with gestational age above 20 weeks. RESULTS Mean maternal age was 27.8 +/- 7.6 years; there was a predominance of patients with rheumatic valve disease (87.8%), of whom 15 (41.6%) underwent reoperation due to prosthetic valve dysfunction. Mean extracorporeal circulation time was 87.4+/- 43.6 min and hypothermia was used in 27 (67.5%) cases. Thirteen (31.7%) mothers experienced no events and gave birth to live healthy newborns. Postoperative outcome of the remaining 28 (68.3%) pregnancies showed: 17 (41.5%) maternal complications and three (7.3%) deaths; 12 (29.2%) fetal losses, and four (10%) cases of neurological malformation, two of which progressed to late death. One patient was lost to follow-up after surgery. Nine (21.9%) patients underwent emergency surgery, and this variable was correlated with maternal prognosis (p<0.001) CONCLUSION Cardiac surgery during pregnancy allowed survival of 92.7% of the mothers, and 56.0% of the patients who presented cardiac complications refractory to medical therapy gave birth to healthy children. Worse maternal prognosis was correlated with emergency surgery.FUNDAMENTO: A cirurgia cardiaca favorece o prognostico materno em casos refratarios a terapeutica clinica, contudo associa-se a riscos ao concepto quando realizada durante a gravidez. OBJETIVO: Analisar a evolucao e o prognostico materno-fetal de gestantes submetidas a cirurgia cardiaca no ciclo gravidico-puerperal. METODOS: Estudou-se a evolucao de 41 gestacoes de mulheres que tiveram indicacao de cirurgia cardiaca no ciclo gravidico puerperal. A cardiotocografia fetal foi mantida durante o procedimento nas pacientes com idade gestacional acima de 20 semanas. RESULTADOS: A media da idade materna foi de 27,8 ± 7,6 anos, houve predominio da valvopatia reumatica (87,8%), e 15 dessas (41,6%) foram submetidas a reoperacao, devido a disfuncao de protese valvar. A media do tempo de circulacao extracorporea foi de 87,4 ± 43,6 min, e a hipotermia foi utilizada em 27 casos (67,5%). Treze maes (31,7%) nao apresentaram intercorrencias e tiveram seus recem-nascidos vivos e saudaveis. A evolucao pos-operatoria das demais 28 gestacoes (68,3%) mostrou: 17 complicacoes maternas (41,5%); tres obitos (7,3%); 12 perdas fetais (29,2%) e quatro casos de malformacao neurologica (10%), dois dos quais evoluiram para obito tardio. Houve uma perda de seguimento apos a cirurgia. Nove pacientes (21,9%) foram operadas em carater de emergencia, situacao que influenciou (p < 0.001) o prognostico materno. CONCLUSAO: A cirurgia cardiaca durante a gravidez permitiu sobrevida materna em 92,7% e nascimento de criancas saudaveis em 56,0% das pacientes que apresentaram complicacoes cardiacas refratarias a terapeutica clinica. O pior prognostico materno teve correlacao com a cirurgia em carater de emergencia.

Can thrombophilia worsen maternal and perinatal outcomes in cases of severe preeclampsia

OBJECTIVE To evaluate whether thrombophilia worsens maternal and foetal outcomes among patients with severe preeclampsia (PE). METHOD From October 2009 to October 2014, an observational retrospective cohort study was performed on pregnant women with severe PE diagnosed before 34 weeks of gestation and their newborns hospitalized at the Clinics Hospital, FMUSP. Patients who had no heart disease, nephropathies, pre-gestational diabetes, gestational trophoblastic disease, foetal malformation, or twin pregnancy and who underwent thrombophilia screening during the postnatal period were included. New pregnancies of the same patient; cases of foetal morphological, genetic, or chromosomal abnormalities after birth; and women who used heparin or acetylsalicylic acid during pregnancy were excluded. Factor V Leiden, G20210A prothrombin mutation, antithrombin, protein C, protein S, homocysteine, lupus anticoagulant, and anticardiolipin IgG and IgM antibodies were analysed. The groups with and without thrombophilia were compared regarding their maternal clinical and laboratory parameters and perinatal outcomes. RESULTS Of the 127 patients selected, 30 (23.6%) had thrombophilia (hereditary or acquired). We found more white patients in thrombophilia group (p = .036). Analysis of maternal parameters showed a tendency of thrombophilic women to have more thrombocytopenia (p = .056) and showed worsening of composite laboratory abnormalities (aspartate aminotransferase ≥ 70 mg/dL, alanine aminotransferase ≥ 70 mg/dL, platelets < 100,000/mm3, serum creatinine ≥ 1.1 mg/dL; p = .017). There were no differences in foetal perinatal outcomes. CONCLUSION The presence of thrombophilia leads to worsening of maternal laboratory parameters among patients with severe forms of PE but without worsening perinatal outcomes.

Resistant Hypertension in Pregnancy: How to Manage?

Purpose of ReviewThe concept of resistant hypertension may be changed during pregnancy by the physiological hemodynamic changes and the particularities of therapy choices in this period. This review discusses the management of pregnant patients with preexisting resistant hypertension and also of those who develop severe hypertension in gestation and puerperium.Recent FindingsThe main cause of severe hypertension in pregnancy is preeclampsia, and differential diagnosis must be done with secondary or primary hypertension. Women with preexisting resistant hypertension may need pharmacological therapy adjustment. Several drugs can be used to treat severe hypertension, with exception of angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists. The most used drugs are methyldopa, beta-blockers, and calcium channel antagonists. There is a general agreement that severe hypertension must be treated, but there are still debates over the goals of the treatment. Delivery is indicated in viable pregnancies in which blood pressure control is not achieved with three drugs in full doses. Resistant hypertension may arise in postpartum.SummaryThe management of resistant hypertension in pregnancy must regard the possible etiology, the fetal well-being, and the mother’s risk. Good care is mandatory to reduce maternal mortality risk.

Caso 4/2011 - agranulocitose e sepse em mulher no puerpério após uso de ceftriaxona

Editor de la Sección: Alfredo José Mansur (ajmansur@incor.usp.br) Editores asociados: Desidério Favarato (dclfavarato@incor.usp.br) Vera Demarchi Aiello (anpvera@incor.usp.br) Mujer de 34 años de edad fue internada en la sala de obstetricia en la 34a semana de gestación, con queja de disnea progresiva hasta ocurrir en el decúbito hace dos días y edema de miembros inferiores. La historia obstétrica de la paciente incluía un aborto espontáneo cuatro años antes y un parto hacía dos años. Hacía control prenatal en Unidad Básica de Salud, en uso de suplementación vitamínica. La paciente sabía ser portadora de soplo cardíaco. Hacía tres días, había recibido ceftriaxona por vía intramuscular para tratamiento de pielonefritis. El examen físico reveló paciente coloreada, hidratada, disneica, peso de 56 kg, altura de 1,70 m, frecuencia cardíaca de 116 latidos por minuto, presión arterial de 110/70 mm Hg. El examen de los pulmones reveló murmullo vesicular presente bilateralmente, sin ruidos adventicios. El examen del corazón reveló ruidos rítmicos, soplo sistólico ++/6 y ruflar diastólico en área mitral. Había edema en miembros inferiores ++/4. El examen obstétrico reveló taquicardia fetal (170 lpm) y reducción del líquido amniótico (oligoamnios). Los exámenes serológicos para diagnóstico de infección por HIV, hepatitis y enfermedad de Chagas fueron negativos. El hemograma reveló leucocitosis de 18.360 células/mm3. El electrocardiograma reveló ritmo sinusal, frecuencia de 70 latidos por minuto, eje eléctrico de QRS a +120°, componente final de onda P negativa en V1, entallada y bífida en II, onda S profunda en V1, V2 y V3, alteraciones del segmento ST y de la onda T en V2,V3 y V4. (Figura 1) La radiografía de tórax demostró área cardíaca aumentada ++/4 y señales de congestión pulmonar en ambos pulmones (Figura 2). El ecocardiograma evidenció aorta de 26 mm, atrio izquierdo de 56 mm, ventrículo izquierdo de 44 mm (diástole) y 33 mm (sístole), fracción de eyección del ventrículo izquierdo a 63%. La válvula mitral estaba espesada con fusión comisural. El gradiente transvalvular máximo fue evaluado en 32 mm Hg, y el gradiente medio fue estimado en 19 mm Hg. El área valvular fue estimada en 1,05 cm2. No había insuficiencia mitral. Las válvulas aórtica y tricúspide mostraban reflujo discreto. La presión sistólica de arteria pulmonar fue estimada en 93 mm Hg.