Walkiria Samuel Avila

Pregnancy and peripartum cardiomyopathy: a comparative and prospective study

OBJECTIVE To assess pregnancy outcome in women with peripartum cardiomyopathy and to compare it with idiopathic cardiomyopathy. METHODS Twenty-six pregnant women, aged 28.4+/-6.1 years, with dilated cardiomyopathy were followed. Eighteen patients had peripartum cardiomyopathy [11 with persistent left ventricular systolic dysfunction (EF=45.2+/-2) and 7 with recovered ventricular function (EF=62.3+/-3.6)]. The 8 remaining patients had idiopathic cardiomyopathy (EF= 43.5+/-4.1). During the prenatal period, limited physical activity and a low-sodium diet were recommended, and hospitalization was recommended when complications occurred. RESULTS Of the 26 patients, 11 (42.3%) had a normal delivery; 9(35.5%) had cardiac complications, 6 (22.2%) had obstetric complications. Two patients (7.7%) died. Two preterm pregnancies occurred, with 26 health newborns (2 sets of twins). Two miscarriages took place. The cardiac complication rate during pregnancy was lower (p<0.009) in the peripartum cardiomyopathy group without ventricular dysfunction and greater (p=0.01) in the idiopathic group when compared with the peripartum group with ventricular dysfunction. Changes in left ventricular ejection fraction were not observed (p<0.05) in the postpartum period, when compared with that during pregnancy in the 3 groups. CONCLUSION Pregnancy in patients with dilated cardiomyopathy is associated with maternal morbidity. Left ventricular function is a prognostic factor and must be the most parameter when counseling patients with peripartum cardiomyopathy about a new pregnancy.

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.

Obstetric and perinatal aspects in patients with congenital heart diseases

The benefits of surgical treatment for patients with congenital heart disease in relation to pregnancy are still controversial. We studied 48 pregnant women (mean age = 25 years) with surgically-corrected congenital heart diseases (Group 1). This included 15 cyanotic diseases: Fallots tetralogy (11 cases); Ebsteins anomaly (2 cases); transposition of the great arteries (1 case); and double outlet of the right ventricle (1 case). We compared them to 52 pregnant women (mean age = 26 years) with untreated congenital heart diseases, which included 11 cases of Eisenmengers syndrome (Group 2). Group 2 showed a higher incidence of maternal death (12 vs. 0 percent; p = 0.01), perinatal mortality (15 vs. 0 percent; p = 0.01) and prematurity (32 vs. 7 percent; p = 0.01). Spontaneous abortion (4 vs. 10 percent), Caesarean deliveries (48 vs. 66 percent) or growth retardation (13 vs. 28 percent) did not present any significant differences between these groups. Surgical treatment in patients with heart diseases is associated with a better maternal and fetal prognosis. Therefore, surgery must be considered when counseling patients with congenital heart diseases.

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.

Anticoagulação, gravidez e cardiopatia: uma tríade, três domínios e cinco momentos

,esta relacionada em 80% dos casos ao parto e a doencas obste-tricas nem sempre evitaveis, como abortamento espontâneo, pla-centa previa, descolamento prematuro de placenta e parto pre-maturo. A fibrilacao atrial, por ser evento habitual na historianatural das valvopatias reumaticas, e situacao clinica observadacom frequencia na gestante cardiopata

Dissecção aguda da aorta durante a gravidez

Acute aortic dissection is one of the most dreaded clinical conditions during pregnancy. Difficulties in establishing a diagnosis and limitations regarding invasive studies increase mortality rates associated with the disease. The limited experience reported in the literature does not allow the determination of guidelines for clinical and/or surgical management of aortic dissection in pregnancy. The authors present a case of acute aortic dissection in a woman in her 33rd week of gestation and discuss the diagnostic approach considering the peculiarities of the diseases manifestation.

Aortic valvuloplasty with balloon catheter in maternal-fetal emergency in adolescence

O aumento do debito cardiaco durante a gravidez e causa de insuficiencia cardiaca em portadoras de estenose valvar aortica grave. A valvoplastia aortica percutânea tem sido associada a graves complicacoes e reestenose valvar em curto prazo. O presente caso mostrou que a valvoplastia aortica percutânea permitiu o alcance do parto com sobrevida da mae e do feto, e que a interrupcao do tratamento no pos-parto resultou em morte materna no puerperio tardio.The increase of cardiac output during pregnancy is the cause of heart failure in women with severe aortic valvular stenosis. Percutaneous aortic valvuloplasty has been associated with severe complications and short-term valvar restenosis. This case showed that percutaneous aortic valvuloplasty allowed both mother and fetus to survive after childbirth, and that postpartum treatment interruption resulted in maternal death in late postpartum care.

Maternal-fetal monitoring during dental procedure in patients with heart valve disease

BACKGROUND The effects of local dental anesthesia with lidocaine and epinephrine on cardiovascular parameters of pregnant women with heart valve diseases and their fetuses are not fully understood. OBJECTIVES To assess and analyze cardiotocographic, blood pressure and electrocardiographic parameters of pregnant women with rheumatic heart valve disease undergoing local anesthesia with 1.8mL of lidocaine 2% with or without epinephrine 1:100,000 during restorative dental treatment. METHODS Maternal ambulatory blood pressure and electrocardiographic monitoring as well as cardiotocography of 31 patients with rheumatic heart disease were performed between the 28th and 37th week of gestation. The patients were divided into two groups, those with or without vasoconstrictor. RESULTS A significant reduction in maternal heart rate was shown in both groups during the procedure in comparison with the other periods (p<0.001). Cardiac arrhythmia was observed in nine (29.0%) patients, of which seven (41.8%) were from the group of 17 pregnant women who received anesthesia plus epinephrine. No difference in maternal blood pressure was observed when periods or groups were compared (p>0.05). The same occurred (p>0.05) with the number of uterine contractions, baseline level and variability, and number of accelerations of fetal heart rate. CONCLUSION The use of 1.8mL of lidocaine 2% in combination with epinephrine was safe and efficient in restorative dental procedures during pregnancy in women with rheumatic heart valve disease.FUNDAMENTO: Los efectos de la anestesia local en odontologia con lidocaina y epinefrina, sobre los parametros cardiovasculares de gestantes portadoras de valvulopatias y sus conceptos, no son claros. OBJETIVO: Evaluar y analizar parametros de la cardiotocografia, de la presion arterial y electrocardiograficos de la gestante portadora de enfermedad valvular reumatica, al someterse a anestesia local con 1,8 ml de lidocaina 2% sin vasoconstrictor y con epinefrina 1:100.000, durante procedimiento odontologico restaurador. METODOS: Realizamos monitoreo ambulatorio de la presion arterial, electrocardiografia ambulatoria materna y cardiotocografia de 31 portadoras de cardiopatia reumatica, entre la 28a y la 37a semana de gestacion, divididas en dos grupos segun la presencia o no del vasoconstrictor. RESULTADOS: Se observo reduccion significativa de los valores de frecuencia cardiaca materna en los dos grupos, durante el procedimiento, al compararlo con los demas periodos (p 0,05). Lo mismo ocurrio (p > 0,05) con el numero de contracciones uterinas, nivel de variabilidad de la linea de base y numero de aceleraciones de la frecuencia cardiaca fetal. CONCLUSION: El uso de 1,8 ml de lidocaina 2% asociado a la adrenalina se mostro seguro y eficaz en procedimiento odontologico restaurador durante la gestacion de mujeres con cardiopatia valvular reumatica.

Monitorização materno-fetal durante procedimento odontológico em portadora de cardiopatia valvar

BACKGROUND The effects of local dental anesthesia with lidocaine and epinephrine on cardiovascular parameters of pregnant women with heart valve diseases and their fetuses are not fully understood. OBJECTIVES To assess and analyze cardiotocographic, blood pressure and electrocardiographic parameters of pregnant women with rheumatic heart valve disease undergoing local anesthesia with 1.8mL of lidocaine 2% with or without epinephrine 1:100,000 during restorative dental treatment. METHODS Maternal ambulatory blood pressure and electrocardiographic monitoring as well as cardiotocography of 31 patients with rheumatic heart disease were performed between the 28th and 37th week of gestation. The patients were divided into two groups, those with or without vasoconstrictor. RESULTS A significant reduction in maternal heart rate was shown in both groups during the procedure in comparison with the other periods (p<0.001). Cardiac arrhythmia was observed in nine (29.0%) patients, of which seven (41.8%) were from the group of 17 pregnant women who received anesthesia plus epinephrine. No difference in maternal blood pressure was observed when periods or groups were compared (p>0.05). The same occurred (p>0.05) with the number of uterine contractions, baseline level and variability, and number of accelerations of fetal heart rate. CONCLUSION The use of 1.8mL of lidocaine 2% in combination with epinephrine was safe and efficient in restorative dental procedures during pregnancy in women with rheumatic heart valve disease.FUNDAMENTO: Los efectos de la anestesia local en odontologia con lidocaina y epinefrina, sobre los parametros cardiovasculares de gestantes portadoras de valvulopatias y sus conceptos, no son claros. OBJETIVO: Evaluar y analizar parametros de la cardiotocografia, de la presion arterial y electrocardiograficos de la gestante portadora de enfermedad valvular reumatica, al someterse a anestesia local con 1,8 ml de lidocaina 2% sin vasoconstrictor y con epinefrina 1:100.000, durante procedimiento odontologico restaurador. METODOS: Realizamos monitoreo ambulatorio de la presion arterial, electrocardiografia ambulatoria materna y cardiotocografia de 31 portadoras de cardiopatia reumatica, entre la 28a y la 37a semana de gestacion, divididas en dos grupos segun la presencia o no del vasoconstrictor. RESULTADOS: Se observo reduccion significativa de los valores de frecuencia cardiaca materna en los dos grupos, durante el procedimiento, al compararlo con los demas periodos (p 0,05). Lo mismo ocurrio (p > 0,05) con el numero de contracciones uterinas, nivel de variabilidad de la linea de base y numero de aceleraciones de la frecuencia cardiaca fetal. CONCLUSION: El uso de 1,8 ml de lidocaina 2% asociado a la adrenalina se mostro seguro y eficaz en procedimiento odontologico restaurador durante la gestacion de mujeres con cardiopatia valvular reumatica.

Estudo da reatividade vascular induzida pelo estresse mental na gravidez de mulheres portadoras de estenose mitral

OBJECTIVE To study vascular reactivity according to the analysis of blood flow and peripheral vascular resistance at rest and during mental stress in pregnant women with mitral stenosis. METHODS Twenty two women with mitral stenosis, 13 of whom were pregnant (PS) and 9 were non-pregnant (MIS), and 9 healthy pregnant women (NP) were studied. During gestation, 9 out of the 13 patients of the PS group required a beta-blocker (PSB) and the remaining 4 progressed without medication (PSWB). Plethysmography at rest and during mental stress analyzed muscle blood flow, peripheral vascular resistance (PVR), mean arterial pressure (MAP) and heart rate (HR) during gestation and puerperium. RESULTS During gestation of PSWB, muscle blood flow and HR were higher in 1.6% and 20.5% (p = 0.05), and PVR and MAP were lower in 19.3% and 4.4%, respectively, in comparison to the puerperium; during mental stress, the muscle blood flow increased by 55.9%, HR decreased by 30.2% and PVR and MAP were similar. In PSB, muscle blood muscle blood flow and HR were greater in 5.9% and 14.9% (p= 0.001) and MAP and PVR were lower in 10.3% and 9.1%, respectively, when compared to the puerperium. During mental stress, muscle blood flow and MAP increased by 69.8% and 174.1%, respectively. HR was similar and PVR decreased by 53.7%. The comparative study showed that in the NP group the muscle blood flow was higher, PVR was lower, and MAP and HR were similar in relation to the PS group, and that the PS, NP, MIS groups had a similar response to mental stress. CONCLUSIONS Vascular reactivity in pregnant women with mitral stenosis was preserved and the analysis of measurements showed lower values of muscle blood flow and higher values of PVR when compared to those of healthy pregnant women.