A patência do ducto arterioso fetal é dependente da presença de prostaglandinas circulantes, especialmente no terceiro trimestre de gestação. Substâncias com capacidade de interferir na rota metabólica das prostaglandinas, através da inibição da COX-2 ou do ácido aracdônico, podem apresentar efeito constritivo sobre o ducto arterioso.
São já bem conhecidos os efeitos da ingestão materna de indometacina e de outros anti-inflamatórios não-esteróides, e mesmo de corticóides, sobre o metabolismo das prostaglandinas na vida fetal e sua conseqüência deletéria mais importante, a constrição prematura intra-uterina do canal arterial. A constrição ductal intra-uterina pode ser grave, com comprometimento hemodinâmico e potencialmente pode provocar conseqüências nocivas no período fetal e neonatal, como a insuficiência cardíaca pré-natal e hipertensão pulmonar neonatal. A conscientização de que o ducto arterioso constrito no feto pode ser um importante fator de risco para hipertensão pulmonar persistente neonatal, situação clínica com considerável morbidade e até potencialmente letal. Tendo em vista que a asfixia perinatal é a primeira causa de morte em recém-nascidos no Rio Grande do Sul, e a hipertensão pulmonar neonatal é uma de suas manifestações mais importantes, justificam-se ações dirigidas à sua prevenção, e essas se iniciam durante o pré-natal. A hipertensão pulmonar neonatal “idiopática” é responsável pela terceira causa dessa doença em nosso meio, seguindo a aspiração meconial e a pneumonia. Nesse contexto tem-se
estimulado estudos sobre o diagnóstico, a patogênese, a evolução clínica e a conduta terapêutica dessa entidade patológica.
Um grande número de casos de constrição do ducto arterioso fetal não associado à exposição materna de drogas anti-inflamatórias conhecidas tem sido observado. Uma revisão de nossa casuística ao longo dos últimos 10 anos demonstrou que a maioria dos fetos com diagnóstico de constrição ductal não apresentava história de uso materno de indometacina ou de outros anti-inflamatórios conhecidos. Por outro lado, uma parcela significativa das gestantes relatava ter ingerido alimentos ricos em polifenóis.
Como demonstramos na base teórica desse projeto, uma revisão atualizada da literatura sobre as características químicas dessas substâncias, assim como da sua ação farmacológica, tanto em modelos animais como em humanos, mostra que esses alimentos contêm elementos químicos com anti-inflamatória através da supressão da biossíntese das prostaglandinas.
A hipótese conceitual desse projeto, já corroborada por estudos preliminares, é de que ocorre melhora ou reversão da constrição ductal fetal associada ao consumo habitual de bebidas e alimentos ricos em polifenóis ou flavonóides pelas gestantes no terceiro trimestre de gestação, com a suspensão desses alimentos.
Para testar essa hipótese, planejamos um modelo de seguimento clínico dos fetos com diagnóstico Doppler-ecocardiográfico de constrição ductal no terceiro trimestre de gestação, com relato materno de uso de polifenóis, sem evidência de uso concomitante de drogas anti-inflamatórias conhecidas, quantificado por um questionário de frequência alimentar, com orientação de completa suspensão das substâncias ricas em polifenóis em uso e reavaliação Doppler ecocardiográfica e nutricional após um período igual ou maior a 3 semanas.
5. OBJETIVOS
5.1. OBJETIVO GERAL
Avaliar o papel da intervenção nutricional, com suspensão da ingesta materna de alimentos ricos em polifenóis, sobre a constrição prematura do ducto arterioso fetal não relacionada ao consumo de anti-inflamatórios não esteróides.
5.2. OBJETIVO ESPECÍFICO
Testar a hipótese de que fetos com diagnóstico de constrição ductal, de gestantes com relato de ingestão de alimentos ricos em polifenóis e ausência de história de uso de anti-inflamatórios não esteróides no terceiro trimestre de gestação, apresentam reversão completa do efeito constritivo sobre o ducto arterioso fetal após uma a três semanas da orientação dietética de interrupção do uso dessas substâncias, mediante controle Doppler-ecocardiográfico e nutricional.
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