T e n ils o n A m a ra l O liv e ira , W a lk fria S a m u e l A v ila , M a x G rin b e rg
O b s te tric a n d p e rin a ta l a s p e c ts in p a tie n ts
w ith c o n g e n ita l h e a rt d is e a s e s
"Leon or Mendes de Barros" Maternity,
Heart Institute of the University of Sao Paulo - Sao Paulo, Brazil
The benefits of surgical treatm ent for patients w ith congenital heart disease in relation to pregnancy are still controversial. W e studied 48 pregnant w om en (m ean age = 25 years) w ith surgically-corrected congenital heart diseases (G roup 1). This included 15 cyanotic diseases: Fallot's tetralogy (11 cases); E bstein's anom aly (2 cases); transposition of the great arteries (1 case); and double outlet of
the right ventricle (1 case). W e com pared them to 52 pregnant w om en (m ean age = 26 years) w ith untreated congenital heart
diseases, w hich included 11 cases of E isenm enger's syndrom e (G roup 2). G roup 2 show ed a higher incidence of m aternal death (12 vS .O percent; p=O .01), perinatal m ortality (15 vs. 0 percent; p=O .01) and prem aturity (32 vs. 7 percent; p=O .01). S pontaneous abortion (4 vs. 10 percent), C aesarean deliveries (48 vs. 66 percent) or grow th retardation (13 vs. 28 percent) did not present any significant differences betw een these groups. S urgical treatm ent in patients w ith heart diseases is associated w ith a better m aternal and fetal prognosis. Therefore, surgery m ust be considered w hen counseling patients w ith congenital heart diseases.
U N ITE R M S : P regnancy. C ongenital heart disease, new born.
IN TR O D U C TIO N
I
th e p a s t te n y e a r s , th e d e c r e a s en in d e a th s d u e to h e a r t d is e a s e h a s b e e n e x p r e s s e d a s th e p r o p o r tio n o f w o m e nw ith c o n g e n ita l h e a r t d is e a s e s w h o s u c c e s s f u lly
c o m p le te th e ir p r e g n a n c ie s .' S u r g ic a l a d v a n c e s in c o n g e n ita l
h e a r t d is e a s e tr e a tm e n t h a v e d im in is h e d r is k s to th e m o th e r
a n d h a v e a llo w e d b e tte r f e ta l d e v e lo p m e n t.2 H o w e v e r , th e m a in c a u s e o f m a te r n a l d e a th , b e s id e s g e s ta tio n a l c o m p lic a tio n s , is s till h e a r t d is e a s e , c o n g e n ita l o r n o t.3
G e s ta tio n a l c o m p lic a tio n r is k s d e p e n d o n th e d e g r e e
o f h e m o d y n a m ic im p a ir m e n t o f e a c h c lin ic a l s itu a tio n .
A dress for correspondence:
T e n ils o n A m a ra l O liv e ira
R u a A z e v e d o J r., 143, a p to . 73, b lo e o 0 3 - B ra s S a o P a u lo /S P - B ra s il - C E P 0 3 0 4 0 -9 0 0
T h is f u n c tio n a l c la s s in te r f e r e s w ith th e c o u r s e o f th e
p r e g n a n c y , c a u s in g m a te r n a l d e a th in u p to 3 0 p e r c e n t o f
C la s s I V p a tie n ts .2 P u lm o n a r y h y p e r te n s io n , c y a n o s is , o r
v e n tr ic u la r d y s f u n c tio n a r e a s s o c ia te d w ith a p o o r
m a te r n a l/f e ta l p r o g n o s is , a n d w ith a h ig h e r in c id e n c e o f
h e a r t f a ilu r e , p u lm o n a r y c o n g e s tio n , a r r h y th m ia a n d th r o m b o e m b o lis m s .4
T h is s tu d y a n a ly z e s o b s te tr ic a n d p e r in a ta l a s p e c ts
o f p a tie n ts w ith c o n g e n ita l h e a r t d is e a s e in c o m p a r is o n w ith n o r m a l s u b je c ts .
M A TE R IA L A N D M E TH O D S
W e s tu d ie d 1 0 0 p r e g n a n t w o m e n w ith c o n g e n ita l h e a r t d is e a s e s d u r in g p r e g n a n c y a n d p u e r p e r iu m . F o llo w
-S ao P aulo M edical Journal/R P M 114(5): 1248-1254, 1996 O LIV E IR A , T.A .; A V ilA , W .S . & G R IN B E R G , M . - O bstetric and perinatal aspects in
u p w a s s ta rte d d u rin g th e firs t trim e s te r (2 7 c a s e s ) o r th e
T a b le
1
s e c o n d trim e s te r (7 3 c a s e s ), o n a v e ra g e a t 1 8 w e e k s , a n d T y p e s o f h e a rt a n o m a lie s
w a s c o n tin u e d fo r th re e m o n th s a fte r d e liv e ry . A ll c a s e s
15
w e re d iv id e d in tw o g ro u p s : G ro u p 1 (G 1 ): P a tie n ts w h o O b s tru c tiv e 4
h a d u n d e rg o n e s u rg e ry (v a ry in g fro m 1 to 2 7 y e a rs b e fo re A o rtic s te n o s is 1 6
p re g n a n c y . M e a n = 1 0 y e a rs ); G ro u p 2 (G 2 ): P a tie n ts w h o C o a rc ta tio n o f th e a o rta 1 2
h a d n o t u n d e rg o n e s u rg e ry . S u b a o rtic s te n o s is 1
C lin ic a l, c a rd io lo g ic , a n d o b s te tric e x a m in a tio n s A o rtic s te n o s is + c o a rc ta tio n 1
w e re c a rrie d o u t e v e ry 3 0 d a y s u n til th e th irty -s e c o n d o f th e a o rta
w e e k . A fte rw a rd s , e x a m in a tio n s w e re e v e ry 1 5 d a y s u n til
P u lm o n a ry s te n o s is 2 5
d e liv e ry . E le c tro c a rd io g ra m s a n d e c h o d o p p le rc a rd io g ra m s
A b n o rm a l c o m m u n ic a tio n s a n d s h u n ts
21
18
w e re d o n e in th e s e c o n d a n d th ird trim e s te r. F e ta l
u ltra s o n o g ra m s w e re d o n e in th e s e c o n d trim e s te r a n d A tria l s e p ta l d e fe c t (A S D ) 8 9
w h e n e v e r in d ic a te d . P ro p h y la c tic a n tib io tic th e ra p y fo r V e n tric u la r s e p ta l d e fe c t (V S D ) 4 * 5
e n d o c a rd itis w a s g iv e n to a ll p a tie n ts fo r ris k p ro c e d u re s . P a te n t d u c tu s a rte rio s u s (P D A ) 4 2
D e a th o c c u rrin g u p to th re e m o n th s a fte r d e liv e ry w a s C o m m o n a triu m a n d v e n tric u lu m (C A V ) 2 1
c o n s id e re d a m a te rn a l d e a th . A C + IV C + P D A 1 *
N e w b o rn b a b ie s w e re e v a lu a te d a s to v ita lity , h e ig h t
IV C + P A C 1 *
a n d w e ig h t. T h e y w e re c la s s ifie d a s p re m a tu re o r fu ll-te rm
lA C +A n o m a lo u s p u lm o n a ry v e n o u s
b a b ie s a n d a d e q u a te , s m a ll, o r la rg e in re la tio n to g e s ta tio n a l
c o n n e c tio n (A P V C ) a g e . E a c h b a b y re c e iv e d a c a rd io lo g ic e x a m in a tio n to v e rify
C o m b in e d a n o m a lie s 7
5
th e e x is te n c e o f a n y c o n g e n ita l h e a rt d is e a s e , w h ic h w o u ld
th e n b e c o n firm e d b y e c h o d o p p le rc a rd io g ra p h y . T w in P S + lA C 2 1
b a b ie s w e re w ith d ra w n fro m th e s tu d y . P S + lA C + IV C 1
D a ta w a s a n a ly z e d u s in g th e c h i-s q u a re o r F is h e r's P S + IV C
e x a c t te s t. F o r th e c o m p a ris o n b e tw e e n m e a n s , w e u s e d P S + A V C 2
S tu d e n ts
t
te s t w ith s ig n ific a n c e le v e l o f 0 .0 5 . A o rtic s te n o s is + P S 1A o rtic s te n o s is + IV C + P A C 1
A o rtic s te n o s is + P A C 1
R E S U L T S
S u b a o rtic s te n o s is + P A C 1S u b a o rtic s te n o s is + IV C 1
C y a n o tic a n o rm a lie s
16
14
G l h a d a n a v e ra g e a g e o f 2 4 y e a rs (1 4 - 3 6 y e a rs ), o f F a llo t's te tra lo g y 1 1 *
w h ic h 2 6 w e re in th e ir firs t p re g n a n c ie s . H e a rt d is e a s e s E b s te in 's a n o m a ly 2 1
a re s h o w n in T a b le 1 . N in e p a tie n ts fro m G I p re s e n te d
T ra n s p o s itio n o f th e g re a t v e s s e ls 1 1
re s id u a l h e a rt le s io n s .
R ig h t v e n tric u la r d o u b le o u tle t 1 1
E is e n m e n g e r's s y n d ro m e 1 * 1 1
I. CARDIOLOGIC ASPECTS
T o ta l
48
52
C y a n o s is a n d T ra n s v a lv a r w e d g e * R e s id u a l le s io n s
S ix te e n (1 6 p e rc e n t) p a tie n ts p re s e n te d c y a n o s is , o f
w h ic h 2 (4 p e rc e n t) w e re in G 1 (E is e n m e n g e r's s y n d ro m e ;
rig h t v e n tric le d o u b le o u tle t) a n d 1 4 (2 7 p e rc e n t) w e re in
G 2 (E S - II c a s e s ; P S + V lC + A lC - 1 c a s e ; rig h t v e n tric le
d o u b le o u tle t - 1 c a s e ; A V C + P S - 1 c a s e ). P u lm o n a ry
a rte ria l h y p e rte n s io n (P H ) o c c u rre d in I c a s e (2 p e rc e n t)
in G l, in w h ic h a p a tie n t w ith E is e n m e n g e r's s y n d ro m e
a n d re s id u a l lV C u n d e rw e n t s u rg e ry a t tw e lv e y e a rs .
F ifte e n (2 9 p e rc e n t) p a tie n ts in G 2 (E S -1 1 c a s e s ; A V e +
P S - 2 c a s e s ; P S + lA C + lV C - I c a s e ; G A T - I c a s e )
p re s e n te d th is c h a ra c te ris tic (p < O .O O I).
T ra n s v a lv a r w e d g e w a s o v e r 5 0 m m H g in 1 0 (1 9
p e rc e n t) p a tie n ts in G 2 : a o rtic s te n o s is (5 c a s e s );
s u b a o rtic s te n o s is (I c a s e s ); c o a rc ta tio n o f th e a o rta (I
c a s e ); p u lm o n a ry s te n o s is (1 c a s e ); rig h t v e n tric le d o u b le
o u tle t (I c a s e ); a o rtic s te n o s is + c o a rc ta tio n o f th e a o rta
(I c a s e ). O n e p a tie n t (2 p e rc e n t) w a s in G I w ith a o rtic
s te n o s is (p < O .O I).
O L IV E IR A , T .A .; A V ilA , w .s . & G R IN B E R G , M . - O b s te tr ic a n d p e r in a ta l a s p e c ts in p a tie n ts w ith c o n g e n ita l h e a r t d is e a s e s
II.
PERINATAL AND OBSTETRIC ASPECTS
T a b le 3
A b o r tio n s a n d lo w - w e ig h t n e w b o r n s
F o u r ( 2 7 p e r c e n t) m a te r n a l d e a th s o c c u r r e d a m o n g
1 5 C la s s I I I a n d I V p a tie n ts . T w o ( 2 p e r c e n t) o u t o f e ig h ty
-f iv e C la s s I a n d I I p a tie n ts d ie d . F u n c t i o n a l C l a s s
M o s t c a s e s ( 8 5 p e r c e n t) w e r e c la s s if ie d a s f u n c tio n a l
C la s s I o r I I d u r in g th e f ir s t v is it. C la s s I I I o r I V w e r e
m o r e f r e q u e n t ( p = O .O O I ) in G 2 ( 1 4 c a s e s ) , in c o m p a r is o n
to G I ( I c a s e ) , c o r r e s p o n d in g to : E is e n m e n g e r 's s y n d r o m e
( 3 c a s e s ) ; a o r tic s te n o s is ( 2 c a s e s ) ; A C P ( 2 c a s e s ) ; a o r tic
s te n o s is a n d c o a r c ta tio n o f th e a o r ta ( 1 c a s e ) ; s u b a o r tic
s te n o s is ( I c a s e ) ; c o a r c ta tio n o f th e a o r ta ( 1 c a s e ) ; lA C ( I
c a s e ) ; P S + V I C + A I C ( 1 c a s e ) ; A V C ( 1 c a s e ) ; a n d r ig h t
v e n tr ic le d o u b le o u tle t ( 1 c a s e ) . T h e C la s s I I I c a s e in G I
w a s d u e to a n lA C . E le v e n p a tie n ts e v o lv e d f r o m C la s s e s
I to I I a n d f r o m I I I to I V , f iv e o f w h o m w e r e in G l ( I V C
-2 c a s e s , F a I lo t's te tr a lo g y , r ig h t v e n tr ic le d o u b le o u tle t a n d
a o r tic s te n o s is ) a n d s ix o f w h o m w e r e in G 2 ( A o r tic
s te n o s is - 3 c a s e s , lA C , A V C , a n d P u lm o n a r y s te n o s is ) .
T w o p a tie n ts in G l, w ith d o u b le o u tle t o f th e r ig h t
v e n tr ic le in o n e , a n d a o r tic s te n o s is in th e o th e r , u n d e r w e n t
h e a r t s u r g e r y d u r in g p r e g n a n c y d u e to u n tr e a ta b le h e a r t f a ilu r e . G 1
%
G 2
%
T o ta l
A b o r tio n s L o w - w e ig h t n e w b o r n
2 6
4 % 1 3 %
5 1 8
1 0 % 3 8 %
7 2 4
1 4 % 5 1 %
M a t e r n a l M o r t a l i t y R a t e s A b o r t i o n s
M a te r n a l m o r ta lity w a s h ig h e r ( p = O .0 2 ) a n d /o r in G 2
( s ix d e a th s = 1 2 p e r c e n t; th r e e d u r in g p r e g n a n c y a n d o r
d u r in g p u e r p e r iu m ) in r e la tio n to G l, in w h ic h n o d e a th s
o c c u r r e d .
T a b le 2 c o m p a r e s h e a r t d is e a s e to f u n c tio n a l c la s s ,
h e m o g lo b in e m ia , p u lm o n a r y h y p e r te n s io n o r tr a n s v a lv a r
w e d g e , a n d d e a th p e r io d .
T V W - T r a n s v a lv a l w e d g e P H - P u lm o n a r y H y p e r te n s io n d a d - D a y s a fte r d e liv e r y H G B - h e m o g lo b in c o n c e n tr a tio n * S u d d e n d e a th
w - W e e k o f g e s ta tio n
T a b le 2 M a te r n a l M o r ta lity
2 6 w W e o b s e r v e d a s ig n if ic a n t d if f e r e n c e ( p = O .O I ) b e tw e e n th e p r o p o r tio n o f n e w b o r n s
lo w - w e ig h t n e o n a te s in G 2 ( 3 8 p e r c e n t) a n d G I ,
( 1 3 p e r c e n t) ( T a b le 3 ) . T h is d id n o t o c c u r in th e
g r o u p o f p a tie n ts w ith r e s id u a l le s io n s . O n ly o n e
o u t o f I I c a s e s w ith F a I lo t's te tr a lo g y g a v e b ir th
to a lo w - w e ig h t n e w b o r n . S e v e n o u t o f e ig h t
n e w b o r n b a b ie s , f r o m E is e n m e n g e r 's s y n d r o m e
c a s e s w e r e lo w - w e ig h t.
P r e m a tu r ity w a s m o r e f r e q u e n t ( p < O .O I ) in G 2 ( 1 5
c a s e s = 3 2 p e r c e n t) th a n in G I ( 3 c a s e s - 7 p e r c e n t) .
I n tr a u te r in e g r o w th r e ta r d a tio n o c c u r r e d in 6 ( 1 3 p e r c e n t)
c a s e s in G la n d 1 3 ( 2 8 p e r c e n t) c a s e s in G 2 ( p = O .0 8 ) . N o
g r o w th r e ta r d a tio n w a s r e g is te r e d in p a tie n ts w ith r e s id u a l
le s io n s . T h e r e w a s n o p r e m a tu r ity in th is g r o u p , a n d o n ly T h e r e w e r e a to ta l o f s e v e n a b o r tio n s , o f w h ic h s ix
w e r e s p o n ta n e o u s a n d o n e w a s th e r a p e u tic ; tw o w e r e in
G I a n d f iv e w e r e in G 2 ( T a b le 3 ) . T h e r e w a s n o s ig n if ic a n t
d if f e r e n c e b e tw e e n th e g r o u p s ( 1 0 v s . 4 p e r c e n t) .
T h e r a p e u tic a b o r tio n w a s a m e a s u r e ta k e n in th e f ir s t
tr im e s te r f o r a C la s s I I I p a tie n t w ith E is e n m e n g e r 's
s y n d r o m e . S p o n ta n e o u s a b o r tio n s o c c u r r e d in f iv e C la s s
lI I I p a tie n ts ( E is e n m e n g e r 's s y n d r o m e - 3 c a s e s , E b s te in 's
D is e a s e - 2 c a s e s ) a n d in a C la s s I I I p a tie n t w ith
p u lm o n a r y s te n o s is + lA C + I V C ) .
3 1 w 3 0 d a d 3 7 w 4 0 d a d 6 0 d a d
L o w - w e i g h t n e w b o r n s , p r e m a t u r i t y a n d
P e r io d i n t r a u t e r i n e g r o w t h r e t a r d a t i o n
1 2 0 T V W /P H
9 5
1 3 0 1 2 0
1 0 6
86
1 5 .41 8 .7 1 2 .2 1 2 .5 1 2 .5 H G B ( G /D L ) ( m m H g )
1 6 .4
III
II
III III III
F u n c tio n a l L C la s s
II
E is e n m e n g e r 's s y n d r o m e - E S * E S *
E S *
A o r tic s te n o s is A o r tic s te n o s is S u b a o r tic L e s io n
o n e o f
I Icases o f F allo t's
tetralo g y
w as asso ciated
w ith
in trau terin e
g ro w th retard atio n .
F iv e o u t o f eig h t n ew b o rn
b ab ies
fro m
p atien ts
w ith
E isen m en g er's
sy n d ro m e
sh o w ed
g ro w th retard atio n ,
an d six w ere p rem atu re.
F etal an d n eo n ate d eath s am o u n ted
to 4 (3 1 p ercen t)
cases in 1 3 C lass III an d IV p atien ts
an d 3 d eath s o u t o f
8 0 C lass I an d II p atien ts.
N ew b o rn
b ab ies w ith h eart
d iseases
A n esth esia
A n esth esia
w as u sed d u rin g
d eliv ery
acco rd in g
to
th e ex ten t o f m atern al card iac
in v o lv em en t.
T w en ty -fo u r
(5 2 p ercen t) p atien ts o f G
Iu n d erw en t p erid u ral an esth esia.
In G 2 , 1 5 (3 6 p ercen t) p atien ts w ere su b m itted to p erid u ral
an esth esia
an d 1 7 (4 0 p ercen t) w ere su b m itted
to g en eral
an esth esia.
E isen m en g er's
sy n d ro m e
p atien ts
w ere
su b m itted
to g en eral an esth esia.
F iv e p atien ts
d id n o t receiv e
an esth esia
sin ce th ey
h ad
sp o n tan eo u s
b irth s.
N o clin ical
p ro b lem s
w ere
attrib u ted
to th e u se o f an esth esia.
T h ree (3 .2 p ercen t) n ew -b o rn
b ab ies p reseD ted h eart
m alfo rm atio n s.
T w o cases w ere in G
I:o n e m o th er
w ith
G A T an d lA C
an d a ch ild
w ith lA C ;
o n e m o th er
w ith
A C P + IV C + IA C
an d a ch ild w ith P A C + IA C .
T h ere
w as
o n e m alfo rm atio n
in G 2 , in w h ich
th e m o th er
h ad IV C
an d th e ch ild p resen ted
A V C .
D IS C U S S IO N
T w en ty -tw o
(4 8 p ercen t) cases fro m G
Ian d 3 1 (6 6
p ercen t)
fro m
G 2 u n d erw en t
a caesarean
sectio n
(n o
sig n ifican t
d ifferen ce).
T ab le 5 sh o w s th e in d icatio n s
o f
th e caesarean
d eliv eries.
T y p e o f h eart d isease
w as th e
m o st im p o rtan t
in d icatio n
in 1 3 cases, o f w h ich elev en
w ere
in G 2 : E isen m en g er's
sy n d ro m e
(4 cases);ao rtic
sten o sis (2 cases);co arctatio n
o f th e ao rta (2 cases);ao rtic
sten o sis
+ co arctatio n
o f th e ao rta
(1 case);
su b ao rtic
sten o sis
(Icase);
an d p aten t
d u ctu s
arterio su s
w ith
a
d issectin g
an eu ry sm
o f ao rta
(Icase). T w o cases w ere in
G
I;co arctatio n
o f th e ao rta an d ao rtic sten o sis.
4 7
1 0 0 %
4 6 T o ta l
93
F etal an d n eo n ate
m o rtality
rates
T y p e o f b irth
T a b le 4 T yp e s o f d e live ry
D e live ry N o rm a l F o rce p s C a e sa re a n
G 1 1 1 1 3 2 2
2 4 % 2 8 % 4 8 %
G 2 9 7 3 1
1 9 % 1 5 % 6 6 %
T o ta l 2 0 2 0 5 3
2 2 % 2 1 % 5 7 %
T h e
in cid en ce
o f ab o rtio n s
in b o th
g ro u p s
w as
ap p ro x im ately
IS
p ercen t,
w h ich
is lo w er
th an
th at
ex p ected
in th e n o rm al
p o p u latio n .
5T h is
m ig h t
h av e
o ccu rred d u e to fo llo w -u p
startin g in th e seco n d trim ester
o f p reg n an cy
in 7 0 p ercen t o f th e stu d ied w o m en . S ev en ty
-fiv e p ercen t o f ab o rtio n s
o ccu r
in th e first
1 2 w eek s o f
g estatio n ,
w h ile
2 5 p ercen t
o ccu r
after
th is
p erio d ,
acco rd in g to R E Z E N D E
et al.(1T h e sm all n u m b er o f cases
stu d ied d o es n o t allo w an y ap p ro p riate an aly sis o f th e effect
o f th e su rg ical
co rrectio n s
an d th e fu n ctio n al
class
o n
ab o rtio n s,
alth o u g h
th ey
w ere
m o re
freq u en t
in G 2 .
H o w ev er,
th is d o es sh o w
th at th ere
is a n eed to g u id e
p reg n an t
w o m en
w i th co n g en
i tal
h eart
d iseases
to
ap p ro p riate
sp ecialists
in o rd er to arran g e a m o re efficien t
p ren atal fo llo w -u p .
It is fu n d am en tal
to k n o w ab o u t th e effects o n fetal
T w o fetal an d 5 n eo n ate d eath s o ccu rred
in G 2 , an d
g ro w th
an d d ev elo p m en t
o f h em o d y n am ic
alteratio n s
n o n e o ccu rred
in G
I(p = O .O
I).T ab le 6 sh o w s fetal d eath
b ro u g h t o n b y card iac lesio n s in o rd er to ev alu ate p rin cip al
related to h eart d isease.
p ro g n o stic
facto rs
p ro g n o sis.
L o w -w eig h t
n ew b o rn s,
g ro w th
retard atio n ,
an d p rem atu rity
w ere co m p licatio n s
related
to d iseases
th at
cau sed
cy an o sis,
p u lm o n ary
h y p erten sio n ,
h ig h p ressu re
w ed g es,
an d fu n ctio n al
C lasses III an d IV . G 2 p resen ted
a sig n ifican t
n u m b er
o f d eath s d u rin g an d after p reg n an cy
d u e to th e h ig h er
n u m b er
o f m atern al
co m p licatio n s
in th is
g ro u p .
S u rg ical
co rrectio n
d im in ish ed
th e
n u m b er
o f
p rem atu re
an d lo w -w eig h t
b ab ies,
ex em p tin g
itself
fro m
g ro w th
retard atio n .
T h is
also o ccu rred
in th e
1 0 0 %
g ro u p o f n in e p atien ts,
w ith resid u al
p atien ts
(T ab le
1 ) sh o w in g
resu lts sim ilar to th o se in G
I.V ag in al an d C aesarean d eliv ery reco m m en d atio n s
are
sim ilar
to th o se
in th e
n o rm al
p o p u latio n .?
H em o d y n am ic
alteratio n s are sim ilar in ab d o m in al an d
1 0 0 %_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
v ag in al b irth s, w ith so m e d ifferen ces
d u rin g
lab o r.
xH ow ever, laparotom y
poses a higher risk due to anesthesia,
hem orrhages,
infections,
em boli,
and
pulm onary
com plications.
In heart patients,
these risks are higherY
T herefore,
congenital
heart disease is not an indication for
C aesarean
section.
10A nesthesia
does influence the type of
birth
due to different
effects
of drugs
and anesthesia
techniques
on each kind of heart disease. E isenm enger's
syndrom e,
aortic and subaortic
stenosis indicated
the use
of peridural anesthetic to preserve peripheral resistance w ith
an adequate pre-load. A lthough conduction
anesthetic m ay
be used in these
patients,
it is im portant
to note that a
decrease
in peripheral
resistance,
w hich
is frequently
Table 5
Caesarean section indications
F etal bradycardia F unctional dystocia P elvic presentation
T w o previous C aesarean sections P M R / induction failure
C P O
R C IU
P ost m ortem H eart disease O thers T otal
P M R - P rem ature m em brane rupture C P O - C efalo-pelvic disproportion * p< 0.001
G 1
1 0
3
2
1
3
2*
1
22
G 2
1 1
1
2
1
1
3
11*
1
31
associated w ith a sym pathetic
block, m ay dim inish pre-load
and cause heart failure and sudden death.
In G 2, m ore C aesarean
sections
w ere indicated
due
to heart disease
(aortic stenosis,
coarctation
of the aorta,
or E isenm enger's
syndrom e),
since
there
w ere
m ore
patients
w ith
cyanosis,
pulm onary
hypertension,
and
obstructive
lesions
in the
left
cham bers
w ith
high
transvalvar
w edges. P atients
w ith coarctation
of the aorta
underw ent
C aesarean
sections,
although
G O O D W IN ,
IIcontrarily
to M E N D E L S O N ,
12reported
that there w as no
risk for these patients during labor, si nce none of the deaths
reported
in his study occurred
during this period.
T here w as no significant
difference
betw een
G
Iand
G 2 in relation to presence
of congenital
heatt diseases
in
new born babies. T hree babies (3.2 percent) w ere born w ith
heart disease, w hile in norm al population
this incidence
is
I
percent.
13W H IT T E M O R E
studied 372 babies from 233
w om en during three years, 17.9 percent of w hich w ere from
m others w ho did not undergo surgery and 14.2 percent from
m others w ho underw ent surgery. In this study, there w as no
statistical difference
betw een these tw o groupS .14
W e noted the appearance
of sim ilar diseases (lA C ) in
G J descendants. T he sam e m alform ation
w as observed
by
C Z E IZ E K in seven of 12 cases.
ISIn W H IT T E M O R E 'S
study
approxim ately
half (35 of 60) of the m alform ations
w ere
sim ilartothe
m other's.'4N O R A
&N O R A noted that 8 percent
of congenital diseases w ere genetic and 2 percent w ere due
to the environm ent,
w hile 90 percent com e from a genetic
and environm ental
interaction.
'6A lthough
w e ruled out
m edications
and diseases
that could
be responsible
for
congenital diseases, the sm all num ber of cases does not allow
a distinction betw een genetic and environm ental
factors.
Table 6
Types of lesions, clinical characteristics and fetal and neonatal death
Lesion F C H G B T V W /P H N B w eight D eath
(g/dl) (m m H g) (gram s)
E S 2 17.4 96 510 before bi rth
E S * 2 16.4 120 700 after birth
E S * 3 15.4 95 950 after birth
A ortic stenosis + C oarctation 3 12.1 57 1680 after birth
of the aorta
A ortic stenosis* 3 12.2 120 3000 after birth
P S + A V C 2 17.0 85 950 after birth
R ight ventricular double 3 18.9 100 380 after birth
*post m ortem caesarean section; T V W = T ransvalvar w edge #heart surgery at 26th w eek; P H = P ulm onary hypertension F C = F unctional class; H G B = H em oglobin concentration N B = N ew born
sao P aulo M edical Journal/R P M 114(5): 1248-1254, 1996 O LIV E IR A , T .A .; A V ILA , W .S . & G R IN B E R G , M .• O bstetric and perinatal aspects in
C O N C L U S IO N S
M aternal
and fetal prognosis
w as significantly
m ore
positive
in patients
w ho experienced
operations.
Residual
surgical
lesions did not alter any results. Left obstructive
involvem ent
and cyanosis
w ere associated
w ith m aternal
death and m ost of the neonate deaths. M aternal,
fetal and
neonate
deaths occurred
only am ong
patients
w ho w ere
not operated.
Prem aturity
and
low -w eight
new borns
w ere
significantly
higher
in patients
w ho w ere not operated
upon.
Eisenm enger's
syndrom e,
aortic stenosis, am ong the
lesions that caused left obstruction,
w ere those w ith higher
m aternal,
fetal and neonate
deaths.
Patients w ho w ere not operated underw ent
Caesarean
sections m ore often due to the severity
of their diseases.
The incidence
of heart diseases
in descendants
w as
three
tim es
w hat
is usually
expected
in the
general
population,
w ith no difference
due to surgical correction.
O ur results reinforce the need for fam ily planning
in
patients
w ith congenital
heart
diseases,
w hich
w ould
include
orientation
about
surgery.
Pregnancy
is not
recom m ended
for patients w ith Eisenm enger's
syndrom e
and aortic stenosis.
R ESU M O
O s b e n e fic io s d a c o rre 9 a o c iru rg ic a d e p o rta d o ra s d e c a rd io p a tia c o n g e n ita e m re la 9 a o a e v o lu 9 a o d a g ra v id e z a in d a a p re s e n ta m c o n tro v e rs ia s . E s tu d a m o s 4 8 g e s ta n te s (id a d e m e d ia = 2 5 a n o s ) c o m c a rd io p a tia s c o n g e n ita s c o rrig id a s (G ru p o 1 ), in c lu in d o 1 5 le s o e s c ia n o g e n ic a s : te tra lo g ia d e F a llo t (1 1 c a s o s ), a n o m a lia d e E b s te in (2 c a s o s ). tra n s p o s i9 a o d a s g ra n d e s a rte ria s (1 c a s o ), d u p la v ia d e s a id a d o v e n tric u lo d ire ito (1 c a s o ) e c o m p a ra m o s c o m 5 2 g e s ta n te s (id a d e m e d ia = 2 6 a n o s ) c o m c a rd io p a tia s c o n g e n ita s n a o c o rrig id a s , in c lu in d o 1 1 c a s o s d e S in d ro m e d e E is e n m e rg e r (G ru p o 2 ). O c o rre u m a io r in c id e n c ia n o g ru p o 2 d e 6 b ito s m a te rn o s (1 2 % x 0 ; p = 0 ,0 1 ), m o rta lid a d e p e rin a ta l (1 5 % x 0 ; p = O ,0 1 ), e p re m a tu rid a d e (3 2 % x 7 % ; p < O ,0 1 ). A b o rto e s p o n ta n e o (4 % x 1 0 % ), p a rto c e s a re a (4 8 % x 6 6 % ) e re ta rd o d e c re s c im e n to in tra -u te rin o (1 3 % x 2 8 % ) n a o a p re s e n ta ra m re s u lta d o s e s ta tis tic a m e n te d ife re n te s . C o n c lu im o s q u e a c o rre 9 a o c iru rg ic a d e p o rta d o ra s d e c a rd io p a tia c o n g e n ita e s ta a s s o c i a d a a m e lh o r p ro g n 6 s tic o m a te rn o e fe ta l e m re la 9 a o a s p a c ie n te s c o m c a rd io p a tia s n a o c o rrig id a s . P o rta n to , a c o rre 9 a o c iru rg ic a d e v e s e r c o n s id e ra d a n o p la n e ja m e n to fa m ilia r d e m u lh e re s c o m c a rd io p a tia c o n g e n ita .
R E F E R E N C E S
1 . U e la n d K . C a rd io v a s c u la r d is e a s e s c o m p lic a tin g p re g n a n c y . C lin O b s te t G y n e c o l 1 9 7 8 ;2 1 :4 2 9 .
2 . P e rlo ff J K . P re g n a n c y a n d c a rd io v a s c u la r d is e a s e . In : B ra u n w a ld E , e d . H e a rt d is e a s e . P h ila d e p h ia : S a u n d e rs ,
1 9 8 3 : 1 7 6 3 -8 1 .
3 . S u g ru e D , B la k e S , M a c D o n a ld D . P re g n a n c y c o m p lic a te d b y m a te rn a l h e a rt d is e a s e a t th e N a tio n a l M a te rn ity H o s p ita l, D u b lin , Ire la n d , 1 9 6 9 to 1 9 7 8 . A m J O b s te t G y n e c o l,
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6 . R e z e n d e J , M o n te n e g ro C A B , B a rc e lo s J M . A b o rta m e n to . In : O b s te tric ia , 4 th e d . R io d e J a n e iro : G u a n a b a ra K o o g a n ,
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