RESUMO
Increasing numbers of people are seeking assisted conception. In people with known cardiac disease or risk factors for cardiac disease, assisted conception may carry increased risks during treatment and any subsequent pregnancy. These risks should be assessed, considered and minimized prior to treatment.
Assuntos
Doenças Cardiovasculares , Cardiopatias , Feminino , Gravidez , Humanos , Reprodução , Fertilização , Fatores de RiscoRESUMO
OBJECTIVES: The coexistence of two complex physiologies such as Fontan and pregnancy is still not fully understood. We aim to add a unique and essential knowledge to help our colleagues in the management of Fontan patients that undergo pregnancy as well as the fetus and the placenta perfusion. METHODS AND RESULTS: We analyse the coexistence of Fontan and pregnancy physiology on a complex case of a woman with hypoplastic left heart syndrome palliated with a univentricular repair who became pregnant, delivered very prematurely and had atypical placental findings. CONCLUSION: Histopathological analysis of the placenta could help us to refine the understanding of Fontan physiology adaptation during pregnancy, predict women and fetal outcomes as well as to plan a better pre-pregnancy status. However, further evidence is needed in order to reach a more solid and unified conclusion.
Assuntos
Parto Obstétrico/métodos , Técnica de Fontan/métodos , Cardiopatias Congênitas/cirurgia , Insuficiência Placentária/etiologia , Complicações Cardiovasculares na Gravidez , Feminino , Cardiopatias Congênitas/diagnóstico , Humanos , Recém-Nascido , Imagem Cinética por Ressonância Magnética/métodos , Insuficiência Placentária/fisiopatologia , Gravidez , Adulto JovemRESUMO
Repair of transposition of the great arteries usually involves an atrial switch or arterial switch operation, which can complicate physiological adaptation to the demands of pregnancy and adversely affect the fetus. We retrospectively compared outcomes of 48 completed pregnancies in 23 women with surgically corrected transposition of the great arteries (38 atrial switch/10 arterial switch operation) under joint cardiac-obstetric care in our tertiary referral clinic between 1997 and 2017. Most women delivered vaginally (85%). The pre-term delivery rate was high (atrial switch 39%; arterial switch operation 40%). Small for gestational age occurred in 56% of babies, significantly more in the atrial switch group (66%) than arterial switch operation (20%), p = 0.013. Women with surgically corrected transposition of the great arteries wishing to become pregnant are at high risk of obstetric complications, primarily pre-term delivery and small for gestational age baby. They require more careful ultrasound surveillance beyond 36 weeks' gestation and/or may benefit from early induction of labour. Trial registration: Text/Not applicable.
RESUMO
The Fontan operation is a palliative surgical procedure for patients whose hearts cannot support a biventricular circulation. The haemodynamic changes that occur in pregnancy are particularly challenging for Fontan patients and the outcomes are variable. We present a case where fetal outcome was particularly poor despite a lack of high risk features pre-pregnancy.
Assuntos
Técnica de Fontan/métodos , Cardiopatias Congênitas/cirurgia , Complicações Cardiovasculares na Gravidez , Adulto , Ecocardiografia , Feminino , Cardiopatias Congênitas/diagnóstico , Humanos , Imagem Cinética por Ressonância Magnética , Gravidez , Resultado da GravidezRESUMO
There is a paucity of clinical data regarding the management of pregnancy and lactation in women requiring long-term total parenteral nutrition with complex nutritional needs. This case report and literature review highlights common challenges in care and presents evidence which can guide the obstetrician's approach to care.
RESUMO
OBJECTIVES: To compare the maternal, fetal and cardiac outcomes in women who have undergone aortic valve replacement. METHOD: Retrospective observational study of all women with aortic valve replacement, who underwent a pregnancy (1998-2012). Maternal-, fetal- and valve-related cardiac outcomes were assessed. RESULTS: Thirty-two pregnancies in 16 women with aortic valve replacement (nine bioprosthetic, six Ross and 17 mechanical) were evaluated. There were no adverse maternal events in the bioprosthetic and Ross groups but three in the mechanical group. Fetal loss rate was highest in the mechanical valve pregnancies (53%). One woman in the bioprosthetic group needed valve re-operation, and one woman in the mechanical valve group died. There was no difference in the change of Vmax over the follow-up between the valves (p = 0.25). CONCLUSIONS: There was no difference in deterioration between aortic valve replacements during and after pregnancy. The highest risk of maternal and fetal complications occurred in the mechanical valve group.
RESUMO
OBJECTIVES: Women with cystic fibrosis (CF) now achieve a greater life expectancy and therefore have greater expectations from life. Literature reporting pregnancy outcomes in CF is still sparse. There remains a legacy of advising women with significant disease to avoid pregnancy. We aimed to assess current maternal and fetal outcomes in women with CF with varied pre-pregnancy lung function. STUDY DESIGN: Retrospective case note review of data from 15 pregnancies in 12 women with CF receiving care at a specialist centre between 2003 and 2011. Descriptive statistics were used for the quantitative data. The forced expiratory volume (FEV1) and forced vital capacity (FVC) were calculated and shown as the percentage of their predicted values for BMI, height and age. Changes in lung function pre, 6, and 24 months post delivery were calculated with the paired t-test. RESULTS: Mean maternal age was 28.9 (range 21-36, CI 26.8-31). Maternal FEV1 at booking ranged from 27 to 80% predicted (mean=63.6%, CI 54.62-71.38%). Cystic fibrosis-related diabetes (CFRD) was present in 8 of 14 (live birth) pregnancies. Average gestation at delivery was 38 weeks. There was a 100% vaginal delivery rate (11 spontaneous vertex, 2 ventouse, 1 forceps). Average fetal birth weight was 2.97 kg (range 2.2-3.83 kg, CI 2.72-3.23). The differences between the maternal pre- and 6 months post-pregnancy mean FEV1 (p=0.136) and FVC (p=0.225) were not statistically significant. CONCLUSION: With careful multidisciplinary antenatal and intrapartum management, successful outcomes have been obtained in this group of women with CF.
Assuntos
Fibrose Cística/fisiopatologia , Pulmão/fisiopatologia , Complicações na Gravidez/fisiopatologia , Adulto , Peso ao Nascer , Fibrose Cística/terapia , Inglaterra , Feminino , Volume Expiratório Forçado , Hospitais Universitários , Humanos , Prontuários Médicos , Ambulatório Hospitalar , Gravidez , Complicações na Gravidez/terapia , Resultado da Gravidez , Estudos Retrospectivos , Índice de Gravidade de Doença , Capacidade Vital , Adulto JovemRESUMO
AIMS: The natural history and outcome of pregnancy in patients with a pacemaker or those presenting with atrioventricular conduction block in pregnancy are unknown with only a limited number of case reports published. METHODS AND RESULTS: This study examines the progress and outcome of 25 pregnancies in 18 women who were either paced or presented with untreated atrioventricular conduction block during pregnancy. All patients were seen in a single referral centre between 1998 and 2008 and were evaluated at regular intervals with ECG, echocardiography, and 24 h Holter. Four women (4 pregnancies) had new-onset atrioventricular block, 3 women (5 pregnancies) had previously diagnosed atrioventricular block who had not undergone pacing, and 11 women (16 pregnancies) had known atrioventricular block with a pacemaker prior to pregnancy. Of the four patients presenting for the first time in pregnancy, the frequency or severity of atrioventricular conduction block increased during pregnancy. One required pacing during and one after pregnancy. In two patients the conduction disturbance resolved postpartum. In the three patients who had known but untreated atrioventricular block before pregnancy, this progressed during each pregnancy but did not require pacing. In patients paced before pregnancy, there were no complications as a result of the pacemaker, but maternal complications were seen in patients with underlying structural heart disease. CONCLUSIONS: Atrioventricular block in pregnancy is progressive; pacing is not always required but all patients should be closely monitored during and after pregnancy. In patients paced before pregnancy, pacing is well tolerated.
Assuntos
Bloqueio Atrioventricular/terapia , Marca-Passo Artificial , Complicações Cardiovasculares na Gravidez/terapia , Adulto , Bloqueio Atrioventricular/diagnóstico por imagem , Bloqueio Atrioventricular/fisiopatologia , Progressão da Doença , Ecocardiografia , Eletrocardiografia , Feminino , Humanos , Gravidez , Complicações Cardiovasculares na Gravidez/diagnóstico por imagem , Complicações Cardiovasculares na Gravidez/fisiopatologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: The management of heart disease in pregnancy is highly specialized. Guidelines are based on observational studies. This paper describes our experience of these patients, including adverse cardiac events, adherence to guidelines, and areas of suboptimal management. METHODS: Patients referred to the service between 01/05/1999 and 30/06/2005 were identified using clinic lists and keyword searches in databases. A list of 40 management standards was created from European Society of Cardiology and the Confidential Enquiry into Maternal and Child Health guidelines. Adherence to these was recorded and adverse cardiac events noted. RESULTS: There were 177 pregnancies in 155 women with a mean age of 28+/-6 years. Service referrals increased linearly throughout the study period. Of 131 cardiac pregnancies 101 had congenital heart disease (77.1%). Pulmonary oedema, deteriorating functional class, sustained arrhythmia or cardiac intervention occurred in 13 pregnancies (10.2%), though not always in high risk cases. Management guidelines were largely followed, though areas of suboptimal management included lack of pre-conception advice and inadequate post-partum follow-up. Controversial areas include the use of beta-blockade in coarctation of the aorta and the use of elective Caesarean section in high risk patients. CONCLUSIONS: Cardiac pregnancies are increasing, mainly due to the rise in patients with congenital heart disease. Some patients will experience adverse cardiac events, including low risk patients. Pre-conception advice and post-partum follow-up should be improved. In the absence of prospective studies, management is likely to be driven by observational studies.
Assuntos
Doenças Cardiovasculares/terapia , Cardiopatias Congênitas/terapia , Padrões de Prática Médica/tendências , Complicações Cardiovasculares na Gravidez/terapia , Adulto , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/fisiopatologia , Inglaterra/epidemiologia , Feminino , Fidelidade a Diretrizes , Cardiopatias Congênitas/epidemiologia , Cardiopatias Congênitas/fisiopatologia , Humanos , Guias de Prática Clínica como Assunto , Gravidez , Complicações Cardiovasculares na Gravidez/epidemiologia , Complicações Cardiovasculares na Gravidez/fisiopatologia , Resultado da Gravidez , Gravidez de Alto Risco , Estudos RetrospectivosRESUMO
A 31-year-old primigravida had a 27-mm CarboMedics mitral valve implanted previously for mitral regurgitation. The patient had decided to take low-molecular-weight heparin (LMWH) and aspirin throughout her pregnancy. Monthly echocardiography and anti-Factor Xa levels were satisfactory. She presented at 36 weeks' gestation with 24 h of exertional dyspnea, and was in pulmonary edema. Transthoracic echocardiography suggested valve thrombosis. The patient underwent mitral valve replacement after the vaginal delivery of a healthy infant. The resected valve was found to have adherent fresh thrombus. The recent recommendation that LMWH plus aspirin might provide adequate anticoagulation for mechanical valves in pregnancy does not prevent acute prosthetic mitral valve thrombosis.
Assuntos
Aspirina/administração & dosagem , Fibrinolíticos/administração & dosagem , Implante de Prótese de Valva Cardíaca/efeitos adversos , Heparina de Baixo Peso Molecular/administração & dosagem , Insuficiência da Valva Mitral/cirurgia , Complicações Cardiovasculares na Gravidez/tratamento farmacológico , Trombose/tratamento farmacológico , Adulto , Relação Dose-Resposta a Droga , Ecocardiografia , Feminino , Seguimentos , Cardiopatias/tratamento farmacológico , Cardiopatias/etiologia , Cardiopatias/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Recém-Nascido , Masculino , Gravidez , Complicações Cardiovasculares na Gravidez/etiologia , Complicações Cardiovasculares na Gravidez/cirurgia , Falha de Prótese , Reoperação/métodos , Trombose/etiologia , Trombose/cirurgiaRESUMO
A causal relationship between minor endometriosis and infertility or subfertility has not yet been demonstrated, although a significant association is shown by prevalence studies. This article critically reviews the evidence for pituitary-ovarian dysfunction as a cause for subfertility in women with minor endometriosis. The lack of fertile controls with endometriosis presents a methodological problem. Group comparison in studies using tubal infertility cases as controls has demonstrated impaired follicular growth, reduced circulating oestradiol concentrations during the preovulatory phase and oestradiol and progesterone during the early luteal phase, and disturbed luteinizing hormone (LH) surge patterns. LH concentration in preovulatory follicular fluid is also reduced, and granulosa cells collected at the same time have impaired steroidogenic capacity in vitro. However, these findings are not consistent in published studies. Significantly lower oocyte fertilization rates (49%) are found compared with controls (69%), even after maximum stimulation with exogenous follicle-stimulating hormone and human chorionic gonadotrophin (52% versus 69%). The implantation rate is also lower (11% versus 13%). An inherent disorder of follicular function seems likely, and LH surge impairment is probably a secondary effect. Impairment of oocyte fertilization would thus contribute substantially to the natural subfertility associated with endometriosis, but in vitro fertilization is still successful as excess numbers of oocytes are available.