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1.
Zhong Nan Da Xue Xue Bao Yi Xue Ban ; 46(2): 207-211, 2021 Feb 28.
Artigo em Inglês, Chinês | MEDLINE | ID: mdl-33678660

RESUMO

Anticoagulation drugs should be used for patients with mechanical heart valve (MHV) in case of potential risk of thrombosis. Pregnant women with MHV have to change therapies due to teratogenic effect of some anti-coagulation drugs. European Society of Cardiology clinical guidelines for the management of cardiovascular diseases during pregnancy gives specific suggestions for anticoagulation therapy.We have treated 2 patients with mechanical heart valve thrombosis (MVT) during pregnancy: One received low molecular weight heparin (LMWH) throughout the pregnancy and developed MVT at the third trimester of pregnancy; one developed MVT at the first trimester when replacing vitamin K antagonists (VKA) with LMWH. These patients raised secondary reflection on the balance between clinical guideline and personalized medicine. During LMWH therapy, we should dynamically monitor patients' anti-activated factor X (anti-Xa) level to evaluate coagulation function during pregnancy. When a pregnant woman with MHV develops symptoms of acute heart failure, stuck mechanical valve should be paid attention to and surgery should be promptly performed if necessary.


Assuntos
Próteses Valvulares Cardíacas , Complicações Cardiovasculares na Gravidez , Trombose , Anticoagulantes/efeitos adversos , Feminino , Próteses Valvulares Cardíacas/efeitos adversos , Valvas Cardíacas , Heparina de Baixo Peso Molecular/efeitos adversos , Humanos , Gravidez , Complicações Cardiovasculares na Gravidez/tratamento farmacológico , Trombose/tratamento farmacológico
3.
Yonsei Med J ; 61(11): 970-975, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33107241

RESUMO

We investigated pregnancy morbidities in Korean patients with Takayasu arteritis (TA) in a single tertiary hospital as a pilot study. We retrospectively reviewed the medical records of 12 pregnancies in seven patients with TA. All patients were diagnosed with TA based on the 1990 American College of Rheumatology classification criteria. The medical records of patients were well-documented, allowing review of clinical data including pregnancy morbidities. The angiographic and Ishikawa classifications at diagnosis and TA activity at delivery were assessed. Of the 12 pregnancies, two pregnancies ended in spontaneous abortion (16.7%), and one pregnancy (8.3%) had therapeutic abortion at 9 weeks due to maternal morbidity. Among the remaining nine pregnancies, only one child was delivered via normal spontaneous vaginal delivery, and the remaining eight were delivered by Caesarean section. Two out of nine (22.2%) neonates were born with low birth weight, and one of them was born at 30 weeks of gestation. The most common maternal complication was hypertension affecting 7/12 (58.3%) pregnancies. Preeclampsia occurred in one pregnancy, and gestational diabetes mellitus (GDM) occurred in two pregnancies. At delivery, disease activity of TA was stable in all pregnancies, and glucocorticoids were administered in nine pregnancies. Live birth rate of pregnant Korean patients with TA was 75%. Future studies are needed to reduce pregnancy-related complications.


Assuntos
Glucocorticoides/uso terapêutico , Complicações Cardiovasculares na Gravidez/tratamento farmacológico , Resultado da Gravidez/epidemiologia , Arterite de Takayasu/tratamento farmacológico , Adulto , Coeficiente de Natalidade , Cesárea/estatística & dados numéricos , Criança , Feminino , Humanos , Hipertensão/complicações , Hipertensão/epidemiologia , Recém-Nascido , Morbidade , Projetos Piloto , Pré-Eclâmpsia/epidemiologia , Gravidez , Complicações Cardiovasculares na Gravidez/diagnóstico , Complicações Cardiovasculares na Gravidez/epidemiologia , República da Coreia/epidemiologia , Estudos Retrospectivos , Índice de Gravidade de Doença , Arterite de Takayasu/diagnóstico , Arterite de Takayasu/epidemiologia
4.
BMJ ; 370: m2177, 2020 08 05.
Artigo em Inglês | MEDLINE | ID: mdl-32759284

RESUMO

Pulmonary embolism is a common and potentially fatal cardiovascular disorder that must be promptly diagnosed and treated. The diagnosis, risk assessment, and management of pulmonary embolism have evolved with a better understanding of efficient use of diagnostic and therapeutic options. The use of either clinical probability adjusted or age adjusted D-dimer interpretation has led to a reduction in diagnostic imaging to exclude pulmonary embolism. Direct oral anticoagulation therapies are safe, effective, and convenient treatments for most patients with acute venous thromboembolism, with a lower risk of bleeding than vitamin K antagonists. These oral therapeutic options have opened up opportunities for safe outpatient management of pulmonary embolism in selected patients. Recent clinical trials exploring the use of systemic thrombolysis in intermediate to high risk pulmonary embolism suggest that this therapy should be reserved for patients with evidence of hemodynamic compromise. The role of low dose systemic or catheter directed thrombolysis in other patient subgroups is uncertain. After a diagnosis of pulmonary embolism, all patients should be assessed for risk of recurrent venous thromboembolism to guide duration of anticoagulation. Patients with a venous thromboembolism associated with a strong, transient, provoking risk factor can safely discontinue anticoagulation after three months of treatment. Patients with an ongoing strong risk factor, such as cancer, or unprovoked events are at increased risk of recurrent events and should be considered for extended treatment. The use of a risk prediction score can help to identify patients with unprovoked venous thromboembolism who can benefit from extended duration therapy. Despite major advances in the management of pulmonary embolism, up to half of patients report chronic functional limitations. Such patients should be screened for chronic thromboembolic pulmonary hypertension, but only a small proportion will have this as the explanation of their symptoms. In the remaining patients, future studies are needed to understand the pathophysiology and explore interventions to improve quality of life.


Assuntos
Anticoagulantes/uso terapêutico , Neoplasias/complicações , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/terapia , Administração Oral , Anticoagulantes/efeitos adversos , Angiografia por Tomografia Computadorizada , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Fibrinolíticos/uso terapêutico , Humanos , Imagem de Perfusão , Gravidez , Complicações Cardiovasculares na Gravidez/tratamento farmacológico , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/etiologia , Recidiva , Medição de Risco , Fatores de Risco , Filtros de Veia Cava , Tromboembolia Venosa/tratamento farmacológico
5.
Medicine (Baltimore) ; 99(23): e20285, 2020 Jun 05.
Artigo em Inglês | MEDLINE | ID: mdl-32501975

RESUMO

The mortality of pregnant women with pulmonary arterial hypertension (PAH) remains high. The aim of this study was to evaluate and analyze perinatal and postpartum outcomes in patients with PAH.A total of 79 pregnant patients with PAH who underwent abortion or parturition were reviewed retrospectively. Preoperative characteristics, anesthesia method, intensive care management, PAH-specific therapy, and maternal and neonatal outcomes were analyzed in this case series study.This study was a retrospective analysis of 79 pregnant women with PAH. We collected data on maternal, obstetrical, and neonatal outcomes. The mean age of the parturient women with mild and severe PAH was 26.6 ±â€Š5.7 and 26.0 ±â€Š4.9 years, respectively, and the mean systolic pulmonary arterial pressure of the 2 groups was 43.8 ±â€Š4.2 mmHg and 76.7 ±â€Š15.6 mmHg, respectively. Of the 79 patients, 43 (54.4%) had severe PAH and 36 (45.6%) had mild PAH. The gestational weeks were significantly shorter and the rate of fetal death was higher in the severe PAH group than in the mild PAH group (36.0 vs 37.3 weeks and 6/24 vs 1/30, respectively; P < .05). Fifty-seven patients received PAH-specific therapy during pregnancy, including sildenafil, iloprost, and treprostinil. Overall, 22 PAH patients underwent therapeutic abortion and 57 continued their pregnancy. A total of 9 women, all of whom had severe PAH, died within 3 months of labor, giving a mortality rate of 15.8% (9/57). Of the 57 parturients, 21 (35.6%) gave birth prematurely and 36 (64.4%) delivered at term. Overall, 55 (96.5%) patients delivered by cesarean section and 2 (3.5%) delivered vaginally. There were 7 fetal deaths - 6 in the severe PAH group and one in the mild PAH group (6/24 vs 1/30).Although the mortality rate of this group of women with PAH was lower than that previously reported, patients with PAH should still be advised against pregnancy.


Assuntos
Complicações Cardiovasculares na Gravidez/epidemiologia , Resultado da Gravidez/epidemiologia , Hipertensão Arterial Pulmonar/epidemiologia , Aborto Induzido , Adulto , Anestesia/métodos , Anti-Hipertensivos/uso terapêutico , Cesárea/estatística & dados numéricos , Cuidados Críticos/métodos , Feminino , Morte Fetal , Idade Gestacional , Humanos , Gravidez , Complicações Cardiovasculares na Gravidez/tratamento farmacológico , Complicações Cardiovasculares na Gravidez/mortalidade , Hipertensão Arterial Pulmonar/tratamento farmacológico , Hipertensão Arterial Pulmonar/mortalidade , Estudos Retrospectivos , Índice de Gravidade de Doença , Adulto Jovem
6.
Am Heart J ; 225: 69-77, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32474206

RESUMO

BACKGROUND: Rheumatic heart disease (RHD) is a neglected disease affecting 33 million people, mainly in low and middle income countries. Yet very few large trials or registries have been conducted in this population. The INVICTUS program of research in RHD consists of a randomized-controlled trial (RCT) of 4500 patients comparing rivaroxaban with vitamin K antagonists (VKA) in patients with RHD and atrial fibrillation (AF), a registry of 17,000 patients to document the contemporary clinical course of patients with RHD, including a focused sub-study on pregnant women with RHD within the registry. This paper describes the rationale, design, organization and baseline characteristics of the RCT and a summary of the design of the registry and its sub-study. Patients with RHD and AF are considered to be at high risk of embolic strokes, and oral anticoagulation with VKAs is recommended for stroke prevention. But the quality of anticoagulation with VKA is poor in developing countries. A drug which does not require monitoring, and which is safe and effective for preventing stroke in patients with valvular AF, would fulfill a major unmet need. METHODS: The INVestIgation of rheumatiC AF Treatment Using VKAs, rivaroxaban or aspirin Studies (INVICTUS-VKA) trial is an international, multicentre, randomized, open-label, parallel group trial, testing whether rivaroxaban 20 mg given once daily is non-inferior (or superior) to VKA in patients with RHD, AF, and an elevated risk of stroke (mitral stenosis with valve area ≤2 cm2, left atrial spontaneous echo-contrast or thrombus, or a CHA2DS2VASc score ≥2). The primary efficacy outcome is a composite of stroke or systemic embolism and the primary safety outcome is the occurrence of major bleeding. The trial has enrolled 4565 patients from 138 sites in 23 countries from Africa, Asia and South America. The Registry plans to enroll an additional 17,000 patients with RHD and document their treatments, and their clinical course for at least 2 years. The pregnancy sub-study will document the clinical course of pregnant women with RHD. CONCLUSION: INVICTUS is the largest program of clinical research focused on a neglected cardiovascular disease and will provide new information on the clinical course of patients with RHD, and approaches to anticoagulation in those with concomitant AF.


Assuntos
Fibrilação Atrial/tratamento farmacológico , Embolia/prevenção & controle , Inibidores do Fator Xa/uso terapêutico , Cardiopatia Reumática/tratamento farmacológico , Rivaroxabana/uso terapêutico , Acidente Vascular Cerebral/prevenção & controle , Vitamina K/antagonistas & inibidores , Adulto , Idoso , Fibrilação Atrial/complicações , Inibidores do Fator Xa/efeitos adversos , Feminino , Hemorragia/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Gravidez , Complicações Cardiovasculares na Gravidez/tratamento farmacológico , Cardiopatia Reumática/complicações , Rivaroxabana/efeitos adversos
7.
Am J Cardiol ; 127: 113-119, 2020 07 15.
Artigo em Inglês | MEDLINE | ID: mdl-32375999

RESUMO

Mechanical prosthetic heart valves (MPHVs) are highly thrombogenic, and a pregnancy-induced procoagulant status increases the risk of MPHV thrombosis. Despite numerous case reports, 2 major registries and meta-analyses/systematic reviews, optimal anticoagulation therapy during pregnancy remains controversial. The goal of this study was to evaluate different anticoagulation regimens in pregnant patients with MPHVs. The outcomes of anticoagulation regimens were assessed retrospectively in pregnant women (110 women; 155 pregnancies) with MPHVs. The study population was divided into 5 groups according to anticoagulation regimens used; high-dose warfarin (>5 mg/d) throughout pregnancy (group 1), low-dose warfarin (≤5 mg/d) throughout pregnancy (group 2), low molecular weight heparin (LMWH) throughout pregnancy (group 3), first trimester LMWH, 2nd and 3rd trimester warfarin (group 4), first 2 trimester LMWH, and 3rd trimester warfarin (group 5). Of 155 pregnancies, 55 (35%) resulted in fetal loss; whereas 41 (27%) cases with abortion (miscarriage and therapeutic) and 14 (9%) stillbirths occurred. The comparison of the groups showed that the whole abortion rates including therapeutic abortion were significantly higher in Group 1, and lower in groups 3 and 5 (p <0.001). However, miscarriage rates were similar between the groups. A total of 53 pregnancies (34%) suffered from prosthetic valves thrombosis (PVT) during pregnancy or in the postpartum period. Group 2 had significantly lower rates of PVT than the other groups (p <0.001). In conclusion, the current data suggests that there is no optimal therapy, and that all managements have advantages and disadvantages. Low-dose warfarin (≤5 mg/day) regimen with therapeutic international normalized ratio levels may provide effective maternal protection throughout pregnancy with acceptable fetal outcomes.


Assuntos
Doenças das Valvas Cardíacas/cirurgia , Próteses Valvulares Cardíacas/efeitos adversos , Heparina de Baixo Peso Molecular/uso terapêutico , Complicações Cardiovasculares na Gravidez/tratamento farmacológico , Sistema de Registros , Tromboembolia/prevenção & controle , Varfarina/uso terapêutico , Adulto , Anticoagulantes/uso terapêutico , Feminino , Seguimentos , Doenças das Valvas Cardíacas/complicações , Humanos , Recém-Nascido , Masculino , Gravidez , Resultado da Gravidez , Estudos Retrospectivos , Tromboembolia/etiologia
8.
Medicine (Baltimore) ; 99(19): e19932, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32384439

RESUMO

RATIONALE: Klippel-Trenaunay Syndrome (KTS) is a congenital vascular disease characterized by cutaneous hemangiomas, venous varicosities, and limb hypertrophy. Although extremely rare in pregnant women, the present vascular alterations may be aggravated, consequent to postural and hormonal changes inherent to the pregnancy. Pregnancy is not advised in KTS women due to increased obstetrical risk. PATIENT CONCERNS: A 31-year-old pregnancy woman presented with prominent vascularity in pelvis, right lower limb, spleen, and liver at 28 weeks of gestation. We started administration of anticoagulant therapy and obstetrics management. DIAGNOSIS: MRI and ultrasound revealed that multiple varicosities in her pelvis, right lower limb, spleen, and liver. She was diagnosed with KTS. INTERVENTIONS: At her first visit at 28 weeks of gestation, multidisciplinary evaluation had been done. Blood transfusion and iron supplement had been given for anemia correction. Anticoagulant therapy was performed to prevent potential thrombus risk. She had a vaginal delivery with a healthy newborn in her second visit without any complications at the gestation of 36 weeks due to rupture of preterm membranes. OUTCOMES: After successful management, the patient was discharged without any complications 2 days after vaginal delivery. No symptoms of hemorrhage or thrombus were observed. At 6 months follow-up, her right lower toes enlarged obviously, MRI revealed that no obvious changes of hemangiomas was found compared to those during the pregnancy and ultrasound revealed that there was no thrombus in her right lower limb. LESSONS: Patients with KTS can be pregnant and have healthy babies safely with regularly monitor and reasonable treatment during pregnancy. A careful follow-up and guidance are necessary.


Assuntos
Anticoagulantes/uso terapêutico , Síndrome de Klippel-Trenaunay-Weber/tratamento farmacológico , Complicações Cardiovasculares na Gravidez/tratamento farmacológico , Adulto , Feminino , Humanos , Recém-Nascido , Nascimento Vivo , Gravidez
12.
Obstet Gynecol Surv ; 75(3): 190-198, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32232497

RESUMO

Importance: Mechanical heart valves (MHVs) pose significant thrombogenic risks to pregnant women and their fetuses, yet the choice of anticoagulation in this clinical setting remains unclear. Various therapeutic strategies carry distinct risk profiles that must be considered when making the decision about optimal anticoagulation. Objective: We sought to review existing data and offer recommendations for the anticoagulation of pregnant women with MHVs, as well as management of anticoagulation in the peripartum period. Evidence Acquisition: We performed a literature review of studies examining outcomes in pregnant women receiving systemic anticoagulation for mechanical valves, and also reviewed data on the safety profiles of various anticoagulant strategies in the setting of pregnancy. Results: Warfarin has been shown to increase rates of embryopathy and fetal demise, although it has traditionally been the favored anticoagulant in this setting. Low-molecular-weight heparin, when dosed appropriately with close therapeutic monitoring, has been shown to be safe for both mother and fetus. Conclusions: We favor the use of low-molecular-weight heparin with appropriate dosing and monitoring for the anticoagulation of pregnant women with MHVs. Data suggest that this approach minimizes the thrombotic risk associated with the valve while also providing safe and effective anticoagulation that can be easily managed in the peripartum period.


Assuntos
Anticoagulantes/uso terapêutico , Doenças das Valvas Cardíacas/tratamento farmacológico , Próteses Valvulares Cardíacas , Complicações Cardiovasculares na Gravidez/tratamento farmacológico , Cuidado Pré-Natal/métodos , Feminino , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Gravidez , Varfarina/uso terapêutico
13.
PLoS One ; 15(3): e0230386, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32218573

RESUMO

Probenecid has been used for decades in the treatment of gout but recently has also been found to improve outcomes in patients with heart failure via stimulation of the transient receptor potential vanilloid 2 (TRPV2) channel in cardiomyocytes. This study tested the use of probenecid on a novel mouse model of peripartum cardiomyopathy (PPCM) as a potential treatment option. A human mutation of the human heat shock protein 20 (Hsp20-S10F) in mice has been recently shown to result in cardiomyopathy, when exposed to pregnancies. Treatment with either probenecid or control sucrose water was initiated after the first pregnancy in both wild type and Hsp20-S10F mice. Serial echocardiography was performed during subsequent pregnancies and hearts were collected after the third pregnancies for staining and molecular analysis. Hsp20-S10F mice treated with probenecid had decreased mortality, hypertrophy, TRPV2 expression and molecular parameters of heart failure. Probenecid treatment also decreased apoptosis as evidenced by an increase in the level of Bcl-2/Bax. Probenecid improved survival in a novel mouse model of PPCM and may be an appropriate therapy for humans with PPCM as it has a proven safety and tolerability in patients with heart failure.


Assuntos
Canais de Cálcio/genética , Cardiomiopatias/tratamento farmacológico , Proteínas de Choque Térmico HSP20/genética , Insuficiência Cardíaca/tratamento farmacológico , Probenecid/farmacologia , Canais de Cátion TRPV/genética , Animais , Apoptose/efeitos dos fármacos , Cardiomiopatias/diagnóstico por imagem , Cardiomiopatias/genética , Cardiomiopatias/patologia , Modelos Animais de Doenças , Ecocardiografia , Feminino , Regulação da Expressão Gênica/efeitos dos fármacos , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/genética , Insuficiência Cardíaca/patologia , Humanos , Camundongos , Mutação/genética , Miócitos Cardíacos/efeitos dos fármacos , Miócitos Cardíacos/patologia , Período Periparto/efeitos dos fármacos , Gravidez , Complicações Cardiovasculares na Gravidez/tratamento farmacológico , Complicações Cardiovasculares na Gravidez/genética
14.
Am J Obstet Gynecol ; 223(4): 525-537, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32199925

RESUMO

OBJECTIVE DATA: Chronic hypertension is associated with adverse perinatal outcomes, although the optimal treatment is unclear. The aim of this network metaanalysis was to simultaneously compare the efficacy and safety of antihypertensive agents in pregnant women with chronic hypertension. STUDY: Medline, Scopus, CENTRAL, Web of Science, Clinicaltrials.gov, and Google Scholar databases were searched systematically from inception to December 15, 2019. Both randomized controlled trials and cohort studies were held eligible if they reported the effects of antihypertensive agents on perinatal outcomes among women with chronic hypertension. STUDY APPRAISAL AND SYNTHESIS METHODS: The primary outcomes were preeclampsia and small-for-gestational-age risk. A frequentist network metaanalytic random-effects model was fitted. The main analysis was based on randomized controlled trials. The credibility of evidence was assessed by taking into account within-study bias, across-studies bias, indirectness, imprecision, heterogeneity, and incoherence. RESULTS: Twenty-two studies (14 randomized controlled trials and 8 cohorts) were included, comprising 4464 women. Pooling of randomized controlled trials indicated that no agent significantly affected the incidence of preeclampsia. Atenolol was associated with significantly higher risk of small-for-gestational age compared with placebo (odds ratio, 26.00; 95% confidence interval, 2.61-259.29) and is ranked as the worst treatment (P-score=.98). The incidence of severe hypertension was significantly lower when nifedipine (odds ratio, 0.27; 95% confidence interval, 0.14-0.55), methyldopa (odds ratio, 0.31; 95% confidence interval, 0.17-0.56), ketanserin (odds ratio, 0.29; 95% confidence interval, 0.09-0.90), and pindolol (odds ratio, 0.17; 95% confidence interval, 0.05-0.55) were administered compared with no drug intake. The highest probability scores were calculated for furosemide (P-score=.86), amlodipine (P-score=.82), and placebo (P-score=.82). The use of nifedipine and methyldopa were associated with significantly lower placental abruption rates (odds ratio, 0.29 [95% confidence interval, 0.15-0.58] and 0.23 [95% confidence interval, 0.11-0.46], respectively). No significant differences were estimated for cesarean delivery, perinatal death, preterm birth, and gestational age at delivery. CONCLUSION: Atenolol was associated with a significantly increased risk for small-for-gestational-age infants. The incidence of severe hypertension was significantly lower when nifedipine and methyldopa were administered, although preeclampsia risk was similar among antihypertensive agents. Future large-scale trials should provide guidance about the choice of antihypertensive treatment and the goal blood pressure during pregnancy.


Assuntos
Descolamento Prematuro da Placenta/epidemiologia , Anti-Hipertensivos/uso terapêutico , Retardo do Crescimento Fetal/epidemiologia , Hipertensão/tratamento farmacológico , Pré-Eclâmpsia/epidemiologia , Complicações Cardiovasculares na Gravidez/tratamento farmacológico , Anlodipino/uso terapêutico , Atenolol/uso terapêutico , Cesárea/estatística & dados numéricos , Doença Crônica , Feminino , Furosemida/uso terapêutico , Idade Gestacional , Humanos , Hipertensão/fisiopatologia , Incidência , Recém-Nascido Pequeno para a Idade Gestacional , Ketanserina/uso terapêutico , Metildopa/uso terapêutico , Metanálise em Rede , Nifedipino/uso terapêutico , Morte Perinatal , Pindolol/uso terapêutico , Gravidez , Nascimento Prematuro/epidemiologia , Índice de Gravidade de Doença
16.
Am J Obstet Gynecol ; 223(2): 250.e1-250.e11, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32067968

RESUMO

BACKGROUND: Obstetric hypertensive emergency is defined as having systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥110 mm Hg, confirmed 15 minutes apart. The American College of Obstetricians and Gynecologists recommends that acute-onset, severe hypertension be treated with first line-therapy (intravenous labetalol, intravenous hydralazine or oral nifedipine) within 60 minutes to reduce risk of maternal morbidity and death. OBJECTIVE: Our objective was to identify barriers that lead to delayed treatment of obstetric hypertensive emergency. STUDY DESIGN: A retrospective cohort study was performed that compared women who were treated appropriately within 60 minutes vs those with delay in first-line therapy. We identified 604 patients with discharge diagnoses of chronic hypertension, gestational hypertension, or preeclampsia using International Classification of Diseases-10 codes and obstetric antihypertensive usage in a pharmacy database at 1 academic institution from January 2017 through June 2018. Of these, 267 women (44.2%) experienced obstetric hypertensive emergency in the intrapartum period or within 2 days of delivery; the results from 213 women were used for analysis. We evaluated maternal characteristics, presenting symptoms and circumstances, timing of hypertensive emergency, gestational age at presentation, and administered medications. Chi square, Fisher's exact, Wilcoxon rank-sum, and sample t-tests were used to compare the 2 groups. Univariable logistic regression was applied to determine predictors of delayed treatment. Multivariable regression model was also performed; C-statistic and Hosmer and Lemeshow goodness-of-fit test were used to assess the model fit. A result was considered statistically significant at P<.05. RESULTS: Of the 213 women, 110 (51.6%) had delayed treatment vs 103 (48.4%) who were treated within 60 minutes. Patients who had delayed treatment were 3.2 times more likely to have an initial blood pressure in the nonsevere range vs those who had timely treatment (odds ratio, 3.24; 95% confidence interval, 1.85-5.68). Timeliness of treatment was associated with presence or absence of preeclampsia symptoms; patients without preeclampsia symptoms were 2.7 times more likely to have delayed treatment (odds ratio, 2.68; 95% confidence interval, 1.50-4.80). Patients with hypertensive emergencies that occurred overnight between 10 pm and 6 am were 2.7 times more likely to have delayed treatment vs those emergencies that occurred between 6 am and 10 pm (odds ratio, 2.72; 95% confidence interval, 1.27-5.83). Delayed treatment also had an association with race, with white patients being 1.8 times more likely to have delayed treatment (odds ratio, 1.79; 95% confidence interval, 1.04-3.08). Patients who were treated at <60 minutes had a lower gestational age at presentation vs those with delayed treatment (34.6±5 vs 36.6±4 weeks, respectively; P<.001). For every 1-week increase in gestational age at presentation, there was a 9% increase in the likelihood of delayed treatment (odds ratio, 1.11; 95% confidence interval, 1.04-1.19). Another factor that was associated with delay of treatment was having a complaint of labor symptoms, which made patients 2.2 times as likely to experience treatment delay (odds ratio, 2.17; 95% confidence interval, 1.07-4.41). CONCLUSION: Initial blood pressure in the nonsevere range, absence of preeclampsia symptoms, presentation overnight, white race, having complaint of labor symptoms, and increasing gestational age at presentation are barriers that lead to a delay in the treatment of obstetric hypertensive emergency. Quality improvement initiatives that target these barriers should be instituted to improve timely treatment.


Assuntos
Anti-Hipertensivos/uso terapêutico , Emergências , Grupos Étnicos/estatística & dados numéricos , Hipertensão Induzida pela Gravidez/tratamento farmacológico , Tempo para o Tratamento/estatística & dados numéricos , Administração Intravenosa , Administração Oral , Adulto , Afro-Americanos , Plantão Médico/estatística & dados numéricos , Doença Crônica , Grupo com Ancestrais do Continente Europeu , Feminino , Idade Gestacional , Hispano-Americanos , Humanos , Hidralazina/uso terapêutico , Hipertensão/tratamento farmacológico , Hipertensão/fisiopatologia , Hipertensão Induzida pela Gravidez/fisiopatologia , Labetalol/uso terapêutico , Trabalho de Parto , Nifedipino/uso terapêutico , Pré-Eclâmpsia/tratamento farmacológico , Pré-Eclâmpsia/fisiopatologia , Gravidez , Complicações Cardiovasculares na Gravidez/tratamento farmacológico , Complicações Cardiovasculares na Gravidez/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença
17.
Cardiovasc J Afr ; 31(3): 136-141, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31742315

RESUMO

OBJECTIVE: To examine whether treatment with beta-blockers (BBs) in pregnant women with structural heart disease (SHD) resulted in a decrease in foetal birth weight (FBW) in a South African cohort. METHODS: This was a prospective cohort study conducted in a tertiary-level hospital in Cape Town from 2010 to 2016. Of the 178 pregnant women with SHD, 24.2% received BBs for a minimum of two weeks. Adverse foetal outcomes and mean FBW were compared between the BB groups and subgroups (congenital, valvular, cardiomyopathy and other). Adverse foetal outcome was defined as: low birth weight (LBW) < 2 500 g, Apgar score < 7, premature birth (< 37 weeks) and small for gestational age (SGA). RESULTS: BB exposure during pregnancy was found to be associated with a non-significant increased FBW (2 912 vs 2 807 g, p = 0.347). A significant decrease (p = 0.009) was noted in FBW for valvular SHD pregnancies using BBs, while a significant increase (p = 0.049) was observed for the same outcome in the cardiomyopathy subgroup using BBs. A significant increase was observed for SGA (p = 0.010) and LBW (p = 0.003) pregnancies within the valvular subgroup when exposed to BBs. CONCLUSIONS: BB use in pregnant women with SHD in a South African cohort showed no association with a decrease in FBW or an increase in adverse foetal outcomes when compared to non-BB usage.


Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Peso ao Nascer/efeitos dos fármacos , Cardiopatias/tratamento farmacológico , Recém-Nascido de Baixo Peso , Complicações Cardiovasculares na Gravidez/tratamento farmacológico , Antagonistas Adrenérgicos beta/efeitos adversos , Adulto , Tomada de Decisão Clínica , Feminino , Idade Gestacional , Cardiopatias/diagnóstico , Humanos , Recém-Nascido , Seleção de Pacientes , Gravidez , Complicações Cardiovasculares na Gravidez/diagnóstico , Estudos Prospectivos , Medição de Risco , Fatores de Risco , África do Sul , Resultado do Tratamento , Adulto Jovem
19.
J Thromb Thrombolysis ; 49(1): 145-148, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31471774

RESUMO

Pregnancy-associated acute myocardial infarction is a rare condition usually occurring during the third trimester of pregnancy, and associated with three-to-four-fold higher mortality compared with rates among non-pregnant women of the same age. As in non-pregnant women, in cases of ST elevation myocardial infarction, the most effective treatment is primary percutaneous coronary intervention with stent implantation. Unfortunately, management of these patients could be challenging because little is known about the optimal medical strategy; the potential teratogenic effects of the third generation thienopyridines are not fully established too. In fact current guidelines do not provide enough recommendations about tailoring dual antiplatelet therapy prescription according to ischemic profile of the pregnant patients. Moreover, the bleeding risk class of cesarean delivery/hysterectomy is not stated in current consensus documents. We report the second pregnancy-associated acute myocardial infarction case successfully treated with ticagrelor before and after primary percutaneous coronary intervention with drug eluting stent implantation on left coronary artery, but also the first report on use of bridging antiplatelet therapy with tirofiban during temporary withdrawal of ticagrelor because of a C-section.


Assuntos
Nascimento Vivo , Complicações Cardiovasculares na Gravidez/tratamento farmacológico , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Ticagrelor/administração & dosagem , Tirofibana/administração & dosagem , Adulto , Cesárea , Feminino , Humanos , Gravidez
20.
J Matern Fetal Neonatal Med ; 33(6): 1030-1032, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30231658

RESUMO

Pregnancy after mechanical valve replacement involves high risk. Maternal valve thrombosis and hemorrhagic complications are associated with lethal outcomes; therefore, strict anticoagulant therapy is needed. Our patient was 26-year-old primiparous woman. She had undergone aortic valve replacement with a mechanical valve at 4 years of age and had used warfarin 3 mg per day since then. Because of her desire for a baby, she stopped warfarin and conceived spontaneously. She was referred to our hospital. After being informed of her choices, unfractionated heparin (UFH) administration was started. She experienced mild heart failure with sacroiliitis, bacteremia, and hematuria during pregnancy. She delivered her newborn at 37 weeks. Blood loss at delivery was 220 g. Administration of UFH was restarted 4 h after delivery and 3 mg of warfarin was administered from postpartum day (PPD) 6. Hemostatic suturing was required for vaginal bleeding on PPD7. A therapeutic dose of warfarin was achieved on PPD9. Although warfarin use is recommended as anticoagulant therapy for pregnant woman with mechanical valves, the safety and efficacy of UFH have not yet been clarified because of its limited use. More cases are needed to clarify this.


Assuntos
Anticoagulantes/administração & dosagem , Implante de Prótese de Valva Cardíaca , Heparina/administração & dosagem , Cuidado Pós-Natal/métodos , Complicações Pós-Operatórias/tratamento farmacológico , Complicações Cardiovasculares na Gravidez/tratamento farmacológico , Cuidado Pré-Natal/métodos , Adulto , Anticoagulantes/uso terapêutico , Valva Aórtica/cirurgia , Esquema de Medicação , Feminino , Heparina/uso terapêutico , Humanos , Gravidez
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