BACKGROUNDChanges in the fetal heart rate occur in approximately 1% of all pregnancies and in an autoimmune context with positive anti-Ro/ SSA and anti-La/SSB antibodies, the incidence is estimated to be 2-4%. The involvement of neonatal organs, especially heart and skin, is presumed to result from the transplacental passage of these antibodies. It is important to rule out undiagnosed maternal connective tissue diseases, such as systemic lupus erythematosus, Sjögren's syndrome, mixed connective tissue disease and leukocytoclastic vasculitis. The case presented shows an asymptomatic mother that had no criteria to any connective tissue diseases or any other pathologies, and became aware of these antibody reactivities solely based upon the finding of a bradyarrhythmia in her fetus.
CASE REPORTA 28-year-old primigravida, with a singleton pregnancy of 25 weeks and without comorbidities, arrived at the rheumatology outpatient clinic referred by the obstetrician due to fetal bradycardia with a heart rate of 55-59 bpm verified on fetal echocardiogram performed 3 days ago. The patient denied any symptoms or previous diagnoses and did not use any medication or drugs. After performing laboratory tests, anti-Ro/SSA antibodies were detected in high titers (> 240) and anti-La/SSB in lower titers (30). Thus, hydroxychloroquine and betamethasone were started. After one week, the patient returned for consultation with a new echocardiogram showing complete atrioventricular block. Due to good fetal development, the pediatric cardiologist opted to indicate the placement of a pacemaker after birth. At 32 weeks of gestation, it was decided to discontinue betamethasone and maintain hydroxychloroquine. At 45 days of birth, the newborn underwent pacemaker placement. Currently, the patient remains asymptomatic, in follow-up and without the use of any medication, as well her son.
CONCLUSIONThe prenatal diagnosis of the ethology of conceived heart diseases allows early treatment and the guarantee of intrauterine development. This will allow not only treatment during pregnancy, but also delivery assistance to these pregnant women in a tertiary perinatal center with a multidisciplinary team trained in the care of these infants and the implantation of a pacemaker, which is necessary in two thirds of cases. There is presence of bradycardia, ventricular dysfunction and the prolongation QT complications in these cases. Therefore, an accurate diagnosis of the etiology of fetal heart block is very necessary.
Background: In hemodialysis (HD) patients, the presence of Heart failure (HF) at the start of dialysis is a strong and independent predictor of short and long-term mortality, and its prevalence increases with declining kidney function and HD time. Left ventricular (LV) ejection fraction (EF) is widely used as a measure of systolic function. Reduced EF (<50%) is an important prognostic marker, however, less than 15% of End-stage Renal Disease (ESRD) patients have detectable systolic dysfunction and the EF is susceptible to loading conditions, which change dramatically during interdialytic intervals. Global Longitudinal Strain (GLS) derived by 2D Speckle-Tracking Echocardiography (STE) is an emerging technique for measuring more subtle disturbances in LV systolic function. Although ESRD patients have subclinical evidence of impaired strain but preserved EF, there is evidence that GLS is better in ESRD group receiving maintenance HD compared with moderate-advanced CKD patients. This systematic review will evaluate the evidence related to the incremental prognostic value of LV GLS by 2D-STE concerning mortality and cardiovascular (CV) events in ESRD patients. Methods: This protocol is reported according to the PRISMA-P guideline. The databases PubMed, EMBASE, LILACS, Web of Science, and Google Scholar system will be searched and double screening for longitudinal studies that assessed the prospective association of STE-derived parameters with at least one of the pre-specified outcomes in ESRD patients. Discrepancies will be resolved through consensus. A modified version of the Newcastle-Ottawa Quality Assessment Scale of cohort studies will be used. We intend to use the random-effects model, considering at least moderate heterogeneity between studies. If data allow, we will perform meta-regression to explore potential sources of between-study heterogeneity. An adaptation of the GRADE framework for prognostic studies will be employed to judge the quality of evidence for each outcome reported in this systematic review. Discussion: This systematic review will summarize current evidence about STE-derived measures in ESRD patients and clarify the incremental prognostic value of this diagnostic tool versus LVEF in these patients. Evidence about other measures (circumferential and radial strain) or 3D STE-derived indices will also be investigated.
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