Background: The improvement in surgical techniques has contributed to an increasing number of childbearing women with complex congenital heart disease (CCC). However, adequate counseling about pregnancy in this situation is uncertain, due to a wide variety of residual cardiac lesions. Objectives: To evaluate fetal and maternal outcomes in pregnant women with CCC and to analyze the predictive variables of prognosis. Methods: During 10 years we followed 435 consecutive pregnancies in patients (pts) with congenital heart disease. Among of them, we selected 42 pregnancies in 40 (mean age of 25.5 ± 4.5 years) pts with CCC, who had been advised against pregnancy. The distribution of underlying cardiac lesions were: D-Transposition of the great arteries, pulmonary atresia, tricuspid atresia, single ventricle, double-outlet ventricle and truncus arteriosus. The surgical procedures performed before gestation were: Fontan, Jatene, Rastelli, Senning, Mustard and other surgical techniques, including Blalock, Taussing, and Glenn. Eight (20,0%) pts did not have previous surgery. Nineteen 19 (47.5%) pts had hypoxemia. The clinical follow-up protocol included oxygen saturation recording, hemoglobin and hematocrit values; medication adjustment to pregnancy, anticoagulation use, when necessary, and hospitalization from 28 weeks, in severe cases. The statistical significance level considered was p < 0.05. Results: Only seventeen (40.5%) pregnancies had maternal and fetal uneventful courses. There were 13 (30.9%) maternal complications, two (4.7%) maternal deaths due to hemorrhage pos-partum and severe pre-eclampsia, both of them in women with hypoxemia. There were 7 (16.6%) stillbirths and 17 (40.5%) premature babies. Congenital heart disease was identified in two (4.1%) infants. Maternal and fetal complications were higher (p < 0.05) in women with hypoxemia. Conclusions: Pregnancy in women with CCC was associated to high maternal and offspring risks. Hypoxemia was a predictive variable of poor maternal and fetal outcomes. Women with CCC should be advised against pregnancy, even when treated in specialized care centers.

Hyperemesis gravidarum (HG) is a rare condition (1.1%) characterized by excessive vomiting, malnutrition, dehydration, and laboratorial alterations. Herein, we describe the even rarer and serious presentation of refractoriness to the usual treatment of antiemetics and parenteral nutrition, with improvement only after the use of olanzapine and mirtazapine. Two subsequent pregnancies of the same woman with HG are described, which were associated with severe weight loss, anemia, hyponatremia, hypokalemia, and mild dysfunction of liver enzymes. In the third pregnancy, the usual treatment for HG was not successful, requiring enteral nutrition and the introduction of olanzapine. In the fourth pregnancy, the patient refused to use enteral nutrition for refractory HG. Hence, the patient was started on mirtazapine at an initial dose of 15 mg/day, which was gradually increased to 30 mg/day. The patient responded well to the new regimen, as demonstrated by the decrease in symptoms, the gain of 10 kg in the pregnancy, and delivering a healthy newborn. A systematic review of literature showed 11 articles and 30 cases that successfully used mirtazapine in HG. Good clinical outcomes were seen with 4 days of the treatment and at an initial dose of 15 mg/day. However, most of these reports were from psychiatric profiles, with a predominance of depression and anxiety symptoms, and a poor description of the obstetric conditions and the disease progression itself. Pulmonary hypertension was described in one case and neonatal hyperexcitability in another. The case described in this paper reinforces the idea that mirtazapine and olanzapine can be considered in refractory HG, with good results. In the world literature, this is the second case of HG that has been successfully treated with olanzapine and the first in Latin America treated with mirtazapine.

A assistência às pacientes cardiopatas passou por enormes avanços nas últimas décadas. Apesar da queda morbidade, a gravidez nesse grupo representa importante causa de mortalidade materna e de pior prognóstico fetal, mesmo em países desenvolvidos. O acompanhamento obstétrico dessas pacientes precisa ser individualizado conforme a estratificação de risco materno. Há poucos ensaios clínicos randomizados, sendo que a maior parte das condutas é baseada em estudos retrospectivos.Neste artigo realizamos uma revisão de literatura para embasar as melhores práticas na assistência multidisciplinar durante o ciclo gravídico puerperal das pacientes portadoras de cardiopatia.

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Objectives: To describe the clinical features, obstetric and perinatal outcomes of pregnancies in patients diagnosed Takayasu arteritis associated to arterial hypertension. Methods: A retrospective, observational and descriptive study evaluating pregnant patients at a Brazilian tertiary hospital between the years 2002 and 2016 that had been diagnosed with Takayasu arteritis (TA) based on the modified Ishikawa criteria. Arterial hypertension (AH) previous to pregnancies was considered as BP≥ 140/90 mmHg or under treatment. The variables considered for analysis were clinical characteristics, diagnostic criteria, obstetrics and perinatal outcomes of these pregnancies. Results: Twenty-nine pregnancies in 24 patients were followed in the period. Hypertension was detected in 20 patients (83.3%). The most prevalent angiographic criteria were injury in the abdominal aorta, found in 15 women (62.5%). Angiographic classification type 5 was the most common feature. Aside from two drop-outs that were not followed up, the pregnancies resulted in 25 live births. Five (20%) of the newborns were classified as small for gestational age and eight (32%) were premature, most of them in patients with AH. Eighteen deliveries (69.2%) were caesarean sections and the main anesthetic method was the combined spinal-epidural. Preeclampsia was the main maternal complication, present in five cases, all of them with previous diagnosis of AH. There were no acute cardiovascular complications during pregnancy related to underlying disease. The only fetal death in this study was an abortion after judicial authorization by lethal fetal malformation. Conclusion: In general, patients with TA had a good perinatal outcomes despite of severity of disease. Hypertension is highly prevalent and is related to major reported obstetric and perinatal complications, such as preeclampsia, prematurity and newborns that are small for gestational age.

Cardiovascular diseases (CVD) are a risk factor for severe cases of COVID-19. There are no studies evaluating whether the presence of CVD in pregnant and postpartum women with COVID-19 is associated with a worse prognosis. In an anonymized open database of the Ministry of Health, we selected cases of pregnant and postpartum women who were hospitalized due to COVID-19 infection and with data regarding their CVD status. In the SIVEP GRIPE data dictionary, CVD is defined as “presence of cardiovascular disease”, excluding those of neurological and nephrological causes that are pointed out in another field. The patients were divided into two groups according to the presence or absence of CVD (CVD and non-CVD groups). Among the 1,876,953 reported cases, 3,562 confirmed cases of pregnant and postpartum women were included, of which 602 had CVD. Patients with CVD had an older age (p<0,001), a higher incidence of diabetes (p<0,001) and obesity (p<0,001), a higher frequency of systemic (p<0,001) and respiratory symptoms (p<0,001). CVD was a risk factor for ICU admission (p<0,001), ventilatory support (p = 0.004) and orotracheal intubation in the third trimester (OR 1.30 CI95%1.04–1.62). The group CVD had a higher mortality (18.9% vs. 13.5%, p<0,001), with a 32% higher risk of death (OR 1.32 CI95%1.16–1.50). Moreover, the risk was increased in the second (OR 1.94 CI95%1.43–2.63) and third (OR 1.29 CI95%1.04–1.60) trimesters, as well as puerperium (OR 1.27 CI95%1.03–1.56). Hospitalized obstetric patients with CVD and COVID-19 are more symptomatic. Their management demand more ICU admission and ventilatory support and the mortality is higher.

Cardiovascular diseases are a risk factor for severe cases of COVID-19. There are no studies evaluating whether the presence of CVD in pregnant women and in postpartum women with COVID-19 is associated with a worse prognosis. In an anonymized open database of the Ministry of Health, we selected cases of pregnant and postpartum women who were hospitalized due to COVID-19 infection. Among the 1,876,953 reported cases, 3,562 confirmed cases of pregnant and postpartum women were included, of which 602 had CVD. Patients with CVD had an older age (p<0,001), a higher incidence of diabetes (p<0,001) and obesity (p<0,001), a higher frequency of systemic (p<0,001) and respiratory symptoms (p<0,001). CVD was a risk factor for ICU admission (p<0,001), ventilatory support (p=0.004) and orotracheal intubation in the third trimester (OR 1.30 CI95%1.04-1.62). The group CVD had a higher mortality (18.9% vs. 13.5%, p<0,001), with a 32% higher risk of death (OR 1.32 CI95%1.16-1.50). Moreover, the risk was increased in the second (OR 1.94 CI95%1.43-2.63) and third (OR 1.29 CI95%1.04-1.60) trimesters, as well as puerperium (OR 1.27 IC95%1.03-1.56). Hospitalized obstetric patients with CVD and COVID-19 are more symptomatic. Their management demand more ICU admission and ventilatory support and the mortality is higher.