ABC | Volume 110, Nº1, January 2018

Case Report Avila et al Kawasaki disease and Pregnancy Arq Bras Cardiol. 2018; 110(1):97-100 Preventive therapy was planned during patient’s first medical visit at week 9 of pregnancy. The strategy consisting of outpatient follow-up, hospitalization and delivery with interventional support at a cardiology hospital was chosen because of patient instability. However, such procedure is not considered routine in the literature in symptomatic patients. 3 We also considered the influence of the hyperkinetic, hypercoagulable state of pregnancy on the occurrence of expected complications (thrombosis, myocardial infarction and sudden death) in this patient. The potential risk of arterial rupture and/or dissection is increased with presumed arterial changes including fragmentation of reticular fibers, decrease in mucopolysaccharide content and loss of normal elastic fiber structure. 4 In the study by Wei et al., 5 that included 38 cases of KD, thrombosis was seen in 17 patients, which has been hypothesized to be caused by insufficient anticoagulant therapy. In a meta-analysis including 159 children with giant CAA, Su et al. 6 reported that coronary occlusion, AMI and death were significantly lower in children treated with warfarin plus aspirin than in those treated with aspirin alone. In this line of thought, the progressive activation of coagulation factors in the second half of pregnancy, and the maximum activation at delivery made the authors recommend anticoagulation with dose adjustment combined with ASA. Enoxaparin was used in place of warfarin during pregnancy due to risk of hemorrhage and fetal toxicity, in prophylactic dose until week 34 and then therapeutic dose until 12 hours before delivery. The drug was then restarted until warfarin was reintroduced for maintenance of INR within target range. The history of myocardial infarction increased the pregnancy risk, although ventricular function was preserved and was favorable to patient’s progression. Increased myocardial metabolic demand, due to increased cardiac output and oxygen consumption related to pregnancy, was the cause of frequent complaints of angina and dyspnea, which were controlled by propranolol. At 60 mg/day, the drug did not affect fetal growth until week 32 of pregnancy. Arterial hypotension, resulting from a decrease in peripheral vascular resistance, limited the use of nitrates for the supposed risk of decreased uteroplacental blood flow. During the third trimester of pregnancy, high-amplitude uterine contractions (Braxton Hicks) become more frequent and may be confused with premature labor, accounting for 75% of births before week 37 of pregnancy. 7 These contractions cause oscillations in venous return and in heart rate, and may cause instability in women with limited cardiac reserve, which was the cause of hospitalization of the patient in the week 32. Together with the obstetrician, a decision was made to not anticipate delivery, adjust medication for control of clinical obstetric symptoms until fetal maturity was reached. With respect to the type of delivery chosen, a study on 13 women with KD 8 and coronary artery lesions, showed that vaginal deliveries under epidural anaesthesia in 9 patients, and caesarean section was performed in 3 symptomatic patients. These data corroborate the clinical decisions made in this case. Also, tubal ligation was chosen as the safest contraceptive method due to contraindications of a new pregnancy. Conclusion This report added to the literature one case of successful term pregnancy in a symptomatic patient with multiple CAAs secondary to KD and history of myocardial infarction. The study illustrated the importance of the multidisciplinary approach to reach the full-term of a high-risk pregnancy. However, family planning, including counseling on genetics and possibility of a new pregnancy, is still essential. The risk of complications cannot be neglected regardless of the therapeutic strategy adopted. Author contributions Conception and design of the research: Avila WS; Acquisition of data: Avila WS, Freire AFD, Soares AAS, Pereira ANRE; Analysis and interpretation of the data and Writing of the manuscript: Avila WS, Freire AFD, Soares AAS; Critical revision of the manuscript for intellectual content: Avila WS, Nicolau JC. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This study is not associatedwith any thesis or dissertationwork. 99