ABC | Volume 113, Nº6, December 2019

Original Article Avila et al. Pregnancy and complex congenital heart disease Arq Bras Cardiol. 2019; 113(6):1062-1069 Figure 1 – Maternal and fetal outcomes: 42 pregnancies. HF: heart failure; Acretism: placental acretism; CHD: congenital heart disease. Uneventful – 17 (40.5%) cases No maternal complications 27 (64.3%) cases Fetal/Newborn complications 22 (52.3%) cases Maternal complications Clinical and obstetrical 13 (30.9%) cases Spontaneous Miscarriage Placental abruption Acretism Hemorragea Pre-eclampsia 3 1 1 1* 1* HF Arrhythmia 5 cases 1 case Maternal Death 2 (4.7%) cases Obstetrical complications Stillbirth 7 (16.6%) cases Abortion – 3 cases Stillborn – 1 case Newborn death – 3 cases Prematurity 17 (40.5%) cases Newborns with CHD – 2 (4.7%) cases No premature babies Healthy newborns 20 (47.6%): Mean weight: 2168 g Table 5 – Comparative analysis of presumptive variables of maternal and fetal outcomes Variables No cases Hypoxemia n = 19 No hipoxemia n = 23 p value Univentricular n = 16 Bi-ventricular (n = 26) p value Operated n = 34 Unoperated n = 8 p value Unventfull evolution n = 17 3 (15.7%) 14 (60.8%) < 0.05 4 (25%) 13 (50%) 0.0 14 (41.2%) 3 (37.5%) 1.0 Maternal complications n = 13 9 (47.4%) 4 (17.4%) < 0.05 7 (43.7%) 6 (23.1%) 0.18 10 (29.4%) 3 (37.5%) 0.68 Maternal death n = 2 2 (10.5%) 0 0.19 0 2 (7.7%) 0.51 1 (2.9%) 1 (12.5%) 0.34 Fetal complications n = 23 18 (94.7%) 5 (21.7%) < 0.05 12 (75%) 11 (42.3%) 0.06 18 (52.9%) 5 (62.5%) 0.70 Stillbirths n = 7 7 (36.8%) 0 < 0.05 4 (25%) 3 (11.5%) 0.39 3 (8.8%) 4 (50%) < 0.05 Premature babies n = 17 12 (63.1%) 5 (21.7%) < 0.0.5 10 (62.5%) 7 (26.9%) < 0.05 14 (41.2%) 3 (37.5%) 1.0 Mean weight newborns (g) ± 600 ± 527 < 0.05 1841 ± 454 2531 ± 496 < 0,05 2246 ± 660 2296 ± 749 0.76 death, was significantly associated with histological signs of pulmonary hypertension, also detected in chronic hypoxemia. The third cause of death recorded was infective endocarditis, which reinforced the recommendation of antibiotic prophylaxis during delivery in our protocol. The routine elective hospitalization as of the 28 th week of pregnancy for patients at likely higher risk situation, regardless of the functional condition, was based on the fact that the third trimester is critical for the mother, due to the hemodynamic overload and higher prothrombotic activity, as well as for the fetus, due to the high incidence of prematurity and intrauterine growth restriction, which are characteristics of CCC. Furthermore, elective hospitalization improved maternal and fetal monitoring, allowed intermittent oxygen therapy to be applied, individualized anticoagulation, and optimized therapy for possible complications and delivery planning. Our results showed similar rates of cardiac (14.2%) and obstetric complications (16.6%). In both cases, maternal deaths were associated with obstetric causes (pre-eclampsia and postpartum hemorrhage). This result allows a reassessment of the severe cardiac reserve limitation in these patients, who do not tolerate the events inherent to pregnancy and postpartum, regardless of the baseline functional condition. Pre-eclampsia, one of the causes of death in this study, is responsible for 15% of maternal deaths in Brazil, with an incidence of around 10% in the pregnant population. 10 Early diagnosis and an effective prenatal care, although they do not prevent the disease, can improve maternal mortality in healthy women. However, in patients with complex heart disease, the prognosis of pre-eclampsia is much worse, due to both systemic endothelial dysfunction, inherent to the disease and the circulatory overload caused by arterial hypertension. 1066