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 1. Avila WS, Rossi EG, Ramires JF, Grinberg M, Bortolotto MR, Zugaib M, et al. Pregnancy and heart disease: experience with 1000 cases. Clin Cardiol. 2003;26(3):135-42. 2. Roos-Hesselink JW, Ruys TP, Stein JI, Thilén U, Webb GD, Niwa K, et al. Outcome of pregnancy in patients with structural or ischaemic heart disease: results of a registry of the European Society of Cardiology. Eur Heart J. 2013;34(9):657-65. 3. Thorne S, Mac gregor A, Nelson-Piercy C. Risks of contraception and pregnancy in heart disease. Heart. 2006;92(10):1520-5. 4. Balci A, Sollie-Szarynska KM, van der Bijl AG, Ruys TP, Mulder BJ, Roos- Hesselink JW, et al. Prospective validation and assessment of cardiovascular and offspring riskmodels for pregnant womenwith congenital heart disease. Heart. 2014;100(17):1373-81. 5. Warnes AC, Liberthson MD, Danielson KG, Dore A, Harris L, Hoffman JI et al. Taske Force 1: the changing profile of congenital heart disease in adult life. J Am Coll Cardiol. 2001;37(5):1170-5. 6. Connelly MS, Webb GD, Somerville J, Dore A, Harris L, Hoffman JI, et al. Canadian Consensus Conference on Adult Congenital Heart Disease 1996. Can J Cardiol. 1998;14(3):395-452. References population. This rate is still above the value by Oliveira et al. reporter which identifies 3 (3.2%) of cardiac malformations in children from 100 pregnant women with congenital heart diseases followed at InCor. 19 The recurrence of heart disease in the babies of mothers with congenital heart diseases should be considered in counselling before pregnancy in response to the questions about hereditary as well as indication of routine fetal echocardiography study. Study limitations Both the small number of patients and the wide heterogeneity of the anatomical defects contribute to a limitation of the accurate statistical analysis. However, it should be considered that this sample of patients was exclusively from the high risk group, in which pregnancy is not advised and constitutes a great guidance dilemma regarding family planning provided to women with CCC. The character of the study (retrospective and observational, restricted to a single center) can also influence the appropriate conclusions. Final comments Congenital heart diseases affect approximately 0.8% of all live newborns and the survival rate of 86% are highlighted in international records. It is estimated that there are currently more adults with congenital heart diseases than children, which naturally provides a considerable number of women at childbearing age. The qualification of the multidisciplinary team is fundamental in the counselling of young women with heart disease regarding pregnancy, including advice such as alternatives to a safe and effective childbirth. Despite the stratification of the WHO risk III that allows the advice against pregnancy, the provision contained in the Brazilian Legislation should be considered: Furthermore, article 226 should be considered: Based on the principles of human dignity and responsible parenthood, family planning is a free decision made by the couple, and it is the State’s responsibility to provide educational and scientific resources to exercise this right, prohibiting any enforcement by official or private institutions” (our emphasis). This standard applies to other institutes: a) human dignity (article 1, III) and b) right to freedom (article 5, caput) 20 Conclusions The strict care protocol during pregnancy, delivery, and puerperium did not prevent maternal deaths, prematurity or miscarriage in patients with CCC. Hypoxemia was a poor prognostic factor and maternal evolution was unsatisfactory, but the fetal outcome was worse.. Although the autonomy of intention to conceive should be respected, women with CCC should still be advised against getting pregnant. Author contributions Conception and design of the research: Avila WS, Rossi EG, Rossi EG, Miura N; Acquisition of data: Avila WS, Ribeiro VM, Testa C; Analysis and interpretation of the data: Avila WS, Ribeiro VM, Rossi EG, BinottoMA; Statistical analysis: Rossi EG; Writing of the manuscript: Avila WS; Critical revision of the manuscript for intellectual content: Avila WS, Rossi EG, Binotto MA, Bortolotto MR, Testa C, Hajjar LA, Miura N. 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. Ethics approval and consent to participate This study was approved by the Ethics Committee of the Instituto do Coração under the protocol number XXX. All the procedures in this study were in accordance with the 1975 Helsinki Declaration, updated in 2013. Informed consent was obtained from all participants included in the study. 1068