ABC | Volume 115, Nº1, July 2020

Editorial Avila & Carvalho COVID-19: pregnancy and heart disease Arq Bras Cardiol. 2020; 115(1):1-4 Table 2 – COVID-19 / Heart Disease / Pregnancy - Features of trinity and Differential Diagnosis Covid-19 Cardiopathy Normal Pregnancy Symptoms Fever (>37,8 ºC), myalgia, fatigue, anorexia, sore throat, nasal and conjuctival congestions, cough, Dyspnea, anosmia, anorexia, odynophagia, nausea, vomiting, diarrhea, abdominal pain Dyspnea, palpitations, chest pain, syncope, hemoptysis, fadigue, lower limb edema, orthopnea, dry cough. Náusea, vomiting, edema / dyspnea / fatigue, palpitations, dizziness, epistaxis, gestational rhinitis, headache and abdominal pain Time of symptoms and age gestational Any of gestational age 2 nd and 3 rd trimester Any gestational age History Without previous heart disease Previous heart disease Without previous heart disease Laboratory COVID-19 Positive RT-PCR nasopharygeal Lymphocytopenia Increased aminotransferase- Alt/AST ureia / creatinine D-dimer -increased High level of B-type natriuretic peptide BNP D - dimer normal or slight increase Imaging Exams Normal echocardiogram Chest X-ray alterede or not Chest tomography - ground glass opacities image Echocardiogram - structural cardiac lesion Chest X ray / Tomography altered: Cardiomegaly and / or pulmonary congestion Normal echocardiogram Normal Chest-X ray RT-PCR: reverse transcription polymerase chain reaction assay; ALT: alanine aminotransferase; AST: aspartate aminotransferase. Heart diseases and COVID-19 have symptoms in common, which can lead to a misdiagnosis (Table 2). In view of this and considering the current pandemic, tests for SARS-CoV-2 should be included in the good practice screening for pregnant women with heart disease. Physiological changes in the cardiorespiratory system due to pregnancy do not increase susceptibility to infection by the virus but can induce worse maternal outcome 4-6 (Table 1). Respiratory changes in pregnancy result in decreased total lung capacity and chest compliance at the end of pregnancy. In addition, it is reasonable to consider that maternal hypoxia resulting from hypoventilation and impaired gas exchange reduces the offer of oxygen to the fetus, consequently, intra-uterine death . In this context, COVID-19 pneumonia progresses rapidly from focal to bilateral diffuse pulmonary consolidation and more readily predisposes to severe hypoxemic respiratory failure. Table 1 – Impact of physiological changes of cardiovascular and respiratory systems of pregnancy in women with cardiac disease with SARS-CoV-2 • Downregulation of maternal immune system - Risk to Severe Respiratory Disease • Oxygen consumption - hypoventilation, apnea or impaired gas exchange - Hypoxemia • Decreased Functional Residual Capacity - (10 a 25%) - Hypoxemia • Hyperemia and edema of the upper airway - Challenges to endotracheal intubation • Increased breast volume and the need for crush induction due to impaired gastric emptying - Risk of aspiration • Decreased systemic vascular resistance - Hypotension, Hypoxemia • Incresead heart rate and stroke volume - Heart failure • Mechanical ventilation carefulness Hyperventilation and alkalosis - Uterine vasoconstriction Hypoventilation and hypercapnia - Fetal respiratory acidosis Matenal PaO 2 should be kept greater than 70 mmHg for adequate fetal oxigenation • Increase thromboembolic risks increase in coagulation factors (V, VIII, X, and von Willebrand factor) Fall in protein S levels Uterine compression of the inferior vena cava and the left iliac vein Local trauma to pelvic veins during delivery Pospartum period of cesarean section 2