ANALYSIS OF COMPLICATIONS OF PREGNANT WOMEN WITH HEART DISEASE ATTENDED AT A HOSPITAL OF VITÓRIA-ES

Abstract

Introduction: heart disease remains the leading non-obstetric cause of maternal mortality in pregnancy and childbirth, and predispose the infant to complications. Objective: to analyze neonatal and maternal complications in pregnant women with heart disease. Method: case series study with retrospective data collection through medical records. Thirteen pregnant women with heart disease, served from 2005 to 2014, constituted the sample. Proceeded to the analysis of complications in pregnancy: prenatal time, gestation time, delivery, complications during pregnancy, medications used in pregnancy, breastfeeding in the recent postpartum and death. As for the newborn: weight, length, Apgar score, intrauterine growth restriction, length of stay in the neonatal intensive care unit, oligohydramnios, preterm birth and death. Results: among the 13 pregnant women, 15 pregnancies occurred. There were no maternal or neonatal deaths. All pregnancies were full term, cesarean delivery and prenatal care was initiated in the 1^st quarter. Out of the 15 monitored pregnancies, 5 had complications. Regarding neonates: All had adequate weight for gestational age and three newborns needed hospitalization in the neonatal intensive care unit. Conclusion: the incidence of maternal complications occurred in 33% of the pregnancies, 60% were women with valvular disease. The complications which occurred could have been found in normal pregnancies, having no direct relationship to heart disease. It can be inferred that prenatal associated with the multidisciplinary team and the stability of the disease were fundamental in the absence of complications related to heart disease.

Introduction

When modifying the maternal physiology, the gestation promotes metabolic, anatomic and hemodynamic changes in the woman’s body. These phenomena may worsen previous morbid situations or produce symptoms that, despite being physiological, are harmful.¹

Due to expected changes in pregnancy, women with cardiac lesions of obstructive character can experience, for the first time, symptoms on that period. This is due to the raise of preload generated by the increase of blood volume. The reduction in afterload, added to systemic vasodilation, can further worsen the symptoms in these patients.²

The hypercoagulable state of the second half of pregnancy and the postpartum period increases the risk of patients with mitral lesion, atrial fibrillation and prosthetic heart valves to acquire thromboembolic events. Therefore, it is justified, that the stenotic valvular lesions present an unfavourable clinical outcome when compared to failure, due to those physiological changes.³

Heart disease stands as the main non-obstetric cause of maternal mortality in the cycle of the postpartum period.⁴

As demonstrated by Avila et al.,⁴ in a study with 1000 pregnant women with heart disease, was found heart disease of rheumatic origin in 55.7% of cases and congenital diseases in 19.1%. During the study, 76.5% of pregnant women with heart disease had no cardiovascular complications and, among the complications, the most relevant was heart failure, which represented 12.3% of cases among the remaining 23.5%.⁴

The most common complications are premature birth, low birth weight at gestational age and perinatal death.⁵ Siu et al.,⁶ in a study with 562 pregnant women with heart disease, found neonatal complications in 122 pregnancies (20%). Akther et al.,⁷ in a study with 60 pregnant women with valvular heart disease, found mitral stenosis as the most common valvular heart disease, accounting for 50% of valvular abnormalities

The evaluation of the relationship between maternal cardiac function and pregnancy outcomes plays an important role in reducing the risks for pregnant women with heart disease.⁵

Accordingly, it is necessary the development of more research in this field.

Method

It was conducted a study of series of cases with retrospective data collection through medical records in the files of Hospital Santa Casa de Misericórdia de Vitória-ES (HSCMV).

The sample consisted in pregnant women with heart disease at the Obstetrics and/or Cardiology Ward of HSCMV, during January 1 2005 to January 1 2014.

Criteria of inclusion: pregnant women with heart disease: valvular heart disease, congenital diseases, coronary artery disease, cardiomyopathy, post-operative cardiac surgery and cardiac arrhythmias; Exclusion criteria: women with morphological abnormalities of the reproductive system and kidney disease.

It was analyzed the incidence of pregnancy complications in relation to the mother and the newborn: regarding to the newborn, weight, length, Apgar score, intrauterine growth restriction, length of stay in the neonatal intensive care unit, oligohydramnios, prematurity and death were analyzed; with respect to the mother, prenatal time, gestation time, method of delivery, pregnancy complications, medications used in pregnancy, breast-feeding in the postpartum period and death were analyzed.

The study was approved by the Ethical Committee of research by the Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória – EMESCAM. All data was compiled using the Microsoft Excel^® program.

Results

Regarding maternal outcomes, there were no deaths. Only an abortion was recorded, being in a pregnancy previous to specialized cardiac monitoring. The prenatal care for all pregnant women started in the first trimester of pregnancy.

Of the 15 watched gestations, ten (67%) had no complications. The registered complications are shown on table 1.

TABLE 1– Registered gestational complications

Source: the author

Regarding drugs used during pregnancy, women who did not have complications in pregnancy, childbirth and in the newborns made use of nitrofurantoin, enoxaparin and methyldopa. In pregnancies with complications, the medications used were propranolol, furosemide, enoxaparin, captopril, levothyroxine, metoprolol succinate, penicillin G benzathine and escitalopram.

The watched cardiopathies are described in table 2.

TABLE 2– Analyzed maternal cardiopathies (n=15)

Source: the author

All women in the study had their deliveries via caesarean section and breastfed in the recent postpartum period.

Regarding neonatal outcome, nutritional assessment showed that they all had the proper weight for the gestational age.

The average length, at birth, of infants was 48,4cm and standard deviation of 1,3.

All patients in the study had their pregnancy terminated with 38 or 39 weeks, i.e., there were no preterm births.

There were no cases of intrauterine growth restriction.

Regarding Apgar, in the first minute it ranged from 6 to 10 (MA 8,26; DP 1,03) and in the fifth minute ranged from 8 to 10 (MA 9,40; DP 0,63).

Three newborns (20%) required admission to the neonatal intensive care unit: the first, child of a pregnant woman with mitral insufficiency, needed three days of phototherapy; the second, child of a pregnant woman with mitral insufficiency and aortic insufficiency, needed two days of phototherapy; and the third, child of a pregnant woman with mitral stenosis and double aortic lesion, needed three days of hospitalization due to meconium aspiration syndrome

Discussion

A deep vein thrombosis (DVT) case occurred during the first trimester of gestation in a patient with pulmonary stenosis. There is no relation of cause-effect between the existence of pulmonary stenosis and the increase of incidence of DVT in the literature.

Epidemiological studies have reported incidence of up to 12 cases of DVT per every 10000 gestations, and estimated a DVT frequency five times higher in pregnant women, compared to non-pregnant women of same age.⁸

It is possible to explain the predisposition to DVT in the first trimester of pregnancy, because in this period there is an increase in venous pressure due to an overflow in the hypogastric and common iliac arteries, due to the relaxation of vascular smooth muscle and opening of mediated progesterone arteriovenous anastomosis.⁹

According to meta-analysis of 12 studies on the impact of the trimester in the occurrence of thrombosis, 22% of cases occur in the first trimester, reinforcing the hypothesis of no relationship between heart disease and the occurred event.¹⁰

In this study, there were two cases of gestational diabetes mellitus (GDM), identified in a 37-year-old woman with mitral stenosis and double aortic lesion and in a 40-year-old woman with mitral valve prolapse. GDM is defined as any degree of glucose intolerance, resulting in hyperglycaemia of varying severity, with onset or diagnosis during pregnancy.¹¹

The patient who developed GDM in this study was included in the risk group for developing this disease, by being older than 25 years at the time of conception.¹¹

The incidence of GDM in Brazil ranges from 2.4% to 7.2%, depending on the criteria used for diagnosis.¹² There is a lack of studies seeking to establish whether the diseases are a cause of GDM, but currently maternal heart disease is not considered as a risk factor.¹¹ GDM found in women bearer of double aortic lesion and mitral stenosis may be an occasional finding.

In this study, it was documented a case of a 40-year-old patient, already mentioned in the discussion, bearer of mitral valve prolapse, which had placental abruption, oligohydramnios and GDM. Pregnancy in women older than 35 years is associated with increased risk of maternal, fetal and obstetric complications.¹³

The causes of oligohydramnios are the premature rupture of the amniotic membranes, placental insufficiency, presence of fetal abnormalities, hypertensive disorders, smoking and post-maturity.^14,15

The placental abruption may be the result of several pathophysiological processes, often from unknown origin.¹⁶ One of the main causes of this event is the hypertensive disease. The oligohydramnios and maternal age are pointed out in the literature as possible risk factors.^{17, 18}

During this study, one pregnant woman with uncorrected patent ductus arteriosus had pre-eclampsia, pathology that affects 8% of every pregnancy and is the major cause of perinatal and maternal deaths in developing countries.¹⁹

After analysing literature data, it was not found relation between pre-eclampsia and congenital heart disease, it can be inferred that the occurrence of this episode of hypertension during pregnancy was not motivated by underlying heart disease.

A patient with mitral and aortic mechanical prosthesis, in anticoagulation, had abdominal wall hematoma after an elective caesarean section. The incidence of abdominal hematoma in the population is generally small. The most important risk factors associated with this complication are anticoagulation (most important factor), chronic kidney disease, surgery and trauma.²⁰

It is probable that the hematoma that this patient had is related to the use of anticoagulation, being related to cardiopathy secondarily.

During the gestations with neonatal complications, 3 in total, some drugs were used. These pregnancies used: 1 – propranolol with furosemide; 2 – propranolol alone; and 3 – use of levothyroxine with metoprolol succinate and penicillin G benzathine

Levothyroxine can be used safely during pregnancy without adverse effects on the fetus.²¹ Penicillin G benzathine has no adverse effects reported in fetuses, but there are no controlled studies on its use during pregnancy; therefore, it is recommended to use when the benefits outweigh the risks.²² Propranolol, metoprolol and furosemide should be used only when the benefits outweigh the risks and there is no other drug of choice.^23-25

The possible side effects of propranolol are bradycardia and fetal and neonatal hypoglycaemia, intrauterine growth restriction, polycythemia, thrombocytopenia and hypokalemia.²³ Furosemide may be responsible for birth defects in newborns.²⁴ Metoprolol has no reported adverse fetal effects, but there are no controlled studies on its use during pregnancy.²⁵ Possible adverse effects of these medications have not been observed in neonates. These drugs can be ruled out as causes of neonatal complications.

Two infants required hospitalization in the NICU of two to three days to conduct phototherapy. Phototherapy is performed on infants to treat jaundice.²⁶

There may be hyperbilirubinemia according to ABO and Rh incompatibility between mother and fetus. ABO incompatibility occurs almost only when the mother’s blood group O.²⁷

ABO incompatibility occurs in 20% to 25% of pregnancies, and hemolytic disease of the newborn develops in 10% of gestations.²⁸ Other causes of neonatal hyperbilirubinemia is the beginning of breastfeeding, use of diazepam by the mother during pregnancy and gestational diabetes.²⁷

The newborns studied in our research that required hospitalization for phototherapy had blood type A+ with O+ mother and blood type A+ with B+ mother. Blood incompatibility of the ABO system observed in the first case is the likely cause of the need for hospitalization of the infant for three days for phototherapy. In the second case, the newborn had to be hospitalized for two days for performing phototherapy, but the cause of jaundice was unclear.

A newborn had to be admitted to the neonatal intensive care unit due to meconium aspiration syndrome, which occurs between 1% and 3% of pregnancies. Fatal outcome occurs between 5% and 40% of the cases, due to short term and long term complications.²⁹ The exact mechanism of meconium release in this case cannot be clarified.

According to data already reported in the literature by Avila et al.,⁴, 67% of pregnancies that followed the specialized cardiac monitoring protocol were free of complications.

Conclusion

Each cardiopathy, despite its peculiarities, can be enhanced due to physiological alterations resulted from pregnancy.

It was verified the incidence of maternal complications in 33% of pregnancies, 60% of which occurred in women with valvulopathy.

Importantly, the complications that occurred could have been found in normal pregnancies, having no direct relationship to heart disease.

It is possible to be inferred that prenatal associated with a multidisciplinary team and stability of cardiovascular disease were fundamental in the absence of complications related to heart disease.

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