Maternal mortality – ABC CARDIOL

ABC

Original Article

Risk Factors Associated with Preeclampsia and Their Impact on Maternal and Neonatal Morbidity and Mortality in the Dominican Republic

Patricia Severino et al. Fulgencio Severino Rosa Cueto

Abstract

Background

Hypertensive disorders of pregnancy complicate 5%-10% of pregnancies and account for 23%-38% of maternal deaths in the Dominican Republic.

Objective

To identify factors associated with the development of preeclampsia and evaluate their relationship with maternal and perinatal morbidity and mortality.

Methods

This multicenter, prospective, observational, cross-sectional, analytical study included 469 parturients from 17 hospitals across the Dominican Republic over a 30-day period. Statistical significance was set at p < 0.05.

Results

Preeclampsia was significantly associated with chronic hypertension (44.15% vs 16.87%; odds ratio [OR], 3.91; 95%CI, 2.51-6.09), previous preeclampsia (44.64% vs 18.60%; OR, 3.53; 95%CI, 2.24-5.56), and a family history of preeclampsia (42.0% vs 19.38%; OR, 3.01; 95%CI, 1.96-4.62). Preeclampsia was also associated with prematurity (54.6% vs 33.4%; OR, 2.40; 95%CI, 1.62-3.55), low birth weight (37.6% vs 18.5%; OR, 2.65; 95%CI, 1.73-4.07), and placental abruption (5.0% vs 2.4%; OR, 2.14; 95%CI, 0.81-5.62). Maternal and fetal mortality were not significantly associated with preeclampsia. In the multivariable logistic regression analysis, chronic hypertension (adjusted OR [AOR], 3.64; 95%CI, 2.25–5.88), a family history of preeclampsia (AOR, 2.86; 95%CI, 1.85-4.42), and pregestational obesity (AOR, 2.26; 95%CI, 1.52-3.36) emerged as independent predictors of preeclampsia (all p < 0.05).

Conclusion

Preeclampsia is associated with an increased risk of adverse maternal and neonatal outcomes, particularly prematurity and low birth weight.

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ABC

Editorial

The REBECGA Registry: A Landmark in the Care of Pregnant Women with Heart Disease in Brazil

Imara Correia de Queiroz Barbosa et al. Gláucia Maria Moraes de Oliveira

Pregnancy is a major life event for almost every woman. It has been estimated that 1-4% of pregnant women have some form of congenital or acquired cardiac disease, the main non-obstetric cause of maternal mortality worldwide.^– Although many women with heart disease tolerate the hemodynamic changes of pregnancy, others may face significant immediate or late risks of pregnancy, including volume overload, arrhythmias, progressive cardiac dysfunction, and death.^,

There is a growing prevalence of heart disease during pregnancy, driven by two main factors: advances in the treatment of congenital heart disease (CHD), which have allowed more children to survive into adulthood and consider pregnancy, and the trend of delayed childbearing.^,, As maternal age increases, so does the prevalence of comorbidities such as hypertension, diabetes, and hypercholesterolemia, contributing to a higher incidence of acquired heart disease complicating pregnancy.^,

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ABC

Original Article

REBECGA: Brazilian Registry of Heart Disease and Pregnancy. Multicenter Epidemiological Study of Heart Diseases in Pregnancy: Retrospective Cohort

Walkiria Samuel Avila et al. Alexandre Jorge Gomes de Lucena Claudia Maria Vilas Freire Fabio Bruno da Silva … Ivan Romero Rivera Juliana Rodrigues Soares Oliveira Maria Alayde Mendonça Rivera Regina Coeli de Carvalho Vicente Avila Neto Flávio Tarasoutchi

Abstract

Background

Heart disease, which affects approximately 4% of pregnancies, is the leading non-obstetric cause of maternal death. It is estimated that 40% of these deaths could be prevented with a better understanding of pregnancy risks.

Objectives

To develop the Brazilian Registry of Heart Diseases in Pregnancy (REBECGA) to study the prevalence, complications, and maternal mortality associated with heart diseases during pregnancy and postpartum.

Methods

A multicenter retrospective study of pregnancy and postpartum follow up until 12 months after delivery in women with heart diseases, including analysis of predictive variables for maternal outcomes. A two-tailed significance level of 5% was adopted for statistical analysis.

Results

A total of 638 pregnant women were included, with the following diagnoses: valvular disease (37.8%), congenital heart diseases (35.7%), arrhythmias without structural heart damage (14.7%), cardiomyopathies (11.3%), and other heart diseases (6.4%). The main complications were heart failure (16.7%), arrhythmia (10.7%), and syncope (8.0%), with 18 maternal deaths (2.8%), 10 of which occurred during the postpartum period. Cesarean delivery was indicated in 62.9% of cases, with 25.7% preterm births and 3.2% fetal losses. Multivariate analysis identified WHO class IV risk classification (OR 3.51; 95% CI 1.75–7.04; p < 0.001); NYHA class III/IV (OR 2.27; 95% CI 1.12–4.60; p = 0.023), and pulmonary hypertension (OR 2.45; 95% CI 1.05–5.70; p = 0.037) as predictive variables for maternal complications and deaths.

Conclusions

REBECGA highlighted the prevalence of valvular disease, heart failure as the main complication, the postpartum period as a critical time for maternal deaths, and identified predictive risk variables for adverse pregnancy outcomes in women with heart disease.

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ABC

Editorial

Cardiac Valve Prosthesis and Pregnancy: Challenges and Strategies

Marcelo Luis Nomura

Pregnancy in women with valvular prostheses is challenging for caregivers for several reasons. Despite advances in understanding cardiovascular physiology, the intense hemodynamic changes posed by pregnancy itself and the interactions between the mother, placenta, and fetus, along with the unique environment created by the cardiac adaptation, make management one of the most complex situations for maternal-fetal specialists and cardiologists. Add to it the need for effective and safe anticoagulation for both mother and fetus to prevent the greatest threat of valve thrombosis and dysfunction.

In this issue, a large observational and elegant study presented data on the perinatal outcomes of 128 pregnancies in women with cardiac prosthetic valves. As a single-center study, the authors sought to evaluate pregnancy outcomes and 12-month postpartum complications rate and also to compare these results between mechanical and biological prosthetic heart valves. A successful pregnancy was defined by an uneventful term birth and puerperium for both mother and newborn and occurred in 50% of the cases. At first glance, one might look at it as a half-full or half-empty glass situation. At a closer look, however, roughly half of the patients experienced cardiac complications, and one in three had at least one of the following during pregnancy: heart failure, atrial fibrillation, thromboembolism, or infective endocarditis. There were five maternal deaths, which, by any means of comparison, is an extremely high figure. Regarding obstetrical outcomes, the main findings were a high rate of spontaneous miscarriage in the mechanical prosthetic heart valves group and also a high rate of preterm birth in the bioprosthetic valve group. The overall fetal and neonatal loss rate was 30% (miscarriages, stillbirths, and neonatal deaths).

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IJCS

Editorial

Chagas Disease and Maternal Mortality: An Overlooked Link in a Neglected Disease in Brazil

Maria Alayde Mendonça Rivera et al. Ivan Romero Rivera Glaucia Maria Moraes de Oliveira Ana G. Múnera Echeverri Walkiria Avila

Maternal mortality (MM), defined as the death of a woman during pregnancy, childbirth, or within 42 days postpartum, is a key indicator of maternal health and the quality of care provided by the health care system to prevent and manage complications during this period.

In 2020, there were 287,000 maternal deaths worldwide, resulting in a maternal mortality ratio (MMR) of 223 deaths per 100,000 live births. According to the World Health Organization (WHO), 95% of these deaths will occur in low- and middle-income countries, and 90% will be preventable.

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IJCS

Review Article

Maternal Deaths by Chagas’ Disease in Brazil

Danielle Kaiser de Souza et al. Vinicius Medina Lopes Ana Luiza Cafe-Lopes Maria das Dores Medina-Lopes

Abstract

Introduction

Chagas’ Disease is responsible for a high rate of morbimortality in Brazil however its real relevance on the maternal mortality is unknown.

Objective

The aim of this study is to review the literature on the impact of Chagas’ Disease on the Brazilian maternal mortality during the pregnancy-puerperal cycle.

Method

A review of literature was conducted to identify publications about maternal mortality and Chagas’ Disease. Documents were also searched in the websites of the Brazilian Ministry of Health, World Health Organization (WHO), System of Information about Mortality (SIM) and Brazilian Society of Cardiology (SBC). Manuscripts, master’s degree and PhD thesis, consensus, epidemiologic bulletins and manuals were analyzed.

Results

Initially were found 1326 paper, however just 14 answered the objective. Five epidemiologic bulletins, 4 manuals of Ministry of Health, 3 consensuses of SBC, 1 book and 3 master’s degree thesis were also used. There is no description of the number of deaths of pregnant women per year caused by complications of Chagas’ Disease in the data of the Ministry of Health and in the SIM. According to the data found, one third of pregnant women with Chagas’ Disease are cardiac patients and the mortality among them is 3.5%, therefore is expected a mortality of about 1% in the pregnant-puerperal cycle. There is evidence of underreporting of maternal mortality among chagasic pregnant women.

Conclusion

The maternal mortality caused by Chagas’ Disease is not known, therefore more studies about it are necessary, in all clinical forms of the disease.

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ABCHF

Review Article

Peripartum Cardiomyopathy

Walkiria Samuel Ávila et al. Regina Coeli Marques de Carvalho

Abstract

Peripartum cardiomyopathy (PPCM) is a low frequent, but potentially fatal disease, that manifests with heart failure and reduced ejection fraction, with no other identified cause, and related to the puerperal pregnancy cycle. It is a global disease with different clinical manifestations and prognosis. Known risks include preeclampsia, advanced maternal age, multifetal gestation, and African ascendence. Genetic tests have shown that up to 20% of women with PPCM have an identifiable variant of cardiomyopathy. The etiopathogenesis of PPCM, although still unclear, is characterized by endothelial dysfunction caused by anti-angiogenic agents in the placenta, and prolactin degradation products. Clinical manifestation of PPCM does not differ from that of heart failure in other cardiomyopathies, with symptoms varying from mild to cardiogenic shock. Mortality rates in PPCM patients vary widely, and are related to cardiogenic shock, thromboembolism, and complex arrhythmias. The disease may progress rapidly to severe HF, with indication for mechanical circulatory support or cardiac transplant. The treatment of PPCM during gestation is distinct due to potential adverse effects of drugs to pregnancy. However, a careful selection of beta-blockers, diuretics and vasodilators has achieved therapeutic success for the mother and the fetus. Although the treatment meets traditional guidelines developed for nonpregnant adults, the use of bromocriptine (ergot alkaloid) and cabergoline (dopamine D2 receptor agonist) has shown favorable results in ventricular recovery in patients with LVEF < 35% when treated with optimized treatment for heart failure.

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IJCS

Original Article

The REBECGA Brazilian Registry of Pregnancy and Heart Disease: Rationale and Design

Walkiria Samuel Avila et al. Maria Alayde Mendonça Rivera Celi Marques-Santos Ivan Romero Rivera … Maria Elizabeth Navegantes Caetano Costa Alexandre Jorge Gomes de Lucena Claudia Maria Vilas Freire Regina Coeli Marques de Carvalho Daniel Born Felipe Favorette Campanharo Fabio Bruno Silva

Abstract

Background:

Maternal mortality rates in Brazil remain above the goals established by the United Nations Sustainable Development Goals. Heart disease is estimated to affect 4% of all pregnancies and remains by itself the main indirect obstetric cause of maternal death. In the last decades, a significant improvement in the prognosis of heart diseases has made pregnancy possible in women with heart disease and provided better maternal and fetal outcomes.

Objective:

To establish a multicenter Brazilian Registry of pregnant women with heart disease; to study the causes of immediate and late maternal mortality; and to assess the prevalence of heart disease in the country’s macro-regions.

Method:

This is an observational study, with retrospective and prospective stages, of the clinical and obstetric progression of pregnant women with heart disease. These women consecutively received care during pregnancy and will be followed up for up to a year after delivery at public and private hospitals with infrastructure for the execution of this project, a principal investigator, and approval by Ethics and Research Committees.

Results:

Our results will be presented after data collection and statistical analysis, aiming to demonstrate immediate and late maternal mortality rates, as well as the prevalence of heart disease in the country and its cardiovascular and obstetric complications during pregnancy.

Conclusion:

REBECGA will be the Brazilian Registry of heart disease and pregnancy and it will contribute to planning preventive measures, raising financial resources for the improvement of high-risk prenatal care, and reducing immediate and late maternal mortality due to heart disease.

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IJCS

Editorial

REBECGA Registry: A Multicenter Study for the Reduction of Maternal Mortality Due to Heart Diseases Manifested During Pregnancy

Karyne Pollo de Souza et al. Christianne Brêtas Vieira Scaramello

According to the literature, although the prevalence of heart disease in pregnancy varies considerably among countries, cardiovascular disease is responsible for 1% to 4% of complicated pregnancies in industrialized countries. This pattern is related to cardiovascular risk factors, such as smoking, diabetes, obesity, and hypertension, especially in low- and middle-income countries, as well as late motherhood and the presence of congenital heart disease, mainly in high-income countries.^,

Improved diagnostic methods and therapeutic alternatives have encouraged maternity by promoting safer pregnancies. However, heart disease is still the leading non-obstetric cause of maternal mortality worldwide. Although the rate of maternal mortality has decreased in Brazil over the last three decades, it continues to be higher than estimated for this millennium.

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ABC

Editorial

Complex Congenital Heart Diseases and Pregnancy: Maternal and Fetal Risks

Valéria de Melo Moreira

The diagnosis and treatment of congenital heart disease has made remarkable progress in recent decades and the success of this approach is evidenced by the increasing number of adults with congenital heart disease. Many of these patients have residual injuries or have undergone palliative surgery and face additional challenges in adulthood, requiring integrated care to reach a full life potential.

Consequently, the number of women of childbearing age with congenital disease submitted to surgical repair, palliative procedure or the natural evolution of the disease is increasing, with a higher maternal and fetal risk in the presence of heart disease. Reproductive counseling is essential, by informing the consequences and possible complications and advising against pregnancy in the presence of more complex defects.

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