Obstetric and perinatal aspects in patients with congenital heart diseases "

The benefits of surgical treatment for patients with congenital heart disease in relation to pregnancy are still controversial. We studied 48 pregnant women (mean age = 25 years) with surgically-corrected congenital heart diseases (Group 1).This included 15 cyanotic diseases: Fallot's tetralogy (11 cases); Ebstein's anomaly (2 cases); transposition of the great arteries (1 case); and double outlet of the right ventricle (1 case). We compared them to 52 pregnant women (mean age = 26 years) with untreated congenital heart diseases, which included 11 cases of Eisenmenger's syndrome (Group 2). Group 2 showed a higher incidence of maternal death (12 vS.Opercent; p=O.01), perinatal mortality (15 vs. 0 percent; p=O.01) and prematurity (32 vs. 7 percent; p=O.01). Spontaneous abortion (4 vs. 10 percent), Caesarean deliveries (48 vs. 66 percent) or growth retardation (13 vs. 28 percent) did not present any significant differences between these groups. Surgical treatment in patients with heart diseases is associated with a better maternal and fetal prognosis. Therefore, surgery must be considered when counseling patients with congenital heart diseases.


INTRODUCTION
I n the past ten years, the decrease in deaths due to heart disease has been expressed as the proportion of women with congenital heart diseases who successfully complete their pregnancies.' Surgical advances in congenital heart disease treatment have diminished risks to the mother and have allowed better fetal development. 2 However, the main cause of maternal death, besides gestational complications, is still heart disease, congenital or not. 3 Gestational complication risks depend on the degree of hemodynamic impairment of each clinical situation.
This functional class interferes with the course of the pregnancy, causing maternal death in up to 30 percent of Class IV patients. 2 Pulmonary hypertension, cyanosis, or ventricular dysfunction are associated with a poor maternal/fetal prognosis, and with a higher incidence of heart failure, pulmonary congestion, arrhythmia and thromboembolisms. 4 This study analyzes obstetric and perinatal aspects of patients with congenital heart disease in comparison with normal subjects.

MATERIAL AND METHODS
We studied 100 pregnant women with congenital heart diseases during pregnancy and puerperium. Follow-up was started during the first trimester (27 cases) or the Table 1 second trimester (73 cases), on average at 18 weeks, and Types of heart anomalies was continued for three months after delivery. All cases 15 were divided in two groups: Group  Transvalvar wedge was over 50 mmHg in 10 (19 percent) patients in G2: aortic stenosis (5 cases); subaortic stenosis (I cases); coarctation of the aorta (I case); pulmonary stenosis (1 case); right ventricle double outlet (I case); aortic stenosis + coarctation of the aorta (I case). One patient (2 percent) was in G I with aortic stenosis (p<O.O I). Table 3 Abortions and low-weight newborns Four (27 percent) maternal deaths occurred among 15 Class III and IV patients. Two (2 percent) out of eightyfive Class I and II patients died.

Functional Class
Most cases (85 percent) were classified as functional Class I or II during the first visit. Class III or IV were more frequent (p=O.OOI) in G2 (14 cases), in comparison to G I (I case), corresponding to: Eisenmenger's syndrome (3 cases); aortic stenosis (2 cases); ACP (2 cases); aortic stenosis and coarctation of the aorta (1 case); subaortic stenosis (I case); coarctation of the aorta (1 case); lAC (I case); PS+VIC+AIC (1 case); AVC (1 case); and right ventricle double outlet (1 case). The Class III case in G I was due to an lAC. Eleven patients evolved from Classes I to II and from III to IV, five of whom were in Gl (IVC-2 cases, FaIlot's tetralogy, right ventricle double outlet and aortic stenosis) and six of whom were in G2 (Aortic stenosis -3 cases, lAC, AVC, and Pulmonary stenosis).
Two patients in Gl, with double outlet of the right ventricle in one, and aortic stenosis in the other, underwent heart surgery during pregnancy due to untreatable heart failure.

Maternal Mortality Rates Abortions
Maternal mortality was higher (p=O.02) and/or in G2 (six deaths = 12 percent; three during pregnancy and or during puerperium) in relation to Gl, in which no deaths occurred. Table 2 compares heart disease to functional class, hemoglobinemia, pulmonary hypertension or transvalvar wedge, and death period.  We observed a significant difference (p=O.O I) between the proportion of newborns low-weight neonates in G2 (38 percent) and G I, (13 percent) ( Table 3). This did not occur in the group of patients with residual lesions. Only one out of II cases with FaIlot's tetralogy gave birth to a low-weight newborn. Seven out of eight newborn babies, from Eisenmenger's syndrome cases were low-weight. Prematurity was more frequent (p<O.O I) in G2 (15 cases = 32 percent) than in G I (3 cases -7 percent). Intrauterine growth retardation occurred in 6 (13 percent) cases in Gland 13 (28 percent) cases in G2 (p=O.08). No growth retardation was registered in patients with residual lesions. There was no prematurity in this group, and only There were a total of seven abortions, of which six were spontaneous and one was therapeutic; two were in G I and five were in G2 (Table 3). There was no significant difference between the groups (10 vs. 4 percent).
Therapeutic abortion was a measure taken in the first trimester for a Class III patient with Eisenmenger's syndrome. Spontaneous abortions occurred in five Class lIII patients (Eisenmenger's syndrome -3 cases, Ebstein's Disease -2 cases) and in a Class III patient with pulmonary stenosis + lAC + IVC). Newborn babies with heart diseases Anesthesia Anesthesia was used during delivery according to the extent of maternal cardiac involvement. Twenty-four (52 percent) patients of G I underwent peridural anesthesia. In G2, 15 (36 percent) patients were submitted to peridural anesthesia and 17 (40 percent) were submitted to general anesthesia. Eisenmenger's syndrome patients were submitted to general anesthesia.
Five patients did not receive anesthesia since they had spontaneous births. No clinical problems were attributed to the use of anesthesia.
Three (3.2 percent) new-born babies preseDted heart malformations. Two cases were in G I: one mother with GAT and lAC and a child with lAC; one mother with ACP+IVC+IAC and a child with PAC+IAC. There was one malformation in G2, in which the mother had IVC and the child presented AVC.

DISCUSSION
Twenty-two (48 percent) cases from G I and 31 (66 percent) from G2 underwent a caesarean section (no significant difference). Table 5 shows the indications of the caesarean deliveries. Type of heart disease was the most important indication in 13 cases, of which eleven were in G2: Eisenmenger's syndrome (4 cases);aortic stenosis (2 cases);coarctation of the aorta (2 cases);aortic stenosis + coarctation of the aorta (1 case); subaortic stenosis (I case); and patent ductus arteriosus with a dissecting aneurysm of aorta (I case). Two cases were in G I; coarctation of the aorta and aortic stenosis.  The incidence of abortions in both groups was approximately IS percent, which is lower than that expected in the normal population. 5 This might have occurred due to follow-up starting in the second trimester of pregnancy in 70 percent of the studied women. Seventyfive percent of abortions occur in the first 12 weeks of gestation, while 25 percent occur after this period, according to REZENDE et al.(1The small number of cases studied does not allow any appropriate analysis of the effect of the surgical corrections and the functional class on abortions, although they were more frequent in G2. However, this does show that there is a need to guide pregnant women wi th congen ital heart diseases to appropriate specialists in order to arrange a more efficient prenatal follow-up. It is fundamental to know about the effects on fetal Two fetal and 5 neonate deaths occurred in G2, and growth and development of hemodynamic alterations none occurred in G I (p=O.OI). Table 6 shows fetal death brought on by cardiac lesions in order to evaluate principal related to heart disease. prognostic factors prognosis. Low-weight newborns, growth retardation, and prematurity were complications related to diseases that caused cyanosis, pulmonary hypertension, high pressure wedges, and functional Classes III and IV. G2 presented a significant number of deaths during and after pregnancy due to the higher number of maternal complications in this group. Surgical correction diminished the number of premature and low-weight babies, exempting itself from growth retardation. This also occurred in the 100% group of nine patients, with residual patients (Table  1) showing results similar to those in G I.
Vaginal and Caesarean delivery recommendations are similar to those in the normal population.? Hemodynamic alterations are similar in abdominal and 100% _______________________ vaginal births, with some differences during labor. x However, laparotomy poses a higher risk due to anesthesia, hemorrhages, infections, emboli, and pulmonary complications. In heart patients, these risks are higherY Therefore, congenital heart disease is not an indication for Caesarean section. 10 Anesthesia does influence the type of birth due to different effects of drugs and anesthesia techniques on each kind of heart disease. Eisenmenger's syndrome, aortic and subaortic stenosis indicated the use of peridural anesthetic to preserve peripheral resistance with an adequate pre-load. Although conduction anesthetic may be used in these patients, it is important to note that a decrease in peripheral resistance, which is frequently  associated with a sympathetic block, may diminish pre-load and cause heart failure and sudden death.
In G2, more Caesarean sections were indicated due to heart disease (aortic stenosis, coarctation of the aorta, or Eisenmenger's syndrome), since there were more patients with cyanosis, pulmonary hypertension, and obstructive lesions in the left chambers with high transvalvar wedges. Patients with coarctation of the aorta underwent Caesarean sections, although GOODWIN, II contrarily to MENDELSON, 12reported that there was no risk for these patients during labor, si nce none of the deaths reported in his study occurred during this period.
There was no significant difference between G I and G2 in relation to presence of congenital heatt diseases in newborn babies. Three babies (3.2 percent) were born with heart disease, while in normal population this incidence is I percent. 13 WHITTEMORE studied 372 babies from 233 women during three years, 17.9 percent of which were from mothers who did not undergo surgery and 14.2 percent from mothers who underwent surgery. In this study, there was no statistical difference between these two groupS. 14 We noted the appearance of similar diseases (lAC) in GJ descendants. The same malformation was observed by CZEIZEK in seven of 12cases. IS In WHITTEMORE'S study approximately half (35 of 60) of the malformations were similartothe mother's.'4NORA & NORA noted that 8 percent of congenital diseases were genetic and 2 percent were due to the environment, while 90 percent come from a genetic and environmental interaction.'6 Although we ruled out medications and diseases that could be responsible for congenital diseases, the small number of cases does not allow a distinction between genetic and environmental factors.

CONCLUSIONS
Maternal and fetal prognosis was significantly more positive in patients who experienced operations. Residual surgical lesions did not alter any results. Left obstructive involvement and cyanosis were associated with maternal death and most of the neonate deaths. Maternal, fetal and neonate deaths occurred only among patients who were not operated.
Prematurity and low-weight newborns were significantly higher in patients who were not operated upon.
Eisenmenger's syndrome, aortic stenosis, among the lesions that caused left obstruction, were those with higher maternal, fetal and neonate deaths.
Patients who were not operated underwent Caesarean sections more often due to the severity of their diseases.
The incidence of heart diseases in descendants was three times what is usually expected in the general population, with no difference due to surgical correction.
Our results reinforce the need for family planning in patients with congenital heart diseases, which would include orientation about surgery. Pregnancy is not recommended for patients with Eisenmenger's syndrome and aortic stenosis.