Escola Superior de Ciências da Saúde
Clube de revista: Associação
entre defeitos cardíacos
congênitos e pequeno para a
idade gestacional
Internos: Eduardo Campos
Guilherme Aroeira
Jorge Alberto
Coordenação: Paulo R. Margotto
www.paulomargotto.com.br
Introdução
• Prevalência: 8-11/1000 nascidos vivos
• EUA:
~32000-44000
Cardiopatias
congênitas (CHDs)/ano
• Elevados custos (cirurgias;hospitalizações)
• Fatores prognósticos: complexidade da
lesão cardíaca, peso ao nascer,
graus de maturidade pulmonar e de
prematuridade
Introdução
• Pós-correção/paliação cirúrgica: limitação
do crescimento
– Desordens metabólicas
– Ventilação mecânica prolongada
– Alto risco de infecções
– Hospitalizações prolongadas
Introdução
• Revisão bibliográfica
– Associação positiva entre CHDs e PIG/Baixo
peso ao nascer (risco ~1,8-3,6)
– Ausência de ajuste dos fatores maternos e
fetais determinantes do crescimento
– Etiologia multifatorial (PIGxCHDs)
Objetivo
Investigar a associação entre CHDs e RN-PIG
em uma grande amostra populacional
ajustando os fatores maternos e fetais
envolvidos
Materiais e métodos
• Seleção da amostra
– Nascidos entre outubro de 1997 e dezembro
de 2002 e cadastrados no National Birth
Defects Prevention Study (NBDPS)
– Registros de vigilância (8 estados)
Materiais e métodos
• Seleção de casos
– Criança sem doenças genéticas
– CHDs:
<1
ano;
Ecocardiograma,cirúrgico,cateterismo
ou
autópsia
– Mãe fluente em inglês ou espanhol
– Criança não foi colocada para adoção ou
cuidados adotivos
Materiais e métodos
• Seleção de casos
– Gestações únicas
– Sem doenças extracardíacas
Materiais e métodos
• Seleção controles
– Crianças saudáveis nascidas no mesmo
período e nos mesmos estados
– Selecionadas através das certidões de
nascimento ou registros de alta
Materiais e métodos
• ~ 482000 nascidos/ano no período
• 18% das mães dos casos e 21% das mães
dos controles recusaram-se a participar do
NBDPS
Materiais e métodos
• Classificação das CHDs
– Lesões de grandes vasos
– Defeitos septais
– Lesões obstrutivas direita
– Lesões obstrutivas esquerdas
Materiais e métodos
• CHDs excluídas
– Dupla saída de ventrículo direito (VD)
– Lesões cardíacas com três ou mais defeitos
– Defeito venoso pulmonar parcial ou total
Materiais e métodos
• Variáveis maternas e infantis:
–
–
–
–
–
–
–
–
–
–
–
–
Idade
Raça/etnia
Nível sócio-econômico
Ganho de peso gestacional
Paridade
Diabetes Mellitus prévia
Hipertensão Arterial
Infecções (CMV,Rubeóla etc...)
Tabagismo
Etilismo
Drogas Ilícitas
Sexo da criança
Materiais e métodos
• Parâmetros de crescimento:
– PIG: Peso de nascimento < que percentil 10
– Idade gestacional: exame clínico/DPP
Materiais e métodos
• Análise estatística:
– Comparação entre CHDs e controles: MannWhitney/Wilcoxon rank sum test
– Ajuste de variáveis: regressão linear, Odds
Ratios e IC de 95%
Resultados
Discussão
• Relação CHDs x PIGs
– Crianças com CHDs apresentam maior risco
de prematuridade e de serem PIG
– Concordância com a literatura internacional
• Relação Controles x PIGs
– Discordância com a literatura internacional
Discussão
• Etiologia: CHDs e PIGs
– Fatores de risco comuns
– Fatores de risco independentes
– CHDsPIGs
Discussão
• Repercussões pré e pós-natais do estudo
– Nutrição adequada
– Monitorização cuidadosa do crescimento fetal
e neonatal
– Manejo dependente do tipo de lesão cardíaca
Discussão
• Limitações do estudo
– Dificuldade em classificar os prematuros
Discussão
• Novos
estudos buscando avaliar
relações etiológicas PIGsxCHDs
– Implementar medidas pré e pós-natais
• Diagnóstico precoce
• Monitorização cuidadosa
as
Conclusão
• Crianças
com
cardiopatias
congênitas
apresentam um risco duas vezes maior,
aproximadamente, de serem PIGs. Pigs com
CHDs tem suas condutas clínicas, resposta
terapêutica
e
prognóstico
neonatal
afetados.Embora a etiologia do retardo do
crescimento entre crianças com CHDs seja
incerto, novos estudos podem descobrir uma
patogênese comum ou uma relação causal entre
PIG e CHD.
ABSTRACT:
• OBJECTIVES. Infants with congenital heart defects may experience inhibited growth
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during fetal life. In a large case-control study, we addressed the hypothesis that
infants with congenital heart defects are more likely to be small for gestational age
than infants without congenital heart defects after controlling for selected maternal
and infant characteristics.
METHODS. Using data from population-based birth defect registries, the National
Birth Defects Prevention Study enrolled infants with nonsyndromic congenital heart
defects (case subjects) and infants without congenital heart defects or any other
birth defect (control subjects). Small for gestational age was defined as birth weight
below the 10th percentile for gestational age and gender. Association between
congenital heart defects and small for gestational age was examined by conditional
logistic regression adjusting for maternal covariates related to fetal growth.
RESULTS. Live-born singleton infants with congenital heart defects (case subjects, n
= 3395) and live-born singleton infants with no birth defect (control subjects, n =
3924) were included in this study. Case subjects had lower birth weights compared
with control subjects. Small for gestational age was observed among 15.2% of case
subjects and among only 7.8% of control subjects. Congenital heart defect infants
were significantly more likely to be small for gestational age than control infants.
CONCLUSIONS. Infants with congenital heart defects are approximately twice as
likely to be small for gestational age as control subjects. Small for gestational age
status may affect clinical management decisions, therapeutic response, and
prognosis of neonates with congenital heart defects. Although the etiology of growth
retardation among infants with congenital heart defects is uncertain, further
exploration may uncover a common pathogenesis or causal relationship between
congenital heart defects and small for gestational age.
Key Words: small for gestational age • cardiac disease • congenital anomalies
Abbreviations: CHD—congenital heart defect • NBDPS—National Birth Defects
Prevention Study • OR—odds ratio • CI—confidence interval
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Ddo Eduardo
Ddo Jorge
Obrigado.
Ddo Guilherme