Escola Superior de Ciências da SaúdeEscola Superior de Ciências da Saúde

Clube de revista: Clube de revista: Associação entre defeitos Associação entre defeitos

cardíacos congênitos e cardíacos congênitos e pequeno para a idade pequeno para a idade

gestacionalgestacionalInternos: Eduardo CamposInternos: Eduardo Campos Guilherme AroeiraGuilherme Aroeira

Jorge AlbertoJorge AlbertoCoordenação: Paulo R. MargottoCoordenação: Paulo R. Margotto

www.paulomargotto.com.brwww.paulomargotto.com.br

IntroduçãoIntrodução• Prevalência: 8-11/1000 nascidos vivosPrevalência: 8-11/1000 nascidos vivos• EUA: ~32000-44000 Cardiopatias EUA: ~32000-44000 Cardiopatias

congênitas (CHDs)/anocongênitas (CHDs)/ano• Elevados custos Elevados custos

(cirurgias;hospitalizações)(cirurgias;hospitalizações)• Fatores prognósticos: complexidade da Fatores prognósticos: complexidade da

lesão cardíaca, peso ao nascer,lesão cardíaca, peso ao nascer, graus de maturidade pulmonar e de graus de maturidade pulmonar e de

prematuridadeprematuridade

IntroduçãoIntrodução• Pós-correção/paliação cirúrgica: Pós-correção/paliação cirúrgica:

limitação do crescimento limitação do crescimento – Desordens metabólicasDesordens metabólicas– Ventilação mecânica prolongadaVentilação mecânica prolongada– Alto risco de infecçõesAlto risco de infecções– Hospitalizações prolongadasHospitalizações prolongadas

IntroduçãoIntrodução• Revisão bibliográficaRevisão bibliográfica

– Associação positiva entre CHDs e Associação positiva entre CHDs e PIG/Baixo peso ao nascer (risco ~1,8-PIG/Baixo peso ao nascer (risco ~1,8-3,6)3,6)

– Ausência de ajuste dos fatores maternos Ausência de ajuste dos fatores maternos e fetais determinantes do crescimentoe fetais determinantes do crescimento

– Etiologia multifatorial (PIGxCHDs)Etiologia multifatorial (PIGxCHDs)

ObjetivoObjetivo Investigar a associação entre CHDs e Investigar a associação entre CHDs e

RN-PIG em uma grande amostra RN-PIG em uma grande amostra populacional ajustando os fatores populacional ajustando os fatores maternos e fetais envolvidosmaternos e fetais envolvidos

Materiais e métodosMateriais e métodos• Seleção da amostraSeleção da amostra

– Nascidos entre outubro de 1997 e Nascidos entre outubro de 1997 e dezembro de 2002 e cadastrados no dezembro de 2002 e cadastrados no National Birth Defects Prevention Study (NBDPS)

– Registros de vigilância (8 estados)

Materiais e métodosMateriais e métodos• Seleção de casosSeleção de casos

– Criança sem doenças genéticasCriança sem doenças genéticas– CHDs: <1 ano; CHDs: <1 ano;

Ecocardiograma,cirúrgico,cateterismo Ecocardiograma,cirúrgico,cateterismo ou autópsiaou autópsia

– Mãe fluente em inglês ou espanholMãe fluente em inglês ou espanhol– Criança não foi colocada para adoção ou Criança não foi colocada para adoção ou

cuidados adotivoscuidados adotivos

Materiais e métodosMateriais e métodos• Seleção de casosSeleção de casos

– Gestações únicasGestações únicas– Sem doenças extracardíacasSem doenças extracardíacas

Materiais e métodosMateriais e métodos• Seleção controlesSeleção controles

– Crianças saudáveis nascidas no mesmo Crianças saudáveis nascidas no mesmo período e nos mesmos estadosperíodo e nos mesmos estados

– Selecionadas através das certidões de Selecionadas através das certidões de nascimento ou registros de altanascimento ou registros de alta

Materiais e métodosMateriais e métodos• ~ 482000 nascidos/ano no período~ 482000 nascidos/ano no período• 18% das mães dos casos e 21% das 18% das mães dos casos e 21% das

mães dos controles recusaram-se a mães dos controles recusaram-se a participar do participar do NBDPS

Materiais e métodosMateriais e métodos• Classificação das CHDsClassificação das CHDs

– Lesões de grandes vasosLesões de grandes vasos– Defeitos septaisDefeitos septais– Lesões obstrutivas direitaLesões obstrutivas direita– Lesões obstrutivas esquerdasLesões obstrutivas esquerdas

Materiais e métodosMateriais e métodos• CHDs excluídasCHDs excluídas

– Dupla saída de ventrículo direito (VD)Dupla saída de ventrículo direito (VD)– Lesões cardíacas com três ou mais Lesões cardíacas com três ou mais

defeitosdefeitos– Defeito venoso pulmonar parcial ou totalDefeito venoso pulmonar parcial ou total

Materiais e métodosMateriais e métodos• Variáveis maternas e infantis:Variáveis maternas e infantis:

– IdadeIdade– Raça/etniaRaça/etnia– Nível sócio-econômicoNível sócio-econômico– Ganho de peso gestacionalGanho de peso gestacional– ParidadeParidade– Diabetes Mellitus préviaDiabetes Mellitus prévia– Hipertensão ArterialHipertensão Arterial– Infecções (CMV,Rubeóla etc...)Infecções (CMV,Rubeóla etc...)– TabagismoTabagismo– EtilismoEtilismo– Drogas IlícitasDrogas Ilícitas– Sexo da criançaSexo da criança

Materiais e métodosMateriais e métodos• Parâmetros de crescimento:Parâmetros de crescimento:

– PIG: Peso de nascimento < que percentil PIG: Peso de nascimento < que percentil 1010

– Idade gestacional: exame clínico/DPPIdade gestacional: exame clínico/DPP

Materiais e métodosMateriais e métodos• Análise estatística:Análise estatística:

– Comparação entre CHDs e controles: Comparação entre CHDs e controles: Mann-Whitney/Wilcoxon rank sum testMann-Whitney/Wilcoxon rank sum test

– Ajuste de variáveis: regressão linear, Ajuste de variáveis: regressão linear, Odds Ratios e IC de 95%Odds Ratios e IC de 95%

ResultadosResultados

DiscussãoDiscussão

• Relação CHDs x PIGsRelação CHDs x PIGs– Crianças com CHDs apresentam maior risco Crianças com CHDs apresentam maior risco

de prematuridade e de serem PIGde prematuridade e de serem PIG– Concordância com a literatura internacionalConcordância com a literatura internacional

• Relação Controles x PIGsRelação Controles x PIGs– Discordância com a literatura internacionalDiscordância com a literatura internacional

DiscussãoDiscussão• Etiologia: CHDs e PIGsEtiologia: CHDs e PIGs

– Fatores de risco comunsFatores de risco comuns– Fatores de risco independentesFatores de risco independentes– CHDsCHDsPIGs PIGs

DiscussãoDiscussão• Repercussões pré e pós-natais do Repercussões pré e pós-natais do

estudoestudo– Nutrição adequadaNutrição adequada– Monitorização cuidadosa do crescimento Monitorização cuidadosa do crescimento

fetal e neonatalfetal e neonatal– Manejo dependente do tipo de lesão Manejo dependente do tipo de lesão

cardíacacardíaca

DiscussãoDiscussão• Limitações do estudoLimitações do estudo

– Dificuldade em classificar os prematurosDificuldade em classificar os prematuros

DiscussãoDiscussão• Novos estudos buscando avaliar as Novos estudos buscando avaliar as

relações etiológicas PIGsxCHDsrelações etiológicas PIGsxCHDs– Implementar medidas pré e pós-natais Implementar medidas pré e pós-natais

•Diagnóstico precoceDiagnóstico precoce•Monitorização cuidadosaMonitorização cuidadosa

ConclusãoConclusão• Crianças com cardiopatias congênitas Crianças com cardiopatias congênitas

apresentam um risco duas vezes maior, apresentam um risco duas vezes maior, aproximadamente, de serem PIGs. Pigs aproximadamente, de serem PIGs. Pigs com CHDs tem suas condutas clínicas, com CHDs tem suas condutas clínicas, resposta terapêutica e prognóstico resposta terapêutica e prognóstico neonatal afetados.Embora a etiologia do neonatal afetados.Embora a etiologia do retardo do crescimento entre crianças com retardo do crescimento entre crianças com CHDs seja incerto, novos estudos podem CHDs seja incerto, novos estudos podem descobrir uma patogênese comum ou uma descobrir uma patogênese comum ou uma relação causal entre PIG e CHD.relação causal entre PIG e CHD.

• OBJECTIVES. Infants with congenital heart defects may experience inhibited OBJECTIVES. Infants with congenital heart defects may experience inhibited growth during fetal life. In a large case-control study, we addressed the hypothesis growth 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 that infants with congenital heart defects are more likely to be small for gestational age than infants without congenital heart defects after controlling for gestational age than infants without congenital heart defects after controlling for selected maternal and infant characteristics. selected maternal and infant characteristics.

• METHODS. Using data from population-based birth defect registries, the National METHODS. Using data from population-based birth defect registries, the National Birth Defects Prevention Study enrolled infants with nonsyndromic congenital Birth Defects Prevention Study enrolled infants with nonsyndromic congenital heart defects (case subjects) and infants without congenital heart defects or any 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 other birth defect (control subjects). Small for gestational age was defined as birth weight below the 10th percentile for gestational age and gender. Association weight below the 10th percentile for gestational age and gender. Association between congenital heart defects and small for gestational age was examined by between congenital heart defects and small for gestational age was examined by conditional logistic regression adjusting for maternal covariates related to fetal conditional logistic regression adjusting for maternal covariates related to fetal growth. growth.

• RESULTS. Live-born singleton infants with congenital heart defects (case subjects, RESULTS. Live-born singleton infants with congenital heart defects (case subjects, nn = 3395) and live-born singleton infants with no birth defect (control subjects, = 3395) and live-born singleton infants with no birth defect (control subjects, nn = 3924) were included in this study. Case subjects had lower birth weights = 3924) were included in this study. Case subjects had lower birth weights compared with control subjects. Small for gestational age was observed among 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 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 defect infants were significantly more likely to be small for gestational age than control infants. control infants.

• CONCLUSIONS. Infants with congenital heart defects are approximately twice as CONCLUSIONS. Infants with congenital heart defects are approximately twice as likely to be small for gestational age as control subjects. Small for gestational age likely to be small for gestational age as control subjects. Small for gestational age status may affect clinical management decisions, therapeutic response, and status may affect clinical management decisions, therapeutic response, and prognosis of neonates with congenital heart defects. Although the etiology of prognosis of neonates with congenital heart defects. Although the etiology of growth retardation among infants with congenital heart defects is uncertain, growth retardation among infants with congenital heart defects is uncertain, further exploration may uncover a common pathogenesis or causal relationship further exploration may uncover a common pathogenesis or causal relationship between congenital heart defects and small for gestational age. between congenital heart defects and small for gestational age.

• Key Words:Key Words: small for gestational age • cardiac disease • congenital anomalies small for gestational age • cardiac disease • congenital anomalies • Abbreviations:Abbreviations: CHD—congenital heart defect • NBDPS—National Birth Defects CHD—congenital heart defect • NBDPS—National Birth Defects

Prevention Study • OR—odds ratio • CI—confidence intervalPrevention Study • OR—odds ratio • CI—confidence interval

ABSTRACT:

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Obrigado.

Ddo Eduardo Ddo Jorge Ddo Guilherme