ABC | Volume 112, Nº5, May 2019

Guideline Brazilian Fetal Cardiology Guidelines – 2019 Arq Bras Cardiol. 2019; 112(5):600-648 7.1. Fetal Cardiac Rhythm and Fetal Cardiac Arrhythmias During fetal echocardiography, heart rate and rhythm are assessed with simultaneous examination of the atrial and ventricular systoles employing M-mode, two-dimensional echocardiography and pulsed-wave Doppler with or without color flow mapping. Cardiac rhythm is considered normal when the ratio of atrial and ventricular contractions is 1:1, with heart rate ranging from 120 to 180 bpm. 48,129-131 M-mode allows to evaluate the movement of the posterior atrial wall (atrial systole or A wave), concomitantly with aortic valve opening (ventricular systole or V wave). This trace is obtained from the longitudinal two-dimensional image of the heart, with the cursor positioned crossing the right ventricle, the aortic valve and the LA. Sinus rhythm is identified when, for each movement of the left atrial wall (A wave), there is a corresponding opening movement of the aortic valve (V wave), i.e., 1:1 atrioventricular (A:V) conduction. Positioning the cursor simultaneously across the atrial (A wave) and ventricular (V wave) wall may also be employed. Color M-mode facilitates the identification of aortic flow during ventricular systole and may also be used to identify left atrial activity from mitral flow. The atrioventricular sequence may also be assessed positioning the pulsed Doppler sample volume between the left ventricular inflow and outflow tracts, thus recording the mitral (A wave) and aortic (V wave) flows. Additionally, the sample volume may be placed between the SVC and the aorta in the 3 vessels view. The SVC “A” wave reversal flow represents the atrial contraction (A wave), and the aortic flow represents ventricular systole (V wave). The same concept can be used with Figure 6.3 – Recommendations for fetal ductal constriction prevention during the third gestational trimester. Non-steroidal anti- inflammatory drugs Foods with more than 30 g of polyphenol/100 g Class of recommendation I; level of evidence A DO NOT CONSUME - Green tea - Black tea - Boldo tea - Coffee - Yerba mate - Dark chocolate - Cocoa powder Consume as indicated in Annex 4: - Raw beets - Lettuce - Purple/red plums, unpeeled - Blackberries/mulberries - Red apples/unpeeled - Papaya - Strawberries - Oranges/orange juice - Purple/red/pink grapes/grape juice - Olive oil - Green herbs Class of recommendation IIa; level of evidence C Substances that use interruption may be considered Other medications with possible anti-inflammatory efects Class of recommendation IIa; level of evidence C - Corticoids - Hyoscine - Scopolamine - Aspirin - Fluoxetine - Isoxsuprine - Naphazoline - Sertraline - Dipyrone - Paroxitine - Paracetamol RECOMMENDATIONS FOR FETAL DUCTAL CONSTRICTION PREVENTION DURING THE THIRD GESTATIONAL TRIMESTER Restricted substances FOR DUCT DEPENDENT MALFORMATIONS: RIGOROUS PREVENTION RECOMMEND RESTRICTION OF ALL SUBSTANCES THAT MAY POTENTIALLY CAUSE DUCTAL CONSTRICTION (CLASS OF RECOMMENDATION I, LEVEL OF EVIDENCE C) 626