ABC | Volume 114, Nº5, May 2020

Statement Brazilian Cardiology Society Statement for Management of Pregnancy and Family Planning in Women with Heart Disease – 2020 Arq Bras Cardiol. 2020; 114(5):849-942 Content 1. Introduction .........................................................................................853 2. General Considerations ........................................................................854 2.1. Physiological Adaptation to Pregnancy, Labor and Delivery ..............854 2.1.1. Hemodynamic Modifications .......................................................854 2.1.2 Modifications in Blood Coagulation ..............................................856 2.1.3. Respiratory Changes .....................................................................856 2.1.4. Structural Vascular Changes .........................................................857 2.1.5. Key Points .....................................................................................857 2.2. Maternal and Fetal Assessment ........................................................858 2.2.1. Maternal Clinical Evaluation .........................................................858 2.2.1.1. Anamnesis and Physical Examination ........................................858 2.2.1.2. Key Points ...................................................................................858 2.2.2. Fetal and Obstetric Evaluation ......................................................858 2.2.2.1. Key Points ...................................................................................860 2.3. Complementary Cardiovascular Assessment ....................................860 2.3.1. Electrocardiography ......................................................................860 2.3.2. Echocardiography .........................................................................860 2.3.3. Ambulatory Blood Pressure Monitoring .......................................861 2.3.4. 24-hour Holter Monitoring ...........................................................861 2.3.5. Exercise Test ..................................................................................861 2.3.6. Key Points .....................................................................................862 2.4. Ionizing Imaging Cardiovascular Assessment ...................................862 2.4.1. Administration of Contrast Agents ...............................................863 2.4.2. Nuclear Magnetic Resonance .......................................................863 2.4.3. Key Points .....................................................................................864 2.5. Cardiovascular Drugs during Pregnancy and Breastfeeding ..............864 2.5.1. Antihypertensive Drugs ................................................................864 2.5.2. Antiarrhythmic Drugs ...................................................................866 2.5.3. Drugs in Heart Failure ..................................................................866 2.5.4. Antiplatelet ...................................................................................866 2.5.5. Thrombolytics ...............................................................................867 2.5.6. Anticoagulants ..............................................................................867 2.5.7. Hypolipidemic Agents ..................................................................868 2.5.8. Key Points .....................................................................................869 2.6. Practice Recommendations during Pregnancy ..................................869 2.6.1. Lifestyle .........................................................................................869 2.6.2. Physical Activity ............................................................................870 2.6.3. Diet ...............................................................................................870 2.6.4. Professional Activity ......................................................................870 2.6.5. Key Points .....................................................................................870 2.7. Management of Delivery and Postpartum Period ..............................871 2.7.1. Practice during Delivery ...............................................................871 2.7.2. Practice during the Postpartum Period .........................................872 2.7.3. Key Points .....................................................................................872 2.8. Obstetrical Anesthesia ......................................................................873 2.8.1. Fasting ...........................................................................................874 2.8.2. Anticoagulation and Neuraxial Block ............................................874 2.8.3. Unfractionated Heparin (Subcutaneous) ......................................874 2.8.4. Low Molecular Weight Heparin (Subcutaneous) ..........................874 2.8.5. Hemodynamic Monitoring ............................................................874 2.8.6. Intrapartum Uterotonic Drugs ......................................................874 2.8.7. Postpartum ...................................................................................875 2.8.8. Key Points .....................................................................................875 3. Assessment and Management of Specific Heart Diseases ...................875 3.1. Valvular heart disease ......................................................................875 3.1.1. General Considerations for Treatment .........................................875 3.1.2. Key Points .....................................................................................876 3.1.3. Valve Prosthesis ............................................................................876 3.1.4. Maternal Risk ................................................................................877 3.1.5. Fetal Risks .....................................................................................878 3.1.6. Key Points .....................................................................................879 3.2. Congenital Heart Disease .................................................................880 3.2.1. Pregnancy Management ...............................................................881 3.2.2. Key Points .....................................................................................883 3.3. Cardiomyopathies .............................................................................883 3.3.1. Dilated Cardiomyopathy ..............................................................883 3.3.2. Hypertrophic Cardiomyopathy .....................................................883 3.3.3. Arrhythmogenic Right Ventricular Dysplasia ................................884 3.3.4. Non-compaction Cardiomyopathy ...............................................884 3.3.5. Restrictive Cardiomyopathy ..........................................................884 3.3.6. Key Points .....................................................................................884 3.3.7. Peripartum Cardiomyopathy ........................................................884 3.3.7.1. Key Points ...................................................................................886 3.4. Ischemic Heart Disease ....................................................................887 3.4.1. Key Points .....................................................................................888 3.5. Dyslipidemia .....................................................................................888 3.5.1. Lipid Changes ...............................................................................888 3.5.2. Key Points .....................................................................................888 3.6. Other Diseases .................................................................................889 3.6.1. Takayasu Arteritis ..........................................................................889 3.6.1.1. Prevalence ..................................................................................889 3.6.1.2. Prognosis ....................................................................................889 3.6.1.3. Treatment ...................................................................................889 3.6.1.4. Key Points ...................................................................................889 3.6.2. Kawasaki Disease ..........................................................................889 3.6.2.1. Preconception Evaluation ..........................................................890 3.6.2.2. Key Points ...................................................................................890 3.6.3. Pulmonary Hypertension ..............................................................890 3.6.3.1. Key Points ...................................................................................891 3.6.4. Aortic Diseases .............................................................................891 3.6.4.1. Aortic Dissection and Rupture ...................................................892 3.6.4.2. Key Points ...................................................................................893 3.6.5. Chagas Disease .............................................................................893 3.6.5.1. Prevalence ..................................................................................893 3.6.5.2. Diagnosis and Management of T. cruzi Infection during pregnancy ....................................................................................893 3.6.5.3. Chronic Chagas Heart Disease ...................................................893 3.6.5.4. Vertical Transmission of Trypanosoma cruzi ..............................893 3.6.5.5. Reactivation of Chagas Disease ..................................................893 3.6.5.6. Breastfeeding .............................................................................894 3.6.5.7. Key Points ...................................................................................894 4. Hypertensive syndrome of pregnancy ..................................................895 4.1. Introduction ......................................................................................895 4.2. Recommendations for Measuring Arterial Pressure ..........................895 4.3. Classification ....................................................................................895 4.3.1. Chronic Hypertension, Preexisting (Essential or Secondary) ........895 4.3.2. Preeclampsia/Eclampsia ...............................................................895 4.3.2.1 HELLP Syndrome (Hemolysis, Elevated Liver Enzymes, and Low Platelet Count) ........................................................................................866 4.3.3. Chronic (Preexisting) Hypertension with Superimposed Preeclampsia ..................................................................896 4.3.4. Gestational Hypertension .............................................................896 4.3.4.1. Key Points ...................................................................................896 4.4. Treatment of Gestational Hypertension Syndrome (GHS) ..................897 4.4.1. Non-pharmacological Treatment ..................................................897 4.4.2. When to Treat – Target Arterial Pressure ......................................897 4.4.3. Oral Anti-hypertensive Drugs- Chronic Hypertension / Gestational Hypertension .......................................................................897 4.4.4 Anti-hypertensive Drugs for Severe Hypertension in Preeclampsia ......................................................................................898 4.5. Practice for Hypertensive Emergency in Preeclampsia (PA ≥ 160/110 mmHg) ............................................................................899 4.6. Prevention of Seizure in Preeclampsia-Eclampsia and Magnesium SulfateTherapy .........................................................................................900 4.6.1. Key Points .....................................................................................900 4.7. Prognosis and Prevention of Preeclampsia .......................................900 4.7.1. Key Points .....................................................................................901 4.8. Hypertension during Postpartum Period ...........................................901 852