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 4.8.1. Recomendations ...........................................................................901 4.8.2. Key Points .....................................................................................902 4.9. Hypertension during gestational and Future Cardiovascular Risk ......902 4.9.1. Key points .....................................................................................902 5. Treatment and Prevention of Cardiac Complications ............................902 5.1. Cardiac Arrhythmias .........................................................................902 5.1.1. Epidemiology ................................................................................902 5.1.2. Clinical Presentation .....................................................................903 5.1.3. Maternal-fetal Risks ......................................................................903 5.1.4. Treatment ......................................................................................903 5.1.5. Key Points .....................................................................................904 5.2. Thromboembolism ............................................................................904 5.2.1. Epidemiology ................................................................................904 5.2.2. Risk Factors ...................................................................................905 5.2.3. Thrombophilia ..............................................................................905 5.2.4. Diagnosis ......................................................................................906 5.2.4.1. Deep Vein Thrombosis ...............................................................906 5.2.4.2. D-dimer ......................................................................................907 5.2.4.3. Venous Ultrasound .....................................................................907 5.2.4.4. Iliac Vein Magnetic Resonance ...................................................907 5.2.4.5. Pulmonary Thromboembolism ..................................................907 5.2.4.6. Differential Diagnosis ................................................................908 5.2.5. Treatment ......................................................................................909 5.2.5.1. General Approach ......................................................................909 5.2.5.2. Heparin Use ...............................................................................909 5.2.5.2.1. Recommended Doses ...............................................................909 5.2.5.2.2. Labor and Delivery ...................................................................909 5.2.5.2.3. The Postpartum Period ..............................................................910 5.2.5.2.4. Period of Anticoagulation ..........................................................910 5.2.5.3. Inferior Vena Cava Filters ...........................................................910 5.2.5.4. Thrombolysis ..............................................................................910 5.2.6. Prophylaxis ...................................................................................910 5.2.7. Key Points .....................................................................................910 5.3. Therapy and Prevention ....................................................................910 5.3.1. Heart Failure .................................................................................910 5.3.2 Key Points ......................................................................................913 5.4. Therapy and Prevention ....................................................................913 5.4.1 Infective endocarditis ....................................................................913 5.4.2. Rheumatic Disease .......................................................................914 5.4.3. Key Points .....................................................................................915 5.5. Cardiovascular Surgery During Pregnancy .........................................915 5.5.1. Key Points .....................................................................................916 5.6. Percutaneous Cardiac Intervention ...................................................916 5.6.1. General Principles ........................................................................916 5.6.2. Percutaneous Valve Interventions .................................................916 5.6.2.1. Balloon Catheter Valvuloplasty in Mitral Stenosis .....................916 5.6.2.2. Aortic Stenosis ...........................................................................916 5.6.2.3. Congenital Pulmonary Valve Stenosis ........................................916 5.6.2.4. Percutaneous Implantation of Prosthetic Valve .........................916 5.6.2.5. Valve-in-Valve Procedure for Bioprosthetic Valve Dysfunction ..917 5.6.2.6. Coronary Angioplasty .................................................................917 5.6.3. Key Points .....................................................................................917 5.7. Cardiovascular Emergencies .............................................................917 5.7.1. Acute Heart Failure .......................................................................917 5.7.2. Arrhythmia ....................................................................................919 5.7.3. Acute Myocardial Infarction .........................................................920 5.7.4. Acute Aortic Syndrome .................................................................920 5.7.5. Prosthetic Valve Thrombosis ........................................................920 5.7.6. Cardiorespiratory Arrest ...............................................................921 5.7.7. Key Points .....................................................................................921 6. Family Planning ...................................................................................921 6.1. Pregnancy Counseling and Maternal Risk Stratification ....................921 6.1.1. Key Points .....................................................................................923 6.2. Contraception in Patients with Cardiovascular Disease .....................923 6.2.1. Different Contraceptive Methods .................................................923 6.2.2. Medical Eligibility Criteria ............................................................924 6.2.3. Contraception in Adverse Conditions ...........................................925 6.2.3.1. Hypertension .............................................................................925 6.2.3.2. Diabetes Melittus .......................................................................925 6.2.3.3. Heart Valve Disease ...................................................................925 6.2.3.4. Previous Cardiovascular Events .................................................925 6.2.3.5. Obesity .......................................................................................926 6.2.3.6. Congenital Heart Disease ..........................................................926 6.2.3.7. Pulmonary Hypertension ...........................................................927 6.2.4. Contraception and Adolescence ...................................................928 6.2.4.1. Key Points ...................................................................................929 6.3. Ethical Considerations ......................................................................929 References ..............................................................................................930 1. Introduction The Women’s Cardiology Department (DCM, acronym in Portuguese) presents this document, composed in accordance with the norms established by the Brazilian Cardiology Society (SBC, acronym in Portuguese), with the aim of discussing the most prevalent cardiovascular diseases that affect women during the pregnancy and for which substantial evidence or randomized clinical trials do not exist. In 1999, with the support of the SBC, what was at that time the Department of Heart Disease and Pregnancy published the First Consensus on Heart Disease and Pregnancy, which was groundbreaking worldwide. It drew attention to the evolution of gestation in women with heart disease, at a time when the prevailing maximwas “Women with heart disease should not get pregnant becausematernal mortality is prohibitive.” After 10 years had passed, the experience of the department that has gone on to become the DCMmade it necessary to reconsider the restrictions on pregnancy in women with heart disease. For this reason, in 2009, SBCGuidelines for Pregnancy inWomenwithHeartDisease published the therapeutic strategies available at that time, in a specific and adequate management of clinical situations. Two decades after the first publication, the DCM validates its dedication by publishing the First Statement for Management of Pregnancy and Family Planning inWomen with Heart Disease, which is the result of the experience and work of specialists who write protocols that contribute to therapeutic decisions during the gestational period, as well as counseling for pregnancy and contraception for women with heart disease. A country’s maternal mortality rate is one of the most sensitive indicators of its population’s living conditions, and it especially reflects the quality of healthcare provided to women during prenatal care. Although the rates continue to be higher than what was estimated for this millennium, over the past three decades Brazil has registered an important reduction in the rate of maternal mortality due to complications during the pregnancy and postpartum time. Occurring in 4% of gestations, heart disease in itself continues to be the main non-obstetric cause of maternal mortality worldwide. Nonetheless, cardiology’s advancements in improving diagnostic methods and therapeutic alternatives have promoted significant change in prognosis of cardiovascular diseases and in the characteristics of heart diseases that occur during reproductive age. This has made better life expectancy and quality of life possible for womenwithheart disease, thus encouragingmaternity and promoting safer pregnancies with lower risks. 853