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 Table 2 – Clinical evaluation of normal pregnant women Symptoms Signs Diminished physical exercise capacity Hyperventilation Dyspnea Limb edema Fatigue Distention of neck veins Palpitation Pulmonary base crackles Dizziness Ictus cordis shifted to the left Orthopnea Palpable right ventricular impulse Swelling in the legs Pulmonary trunk impulse Adapted from Davies et al., 2007. 19 2.2. Maternal and Fetal Assessment 2.2.1. Maternal Clinical Evaluation 2.2.1.1. Anamnesis and Physical Examination Initial clinical investigation of pregnant women with heart disease requires questions about family history with respect to genetically transmittable heart diseases. Family history of the following stand out: premature sudden death, cardiomyopathy, congenital heart disease, Marfan syndrome, long QT syndrome, catecholaminergic ventricular tachycardia (VT), and Brugada syndrome. Physiological modifications during pregnancy influence the evaluation of cardiovascular status, and specialized knowledge is required to differentiate between healthy and unhealthy patients (Table 2). Complaints of shortness of breath (hyperventilation), easy fatigue, decreased functional exercise capacity, and basal crackles that disappear with coughing or deep breathing are symptoms that arise with uterine growth and its mechanical effect on diaphragm compression, especially toward the end of gestation. In addition to this, peripheral edema and varicose veins are frequent during later stages of gestation. Systemic arterial pulse is characterized by a rapid increase and a rapid collapse (“small battering ram”) starting with the first trimester. During chest palpation, cardiac ictus is noted to be shifted to the left, anterior, and rotated in the direction of a transverse position to the extent that the uterus enlarges. As a result, the apical impulse is shifted to the fourth intercostal space, laterally to the hemiclavicular line. The left ventricular impulse is relatively hyperdynamic, but it is not sustained; the right ventricle may be palpable, because, like the left ventricle, it supports a greater volume of blood, which is ejected against relatively low resistance. As pregnancy advances, enlargement of the breasts and the abdomen makes precise heart palpation difficult and at times impossible. 18 The changes in auscultation that accompany normal gestation begin at the end of the first trimester and generally subside within one week of delivery. Higher basal heart rate, higher precordial heart sounds, split first and second sounds in the third trimester, and systolic ejection murmurs (as high as grade 2/6) above the pulmonary and tricuspid areas are regularly detected during cardiac auscultation. The third sound may be present in the majority of pregnant women; the fourth heart sound is rarely heard, and it is, in general, pathological. Venous hum is almost universal in healthy women during normal gestation, and it is most audible over the right sternal border. The hum is attributable to an increase in venous return. Breast murmur (systolic or continuous) is audible over the anterior thorax at the end of gestation, and it is peculiar to pregnancy due to increased mammary blood flow. It is especially common after childbirth in breastfeeding women. 20 Diastolic murmurs are not common in normal gestations. When they occur, theymay reflect an increase in flow through the tricuspidormitral valve or physiological dilatationof thepulmonary artery. Alternatively, these murmurs may represent a pathological condition, requiring investigation with further examinations. 20 The hyperdynamic state of pregnancy may manifest with episodes of tachycardia, and baseline resting heart rate may oscillate around 90 bpm. Bradycardias are rare; when they occur, more detailed investigation is necessary. Sinus rhythm should be prevalent among pregnant women, but the presence of supraventricular or ventricular extrasystoles is very common. When measuring pregnant women’s blood pressure, the fourth Korotkoff sound is accepted as diagnosis of diastolic pressure. After this point, the sounds begin to change, and it is not easily reproducible at times. For this reason, it is fundamental to measure arterial pressure in the left lateral decubitus position using a standardized method. Arterial hypotension is a common finding during the first trimester, continuing until week 22 to 24, with arterial pressure returning to pre-pregnancy levels near the term of pregnancy. 2.2.1.2. Key Points • Detailedanamnesis considering current andpast symptoms; • Family history; • Detailed physical examination to differentiate between normal and heart disease. 2.2.2. Fetal and Obstetric Evaluation Obstetrical and perinatal complications are significantly greater in women with heart disease – the leading cause of maternal death during the pregnancy-postpartumcycle. The lack of healthcare protocols for pregnant women with heart disease and fragile multidisciplinary interaction contribute to these poor outcomes in pregnancy. Within this scenario, it is necessary to develop healthcare protocols aligned with prevention and treatment of complications during pregnancy, delivery, and the postpartum period, for pregnant women with cardiac disease. The Heart Disease and Pregnancy Service of the Obstetrics Department of Universidaddse Federal de São Paulo, in this document, have proposed a protocol presented in Figure 5. The care plan includes the following: preparation and readiness for delivery at a reference hospital; routine compliance on the part of anticoagulated patients and patients in premature labor; prevention of postpartum hemorrhage (PPH); and infective endocarditis (IE) prophylaxis. The principal maternal factors that affect fetal growth and development are low cardiac output (heart failure [HF] and 858