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 Figure 5 – Evaluation and practice for women with cardiovascular disease. ECG: electrocardiography; MFM: Maternal-fetal medicine; NYHA: New York HeartAssociation; WHO: World Health Organization. Preconceptional evaluation of maternal-fetal risk Anamnesis and physical examination Previous health and surgical record obtained and reviewed 12-lead ECG, echocardiogram and laboratory examinations NYHA functional class: cardiopulmonary test Assessment of the need for clinical or surgical treatment Genetic evaluation for patients with hereditary heart disease Discuss of discontinuation of teratogenic medications Provide adequate contraception until pregnancy is desired Prenatal evaluation after diagnosis of pregnancy Ensure that teratogenic medications are suspended If pregnancy was not planned, conduct complete risk assessment Discuss care plan, including adequate locations for delivery Gestation Clinically stable patients Joint prenatal practice (cardiology and obstetrics) Review care plan* Perform maternal and fetal echocardiogram (weeks 18 – 22 of gestation) Written delivery plan 28 to 32 weeks Anesthetic evaluation 32 to 34 weeks Preference for vaginal delivery with analgesia Cesarean delivery for obstetric indications Induced delivery at week 39-40, if indicated Gestation in patients with decompensation or WHO risk III/IV Discuss maternal-fetal morbimortality Review care plan* Possibility of early hospitalization Joint decisions (patient, family, medical team) Consider the possibility of Therapeutic abortion + contraception/ sterilization Follow up in a tertiary center Specialists in congenital heart disease and MFM Time of delivery indicated according to clinical situation Therapeutic delivery may be necessary obstructive cardiac lesions), hypoxemia (pulmonary hypertension [PH] or cyanotic heart disease), medication use (anicoagulants, beta-blockers, diuretics, or antiarrhythmics), heredity (genetic transmission), maternal infections (by Trypanosoma cruzi [ T. cruzi ]), and obstetric complications (Table 3). Fetal consequences include greater frequency of prematurity, intrauterine growth restriction (IUGR), miscarriages, cardiac and non-cardiac anomalies, and death. Maternal clinical complications associated with low cardiac output lead to a greater frequency of low birth weight –, with an average weight 300 g lower when compared to pregnancies that progressed without complications – and Apgar score less than 7. 21 Maternal hypoxemia in women with cyanotic heart disease increases fetal risk, even though there is a compensation mechanism to facilitate fetal oxygen delivery. Most newborns with maternal hypoxemia are small for gestational age and premature. A higher frequency of miscarriages has also been observed, proportional to the elevated hematocrit and maternal hemoglobin levels. Anticoagulant use during pregnancy causes expressed fetal loss. It is estimated that the incidence of spontaneous abortion during the first trimester is 28.6% versus 9.2% in pregnant women using warfarin versus heparin, respectively. 22 Sodium warfarin, when used during the first trimester, causes fetal warfarin syndrome in 5% to 10% of cases. This occurs between the sixth and ninth week of gestation 23 (Table 4). The incidence is variable, as, in many cases, the syndrome may not be identified from the clinical point of view; according to geneticists’ evaluation, however, the frequency is much higher. The risk of warfarin syndrome, when compared to the general population, is OR 3.86 (1.86-8.00- IC 95%). For these reasons, these children should receive detailed genetic evaluation during early childhood, and their scholar development should be followed. Newborns whose mothers have used amiodarone, sotalol, angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), or other medications during gestation should receive specific assessment of these drug-related abnormalities during the neonatal period. For patients who have been previously operated or who have undergone previous blood transfusion, it is essential to investigate hepatitis B and human immunodeficiency virus (HIV) infections, given that the use of drugs for these conditions may decrease vertical transmission. The frequency of fetal evaluation should be decided by the obstetrician according to case severity and the parameters to be evaluated. Severe patients, including those with New York Heart Association (NYHA) functional class (FC) III/IV, severe obstructive valve disease, cyanotic heart disease, complex congenital heart disease, and PH, may require fetal reassessment by ultrasound, as often as weekly. Fetal Doppler of uterine arteries during the second trimester aims to predict preeclampsia. This includes evaluation of the umbilical, middle cerebral, and uterine arteries, the cerebroplacental ratio, and the ductus venosus (Table 5). 859