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 3 – Predictors of neonatal events in pregnant women with heart disease. NYHA functional class III/IV Cyanosis Obstructive cardiac lesions Tobacco use Hypoxemia – oxygen saturation < 90% Need for permanent anticoagulation Abnormal uteroplacental blood flow – by Doppler scan Maternal infections ( by Trypanosoma cruzi , human immunodeficiency virus, or toxoplasmosis) Parents with congenital heart disease Medication use during pregnancy (ACEI, ARB, or beta-blockers) Obstetric complications – arterial hypertension, gestational diabetes ACEI: angiotensin converting enzyme inhibitors; ARB: angiotensin receptor blockers; NYHA: New York Heart Association. Table 4 – Fetal warfarin syndrome 23 Affected bones/cartilage (chondrodysplasia punctata) Hypoplasia of extremities (dwarfism and bone dystrophy) Optical defects: blindness, optic atrophy, microphthalmia Central nervous system: mental retardation, deafness Intrauterine growth restriction Scoliosis Congenital heart disease Death During fetal ultrasound evaluation, it is important to estimate gestational age, vitality, morphology, amniotic fluid volume, and fetal growth profile. In the event that an abnormality is detected, evaluation should be complemented by more specific examinations, such as fetal Doppler, fetal biophysical profile, and fetal echocardiography (echo). 24 The latter should be performed routinely, always after week 20, when there are maternal or fetal indications. Maternal indications are diabetes mellitus, a parent with congenital heart disease, maternal infection related to teratogenicity (rubella, cytomegalovirus, HIV), Chagas disease and toxoplasmosis (related to cardiomyopathy or fetal myocarditis), maternal age > 35 years, phenylketonuria, connective tissue disease (most associated with fetal atrioventricular block), and exposure to teratogenic agents. Fetal indications for complementary evaluation include findings of other abnormalities on morphological study, chromosomal disease, and fetal arrhythmias. 2.2.2.1. Key Points • Perinatal morbimortality is higher in newborns whose mothers have heart disease, in comparison with the general population; • Multiple maternal factors are associated with the higher incidence of fetal loss, malformations, IUGR, and prematurity; • Obstetricians and neonatologists must be attentive to neonatal complications related to maternal heart disease. 2.3. Complementary Cardiovascular Assessment 2.3.1. Electrocardiography Electrocardiography (ECG) is the first method used for diagnostic confirmation in clinical cardiology practice. The criteria for performing ECG in pregnant women are the same as those defined for the general population; it should not, however, be part of routine prenatal screening for heart disease. ECG should serve as evaluation and follow up for pregnant women with previous heart disease and for investigation of arrhythmias. 25 Physiological changes during gestation should be considered in the interpretation of the ECG record. The following stand out: electrical axis slightly shifted to the left; T-wave inversion in the DIII, V1, V2, and, at times, V3 leads; prominent q wave in the inferior and anterolateral walls; increased P-wave duration and prolonged QT interval. 26 Measurements of P-wave duration and QT interval during the 3 trimesters of pregnancy have shown prolongation of the P wave during the second trimester, followed by a plateau, as well as prolongation of the maximum QT interval at the term of the gestation. 27 ST-segment depression may be observed in 25% to 47% of pregnant women during cesarean delivery or 30 minutes afterwards, regardless of the type of anesthesia utilized. No alterations suggestive of ischemia have been observed during vaginal birth in healthy pregnant women. 26,27 2.3.2. Echocardiography Echo is the examination of choice for diagnostic investigation of most heart diseases, owing to its easy use, the absence of maternal-fetal risks, and lower costs when compared to other methods. Indications are the same as those for the general population, 28 for initial diagnosis when heart disease is suspected, for risk stratification by 860