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 5 – Fetal procedures First trimester ultrasound (establish gestational age) Second trimester ultrasound (analysis of fetal morphology) Doppler ultrasound of uterine arteries to predict preeclampsia Fetal Doppler ultrasound starting at week 26 (biweekly or weekly in severe cases) Fetal echocardiography (pregnant women with congenital heart disease): week 20 Third trimester ultrasound (fetal growth profile and fetal biophysical profile) biweekly starting at week 26 in severe cases measurement of ejection fraction or global longitudinal strain, and for determining clinical therapeutic practice or percutaneous or surgical intervention in cases with important stenoses in mitral and aortic valves. Pregnancy hypervolemia may cause slight dilatation of the cardiac chambers (up to 20% in the right chambers and 10% to 12% in the left chambers), mild mitral and tricuspid valve reflux, appearance of minimal physiological transvalvular gradients, and increase in prior valve gradients, as in obstructive lesions of the heart. 29 Transesophageal echo is relatively safe, and its conventional indications continue to apply; 29 the risk of vomiting and aspiration mainly increases after week 20 of gestation. This requires the presence of an anesthetist, who will assist in selecting the most appropriate sedation, in controlling ventilation, and in fetal monitoring during the procedure. During the final periods of gestation, small pericardial effusions may be perceived as a consequence of excessive hydrosaline retention, which disappears during the postpartum period. These effusions are not pathologically significant, and they are usually asymptomatic; they do, however, require reevaluation 6 weeks after delivery. Fetal echo may be used to detect congenital heart disease, and it may be performed transvaginal beginning with week 12 of gestation and transabdominally beginning with week 18. Although the main indication for fetal echo is the presence of an alteration in the routine ultrasound examination, some maternal indications are important, including pre-gestational diabetes mellitus or diabetes identified during the first trimester of gestation, phenylketonuria, systemic lupus erythematosus (SLE), and Sjögren syndrome with positive anti-SSA and/or anti-SSB antibodies. 30 In these cases, both the presence of fetal complete atrioventricular block during a previous gestation and neonatal SLE increase the possibility of fetal involvement during a subsequent gestation, or, at times, alteration in fetal cardiac rhythm determines better maternal evaluation for investigating autoantibodies. Other indications are cases of assisted reproduction, maternal congenital heart disease, infections such as rubella during the first trimester of gestation, or other viruses, when there is a suspicion of associated fetal myocarditis or pericarditis. Less precise indications refer to maternal medication use during the first trimester of gestation, such as anticonvulsive drugs, lithium, ACEI, retinoic acid, vitamin A, paroxetine, and non-hormonal anti-inflammatory drugs, due to risks of both fetal malformation and ductal constriction. 31 2.3.3. Ambulatory Blood Pressure Monitoring Ambulatory blood pressure monitoring (ABPM) is considered a safe examination. It is mainly indicated for identification of early arterial hypertension, which occurs during the first 20 weeks of gestation. It is estimated that approximately one third of pregnant women present white coat hypertension, almost half of whom may develop true arterial hypertension which requires treatment. 32 Bloodpressuremonitoringduringdifferent trimesters has shown conflicting results regarding pressure behavior, and it has little utility for identifying pregnant women who develop late hypertension or even for predicting adverse events in hypertensive patients. Reference values are the same as those used for the general population, and there are no studies which recommend routine use of ABPM for diagnosing or monitoring blood pressure as a substitute for conventional measurement with a tensiometer. 33 2.3.4. 24-hour Holter Monitoring Holter monitoring is mainly used for detecting or stratifying arrhythmias during gestation. It ismainly indicated for investigation of palpitation, unexplained syncope, or pre‑syncope, or, less frequently, investigation of neurological events in whose etiology atrial fibrillation (AF) may be implicated. 34 Holter monitoring is an examination method for identifying and characterizing arrhythmias as simple or complex and symptomatic or asymptomatic, which is fundamental information for practice during pregnancy. It is particularly indicated for investigating paroxysmal AF, other tachyarrhythmias, symptomatic sinus bradyarrhythmias, and different degrees of atrioventricular block. Holter is also of great value for evaluation of patients with a pacemaker or an implantable cardioverter-defibrillator (ICD) when symptoms such as palpitation, syncope, or pre-syncope occur, or when there is suspicion of device command failure. 2.3.5. Exercise Test The main indication for ergometric test during gestation would be investigation of ischemic coronary disease. Performance of a submaximal test, reaching 80% of maximum expected heart rate, seems to be a safe method during gestation, but the lack of studies does not make it possible to validate its indication for defining ischemic disease. For this reason, there are no recommendations for performing exercise tes during gestation to investigate ischemic coronary disease. In the same manner, the use of stress with dobutamine should be contraindicated during pregnancy. 861