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 12 – Effects of antiplatelet use during pregnancy and lactation Drugs May be used during pregnancy Maternal-fetal observations and effects Lactation Aspirin Yes Hemorrhage Compatible Clopidogrel Yes (benefit greater than risk) Hemorrhage Probably compatible Prasugrel No Risk/benefit No evidence in humans Probably compatible Ticagrelor No Risk/benefit No evidence in humans Probably compatible Ticlopidine No Thrombocytopenia, neutropenia No Tirofiban Yes (benefit greater than risk) Hemorrhage Compatible Abciximab Yes (benefit greater than risk) Hemorrhage Compatible Epifibatide Yes (benefit greater than risk) Hemorrhage Compatible Table 13 – Effects of thrombolytic drug use during pregnancy and lactation Drugs May be used during pregnancy Maternal-fetal observations and effects Lactation Streptokinase Yes (benefit greater than risk) Risk of hemorrhage Compatible Tenecteplase Yes (benefit greater than risk) Risk of hemorrhage Compatible Alteplase Yes (benefit greater than risk) Risk of hemorrhage Compatible Urokinase Yes Proteinase inhibitors in the placenta inactivate urokinase Compatible placental bleeding. 100 Permanent use of UFH during pregnancy presents maternal risks such as bleeding (2%); osteoporosis (30%); spontaneous fractures (2%) and thrombocytopenia (5 to 15%) 101 However, it appears that these adverse effects are minor with LMWH. Control of UFH anticoagulation should be daily, according to activated partial thromboplastin time (TTPA), with a target of 1.5 to 2 times greater than baseline. Control of LMWH should be weekly according to therapeutic values between 0.6 and 1.2 IU/ml of anti Xa factor in patients with mechanical valve prostheses. Anticoagulation is still a therapeutic challenge. It requires knowledge of the risk of thrombosis for each clinical situation and the side effects of anticoagulants at various moments of the pregnancy-puerperal cycle. The fact is that when there is an indication of anticoagulation, pregnancy should not influence the accuracy and conventional goals. Fondaparinux has proven to be a safe alternative when heparins are not tolerated. 52,102 New oral anticoagulants (NOACS): There is no data available on exposed pregnant women. These drugs should not be used during pregnancy . 2.5.7. Hypolipidemic Agents (Table 16) The first choice is cholestyramine, considered the safest. 103 Statins do not appear to be teratogenic. Its correlation with congenital anomalies is not clear; however, due to the lack of studies, its use shouldbediscouragedduring pregnancy and should be discontinued at conception. 104-106 Gemfibrozil, fenofibrate and ezetimibe are considered to have teratogenic potential. 73 Table 14 – Effects of anticoagulant use during pregnancy and lactation. Drugs May be used during pregnancy Maternal-fetal observations and effects Lactation Warfarin No Warfarin syndrome during the first trimester, other congenital and neurological anomalies during the other trimesters Compatible Risk/benefit Heparin Yes Thrombocytopenia Compatible Enoxaparin Yes Compatible Fondaparinux Yes Various reviews suggest safety during pregnancy Compatible Apixaban No Low risk in animals, evidence does not support safety in humans No Dabigatran No Moderate risk in animals, evidence does not support safety in humans No Rivaroxiban No Low risk in animals, evidence does not support safety in humans No 868