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 a cardiologist should be monthly during the first half of gestation, biweekly following week 21, and weekly until delivery, and they must respect constant interaction with an obstetrician, which ensures the best practice during the various stages of gestation. These routines should, however, be adjusted according to case severity. Accordingly, pregnant women who permanently use anticoagulants are recommended to undergo weekly evaluation for clinical and laboratory control. Women with WHO class IV heart disease should be hospitalized during the third trimester of gestation for clinical stabilization and delivery planning. In addition, care should be recommended regarding diet, physical activity, sleep quality, and reduced stress and workload, depending on the patient’s profession and heart disease. Furthermore, review and adjustment of continuously used medications, as well as suspension or replacement of drugs that are harmful to the fetus, are practices that should take place before conception, i.e., during the pregnancy planning phase. 2.6.2. Physical Activity During pregnancies without complications, the benefits of physical activity are unquestionable. They include improved physical resistance and cardiorespiratory function; reduced stress, anxiety, and risk of comorbidities related to sedentarism; and weight gain. 110,111 Nevertheless, the American College of Obstetricians and Gynecologists contraindicates exercise during pregnancy in patients with heart disease with hemodynamic repercussions, patients classified as WHO risk III or IV, and in cases of preeclampsia, pregnancy-induced hypertension, severe anemia, and restrictive pulmonary disease. 112 2.6.3. Diet A balanced diet provides nutrients that are essential to fetal development, and it prevents complications related to weight loss in pregnant women. Obesity is associated with miscarriage, newborns with low birth weight, macrosomia, gestational diabetes, thromboembolism, and gestational hypertension, whereas malnutrition is linked to low birth weight and perinatal death. 113 Notwithstanding an adequate diet, nutritional goals also require oral supplementation, as shown in Table 17. Consumption of foods rich in folic acid and supplementation with doses of 1 to 5 mg daily before conception and during the first trimester prevent neural tube defects in 72% of cases. 114 Calcium supplementation (≥ 1 g daily) is associated with a significant decrease in the risk of preeclampsia (especially in women with low calcium consumption), as well as a decrease in prematurity and the occurrence of the composite outcome of “maternal death or severe morbidity.” 115 The WHO recommends 1.5 to 2 g of calcium daily for pregnant women with low calcium consumption in their diets. Fish consumption is the main source of non-occupational maternal exposure to methylmercury, which is found in all fish tissues and is absorbed in over 95%. Notwithstanding the risk of mercury poisoning, cohort studies have shown that greater maternal consumption of fish during the prenatal period was associated with better neurological development in newborns 116 and that moderate consumption (up to 3 meals weekly) before week 22 of gestation was linked to reduced repeat prematurity. However, a recent systematic review and meta-analysis of randomized trials did not show statistical significance for the effect of long chain polyunsaturated fatty acids (n-3 PUFA) on reducing prematurity or any other fetal defects, such as neurological, cognitive, or visual acuity development. 117,118 Regarding caffeine consumption, given the lack of adequate studies, it is recommended to limit consumption to less than 200 mg daily. 119 It is important to emphasize that coffee, which the main source of caffeine in many countries, contains 50% to 70% more caffeine than tea and other products. It is accepted that there is a theoretical relationship between caffeine and arrhythmogenesis, especially in women with heart disease. Saline consumption, with no significant restrictions on salt, is generally recommended, especially close to delivery. However, pregnant women with risk of HF should be instructed to consume of 3 to 4 g of sodium chloride daily, without adding salt to food after cooking and avoiding salty items. Diets with 2 g of sodium daily should be restricted to more severe cases (NYHA FC III/IV), in addition to instructions regarding water restriction in these cases. 2.6.4. Professional Activity Currently, most pregnant women work until one month before delivery, and only a small percentage suspend their professional activities earlier. The risk of developing complications is not related to work activity or to the psychosocial stress of work. 120 However, demands and working conditions should be evaluated individually in women with limiting heart disease or obstetric situations, such as preeclampsia and IUGR. Changes or adaptations in work activities, reduced stress at work, or increased rest and relaxation periods are often beneficial measures, especially if the condition worsens or limiting symptoms appear. Pregnant women with symptomatic heart disease or heart disease with hemodynamic repercussion should rest at home from the beginning of the third trimester of pregnancy, or be it, week 28 of gestation. During this phase, cardiac reserve limited by heart disease is insufficient to adapt to maximum hemodynamic changes, thus favoring the occurrence of HF, arrhythmias, IUGR, and prematurity. Under pregnancy protection laws, all women are entitled to at least 6 leaves to perform examinations and consultations, proven by a medical certificate, for the time necessary to perform the procedures, as specified by the certificate. 121 2.6.5. Key Points • Prenatal care for women with heart disease is multidisciplinary, with regular consultations with a cardiologist. Frequency should be in accordance with disease severity and/or possible complications; • Lifestyle orientations should be individualized in accordance with cardiac risk, as classified by the WHO; • Pregnant women should be made aware of diet, weight control, physical activity restrictions, and controlling 870