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 17 – Dietary recommendations during gestation Daily caloric ingestion – 340 to 450 additional kcal 2,200 to 2,900 kcal daily Additional dietary supplements Folic acid 1 to 5 mg daily, preconception Iron 27 mg > week 20 Calcium 250 to 1,000 mg daily Folic acid 0.4 mg; 0.6 mg during the second and third trimesters Iodine 150 mcg daily Vitamin D 200 to 600 IU Vitamins A, E, C, B and Zinc Variable quantities, second and third trimesters stress at work. Measures such as ceasing tobacco use, ceasing consumption of alcoholic beverages, and consuming caffeine moderately are essential during the prenatal period; • Nutritional orientations include controlled calorie intake and a balanced and nutrient-rich diet, avoiding consumption of industrialized products and undercooked and poorly washed foods; • Supplementation of essential vitamins and minerals should be a part of the prenatal routine for women with heart disease. 2.7. Management of Delivery and Postpartum Period The interdisciplinary view of delivery and the postpartum period in women with heart disease should consider clinical and obstetric evolution during pregnancy and the functional status preceding delivery. Programming delivery in women with heart disease requires prior hemodynamic stabilization; screening for possible intercurrences such as infection, anemia, arterial hypertension, and arrhythmias; and adjustment of cardiovascular therapy. From the obstetric point of view, the following are mandatory: discussion with a cardiologist and an anesthetist regarding timing and route of delivery, maternal-fetal monitoring during labor, and special attention to water balance. Accordingly, pregnant women with WHO class III/IV heart disease require assistance in tertiary hospitals with possibility of transfer to intensive care unit (ICU) during the postpartum period. The labor team for women with heart disease should be prepared to prevent and treat the main complications during the intrapartum and postpartum period. The most frequent cardiac complications that stand out are HF, acute pulmonary edema, arrhythmias, thromboembolism, and dissection of the aorta, while preeclampsia, hemorrhage, and infections are included among obstetric complications. 2.7.1. Practice during Delivery The general consensus is that route of delivery should be indicated by the obstetrician. However, in patients considered WHO risk I/II 122 with favorable clinical and hemodynamic conditions, spontaneous delivery at term of gestation is recommended. The consensus regarding type of delivery is based on the opinion of specialists, who believe that vaginal delivery is more advantageous, because it is associated with less blood loss, quicker recovery, and lower risk of thrombosis and infection. For this reason, it is the preferred type of delivery for women with heart disease whose clinical pictures are stable and uncomplicated. Regarding cesarean delivery, its indication for patients with heart disease varies between 21% and 55%, worldwide. 123 Available Brazilian data indicate that the rate of cesarean delivery in the general population is around 52%, and, according to the Brazilian Network for Surveillance of SevereMaternal Morbidity, the rate reached 76% among women with heart disease. 124 There is no plausible clinical justification or explanation for such a high rate. The rate of cesarean deliveries reflects the level of access to this intervention and its use; the task of defining the “desirable” rate in a given population, however, continues to pose a great challenge, as this number would adhere to medical indications, while avoiding “unnecessary” cesarean sections. The European Registry of Pregnancy and Cardiac Disease has shown that the frequency of scheduled vaginal delivery was 69%; among cesarean deliveries, 44% had cardiac indication. 52 In its conclusions, the registry showed that, in terms of maternal results, programmed cesarean section showed no benefits over vaginal birth, and it was associated with worse fetal evolution. 125 Maternal indications for cesarean delivery include very specific clinical situations, such as labor in patients under oral anticoagulation, diseases with increased aortic diameters (WHO risk III/IV), severe coarctation of the aorta, Takayasu arteritis, dissection of the aorta, PAH, acute HF, peripartum cardiomyopathy (PPCM) with severe HF, or other clinical situations in which maternal condition is critical. 52 Although it is controversial, there are recommendations for assisted delivery, either by vacuum extraction or forceps, in situations where there are real maternal-fetal benefits to shortening the active phase of the second stage of labor and the efforts of a prolonged expulsive period. The recumbent left lateral position is recommended to avoid compression of the aorta and the inferior vena cava by the gravid uterus, thus favoring better maternal venous return and facilitating effort during the expulsive period. 871