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 Basic monitoring during delivery includes non-invasive blood pressure measurement, pulse oximetry, and continuous electrocardiography, in addition to fetal monitoring (auscultation of fetal heartbeats by Doppler sonar every 15 minutes during the first stage and every 5 minutes during the second stage, or continuous cardiotocography). The need for additional monitoring should be determined on a case-by-base basis. Excessive fluid infusion should be restricted in order to avoid excessive hydration and pulmonary congestion. The benefits of analgesia for preventing arterial hypertension and tachycardia and reducing cardiac stress are unquestionable. A safe and effective way to reduce anxiety during this moment is with humanized delivery care, i.e., authorizing the presence of a companion chosen by the parturient and allowing her to ambulate freely and to choose the most comfortable position during labor. Delivery in patients under oral anticoagulation should be scheduled from week 37 of gestation. Patients with high thrombotic risks need to use UFH around 36 hours before delivery, and the infusion should be interrupted 4 to 6 hours before birth and reintroduced 6 afterward, with APTT control. In cases with low thrombotic risks, LMWH is used until the day before delivery, and the night dose should be omitted if induced delivery or cesarean section is scheduled for the following morning. Regional block is possible in cases where 24 hours have elapsed since the last dose. Induction of delivery should be considered at week 40 of gestation in all women with heart disease, because the benefits of this practice outweigh the eventual risks. 126 Mode of induction mainly depends on evaluation of the uterine cervix and fetal vitality. Both misoprostol (PGE1) 127 and dinoprostone (PGE2) are recommended for preparing the uterine cervix. The Krause method (balloon), amniotomy, and oxytocin infusion are also considered safe. 128 In contrast, inhibition of premature labor should be considered with great caution and even contraindicated in women with heart disease. The degree of prematurity should be weighed with the risks of tocolysis and corticosteroid therapy, given that both may lead to complications, such as severe HF and cardiac arrhythmias. When indicated, tocolysis should be maintained for 48 hours, which is sufficient time for the action of the corticoid, with the aim of reducing the occurrence of respiratory distress syndrome, peri- and intraventricular hemorrhage, and necrotizing enterocolitis in the newborn. The drugs used for inhibition, such as nifedipine, may induce hypotension, and they are synergistic when used in conjunction with magnesium sulfate. Terbutaline has intense beta-mimetic effect, and it may lead to maternal HF. In this situation, atosiban, a competitive oxytocin receptor antagonist, has been the safest tocolytic agent, when used in intravenous infusion of about 400 ml of solution (0.9% saline solution, Ringer lactate solution, or 5% glucose solution) for 48 hours (approximately 200 ml/24 h). 2.7.2. Practice during the Postpartum Period Maternal care should be intensified during the postpartum period, and preventive measures for the main complications (HF, PPH, and thromboembolism) should be part of high-risk maternity hospitals’ protocols. Maternal blood volume undergoes significant variations during the immediate postpartum period, due either to increased venous return following placental clearance or to estimated blood loss, which is as high as 500 ml in vaginal delivery and 1000 ml in cesarean delivery (as defined by the WHO and the Pan American Health Organization). The impact of these maternal hemodynamic oscillations explains the occurrence of severe complications, such as HF, acute pulmonary edema, and cardiogenic shock. Negligence regarding hemodynamic oscillations during the postpartum period is, in part, responsible for maternal mortality; for this reason, it is mandatory for patients with severe heart disease, even when they are stable, to remain in the ICU 24 to 48 hours after delivery for effective hemodynamic monitoring. PPH is equally important; it occurs in approximately 10% of vaginal deliveries, and it is considered severe in approximately 3%. In women with heart disease, the incidence of PPH reaches 21%, and it is related to cesarean delivery, assisted delivery with forceps, general anesthesia, and use of heparin before delivery. 129 The increase in maternal morbidity due to transfusion, infection, and thromboembolism is, in fact, the leading cause of death in women with heart disease. For this reason, all maternity hospitals should have specific conduct protocols for preventing and treating PPH, including the use of uterotonic drugs, which are recommended during the third phase in both types of delivery, in order to prevent PPH. Oxytocin is the recommended drug, given its benefit in preventing hemorrhage; it should be administered intramuscularly, at a dose of 10 IU for vaginal or cesarean delivery. Intravenous administration is also an option, especially during cesarean delivery, in doses of ≤ 5 IU and slow infusion (> 30 seconds) every 3 minutes, up to 3 infusions. Intravenous prophylaxis should be associated with continuous‑infusion maintenance dose. Misoprostol (600 to 1,000 µg) may be used safely for both prophylaxis and treatment of PPH, but oxytocin administered via bolus should be avoided due to the risk of hypotension. Ergometrine and methylergometrine should be avoided due to their association with coronary vasoconstriction and SAH. It is accepted that there is a high risk of thrombosis during the postpartumperiod; therefore, measures such as early ambulation, which more feasible with vaginal delivery, and heparin anticoagulation should be recommendedwithin the first 48 hours after delivery. Nevertheless, thromboembolismprevention should be individualized, and it will be discussed subsequently. When there is an indication for definitive sterilization, bilateral salpingectomy may be performed via infraumbilical incision during the first 48 to 72 hours following vaginal birth. Generally speaking, discussions about contraception should take place before discharge from the maternity hospital. 2.7.3. Key Points • Multidisciplinary assistance during delivery and the postpartum period should take the following into consideration: risk stratification of heart disease and elaboration of protocols for prevention and treatment of HF, PPH, infection, and thromboembolism; 872