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 • Assistance during delivery and the postpartum period should take place at a high-risk maternity hospital; • Spontaneous vaginal delivery at term is recommended for most women with heart disease; • Maternal indications for cesarean delivery are the following: severe HF, aortic disease with significant dilatation, severe obstructions of the left heart, severe forms of PH, and ventricular dysfunction; • Cesarean delivery is indicated in patients who have gone into spontaneous labor while using oral anticoagulants (vitamin K antagonists) or who have suspended them for a period of less than 15 days; • Delivery in patients under oral anticoagulation should be scheduled from week 37 of gestation, with adjustments to anticoagulation, using heparin as an intra-delivery “bridge”; • Indications for preparing the cervix and inducing delivery are misoprostol (PGE1) and dinoprostone (PGE2); • Indications for inhibiting labor are, initially, contraindicated. In exceptional cases, atosiban is the indicated tocolytic agent; • It is mandatory for maternity hospitals to have a specific protocol for preventing and treating PPH; • Women with severe heart disease should remain in the ICU for a 24- to 48-hour period following delivery; • Contraception should be discussed before discharge from the maternity hospital; • There should be awareness that the postpartum period is as important and risky as pregnancy; • Breastfeeding should always be encouraged. 2.8. Obstetrical Anesthesia Obstetric anesthesia plays a fundamental role in reducing maternal-fetal morbi-mortality, 130 especially in pregnant women with heart disease. The complexity of heart disease requires the involvement of an anesthesiologist in multidisciplinary discussions during prenatal planning and the intrapartum and postpartum periods. Frequency of evaluations should be individualized according to the risk of the heart disease and the patient’s clinical situation. In general, evaluation should take place trimesterly in patients in WHO risk class II and in 2- to 4-week intervals in patients in WHO classes III and IV. 131 Formal planning should be discussed between weeks 32 and 34 of gestation by the whole team, 132 so that the patient will be admitted to delivery with consolidated advice. This assists in the flow of attendance, and it reduces team stress during emergencies and the chance of negative outcomes. The anesthesia team will have an opportunity to get to know the evolution of the gestation and its eventual complications, to adjust medications when selecting anesthesia and analgesia, and to make it possible for the patient to interact with greater clarity in understanding the conduct adopted during the intrapartum period. It is important not to neglect the risks of airway management and aspiration of gastric contents, adjustments of eventual medications, and administration of uterotonic drugs during the intrapartum period. The current indication for pregnant women with heart disease is vaginal delivery with neuraxial analgesia. This type of anesthesia is more efficacious for controlling pain during labor analgesia than other techniques, such as the use of systemic opioids or inhaled nitrous oxide. 133,134 When effective, spinal analgesia decreases circulating endogenous catecholamines, considering that partial sympathectomy induced by the effect of local anesthesia on the neuroaxis leads to decreased systemic vascular resistance and alterations in heart rate related to sympathetic block and cardiac reflexes. During cesarean delivery, neuraxial analgesia has become prominent for managing pregnant women with heart disease, due to the growing expertise of anesthesiologists in using spinal block techniques that allow for better measurement of anesthesia in a gradual manner, thus decreasing hemodynamic impact. 135 World literature demonstrates rates above 60% in elective cesarean deliveries performed with neuraxial block; this number is lower in emergency deliveries, in which case general anesthesia is chosen due to the complexity of factors to be evaluated for decision making. 136,137 Among the neuraxial techniques most used for pregnant women with heart disease, both of the following stand out: • Sequential epidural anesthesia; • Sequential combined spinal-epidural anesthesia, with low dose in the spinal component. These techniques are called “sequential,” because they allow the installation and cephalic progression of the sympathetic block to be performed gradually, preventing sudden installation with its cardiovascular repercussions. Small doses of local anesthesia associated with opioids are initially used, and additional supplements are performed through the epidural catheter until T6 sensory level is reached. 138 In cases with contraindications to the use of neuraxial block for cesarean section, general anesthesia should be performed. The main objective of managing and planning with this anesthesia is to minimize the deleterious hemodynamic effects of systemic anesthetics and the hypertensive response to laryngoscopy, which is the reflex to sudden, exacerbated sympathetic stimulation. In this scenario, preanesthesia evaluation contributes to the identification of dural anomalies and severe scoliosis, which are common in Marfan, Loeys‑Dietz, and Ehlers-Danlos syndromes. Fast-acting drugs with short half-lives are used in doses adapted to maternal hemodynamics, in order to attenuate sympathetic responses to laryngoscopy, avoid large blood pressure variations, and prevent increased heart rate. Opioids such as alfentanil or remifentanil, as well as the use of other classes of drugs, may be useful for managing this. In adequate doses, short-acting beta-blockers and local anesthetics, such as esmolol and lidocaine, respectively, may be presented as good options. Additionally, in some circumstances, the use of inducers, such as ketamine and etomidate, may be a better option than propofol, which has higher cardiodepressive potential when used in bolus or in unadjusted doses. When maintaining general anesthesia, it is necessary to pay attention to the potential negative inotropism of inhaled anesthetics and the decrease in systemic vascular resistance, 873