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 which also occur with venous anesthetics. Dose-dependent uterine hypotonia, related to the use of inhaled anesthetics, may also occur, with greater potential for bleeding. 139,140 In cases where general anesthesia has been utilized, a good plan for postoperative analgesia should be performed with the objective of reducing circulating catecholamines. In these cases, there are some options, including spinal options or epidural analgesia, abdominal wall block (transversus abdominis block and lumbar block), or use of systemic analgesia. 2.8.1. Fasting For elective cesarean delivery, it is recommended to fast from solids for 6 to 8 hours, depending on the fat content ingested and on eventual anatomical or physiological alterations that cause longer delay in gastric emptying. Clear liquids may be consumed up to 2 hours before surgery. Pharmacological prophylaxis for aspiration of gastric contents is recommended, with non-particulate antacids, H 2 receptor antagonists, and dopaminergic antagonists. During labor, women with low risks may consume moderate quantities of clear liquids, 141 such as water, tea, gelatin, and isotonic beverages. In the event of maternal hemodynamic instability, the team should maintain the mother’s fast until it is safe to reintroduce liquids. Delivery analgesia and proximity to the second phase of labor are points that clearly exemplify this practice, given the possibility of hemodynamic instability and bleeding, respectively. In the most severe cases or when faced with a greater probability of cesarean delivery, the patient should continue fasting. 2.8.2. Anticoagulation and Neuraxial Block It is estimated that spinal hematoma occurs in 1:200.000 to 1:250.000 142,143 deliveries. Although rare, it is a severe event; therefore, strategies should be taken to prevent it. Current recommendations consider that doses of anticoagulants and prior period of suspension are parameters for ensuring safe neuraxial anesthesia. This is the case for patients receiving a single anticoagulant, weighing more than 40 kg, with normal renal function, and without any other conditions that would contraindicate neuraxial block. 144 In summary, the recommendations are hereafter explained. 2.8.3. Unfractionated Heparin (Subcutaneous) 144 • Low dose (5,000 IU, 2 to 3 times daily): Wait 4 to 6 hours, with normal APTT or undetectable anti-Xa factor; • Intermediate dose (7,500 to 10,000 IU, 2 times daily; up to 20,000 IU daily): Wait 12 hours or more, with normal APTT or undetectable anti-Xa factor; • High dose (More than 10,000 IU per dose; more than 20,000 IU daily): Wait 24 hours or more, with normal APTT or undetectable anti-Xa factor. 2.8.4. Low Molecular Weight Heparin (Subcutaneous) 144 • Prophylactic dose (enoxaparin 40 mg or deltaparin 5,000 IU, once daily): Wait 12 hours or more; • Therapeutic dose (enoxaparin 1 mg/kg, twice daily or deltaparin 120 IU/kg, twice daily, or 200 IU/kg, single dose): Wait 24 hours. Any anticoagulation regimes different from those mentioned above should be evaluated and individualized by the team, taking not only the risk of spinal hematoma into consideration, but also the thromboembolic risks, fasting time, maternal-fetal conditions, and the evaluation of predictors of difficult intubation for general anesthesia. Time period for reinitiating anticoagulation should mandatorily include the participation of the anesthesiologist in cases where the approach is neuraxial. Reintroduction of anticoagulation should be individualized, because there are technical conditions for performing spinal or epidural anesthesia that interfere with the practice of reintroducing anticoagulation. 2.8.5. Hemodynamic Monitoring The use of invasive monitoring in high-risk patients should be necessary, with the objective of reducing time between recognition of hemodynamic deterioration and their respective treatments. Before performing neuraxial block and inducing general anesthesia in patients in WHO-risks II/IV, invasive blood pressure (IBP) monitoring may be fundamental to a better outcome. 140 Lack of validation of the use of non-invasive methods for monitoring cardiac output during delivery in women with heart disease makes it possible to individualize cases and indicate the utilization of invasive methods, such as central venous catheter (CVC) and pulmonary artery catheter (PAC). Nevertheless, the information obtained may be imprecise due to the complexity of the heart disease, in addition to the risk of inducing arrhythmias and other risks of complications. For this reason, there is low adherence to these forms of monitoring. In cases of cesarean delivery with general anesthesia, intermittent transthoracic echo and transesophageal echo have gained prominence as options for monitoring, and they may assist in the evaluation of ventricular function and filling. 140 2.8.6. Intrapartum Uterotonic Drugs The most used uterotonic drug during the peripartum period is oxytocin, which has an immediate effect on systemic vascular resistance, when administered in high doses or rapid transfusion. These regimes should be avoided for all pregnant women, especially in those with heart disease. The infusion of 2 IU of the drug for 10 minutes appears to be effective and not to have significant cardiovascular effects in pregnant women with heart disease. 135 In general, it is possible to maintain an infusion of 2 to 5 IU for an interval of 15 to 30 minutes with low cardiovascular effects. Ergot derivatives induce smooth muscle contraction with vasoconstriction and consequent hypertension. Misoprostol may cause hyperthermia and tremors, and it results in increased oxygen consumption, which is harmful at times, especially in women with severe heart disease. The rule that is most commonly used by anesthetists for oxytocin administration in patients without comorbidities is controversial, namely, the “rule of 3s,” consisting of 3 IU, every 3 minutes, up to 3 times, whereas an infusion of oxytocin at 2 IU for 10 minutes appears to be too slow. 139,142 874