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 2.8.7. Postpartum Follow up of pregnant women with intermediate to high risks should take place in the ICU for 24 to 48 hours. This observation period is important, keeping in mind that most deaths occur during the postpartum period. Inadequate monitoring and inappropriate blood volume management may lead to cardiovascular dysfunction. 140 2.8.8. Key Points • Anesthesia planning for delivery in women with heart disease should be discussed with a multidisciplinary team between weeks 32 and 34 of gestation; • The indication for pregnant women with heart disease is vaginal delivery with neuraxial analgesia; • In cases of cesarean delivery, neuraxial analgesia has gained prominence, when using spinal block techniques; • General anesthesia is indicated in cases of severe heart disease; • Anesthesia should be individualized in patients under anticoagulation; • Maternal monitoring is indispensable during delivery and during the immediate postpartum period. 3. Assessment and Management of Specific Heart Diseases 3.1. Valvular heart disease In Brazil, rheumatic disease is the most frequent cause of heart disease during pregnancy, with an estimated incidence of 50% in relation to other heart diseases. 145 Rheumatic fever is an episode from early childhood and/or adolescence, the onset of the clinical phase coincides with fertile age in women. Cardiovascular adaptation of heart valve diseases to the increase in cardiac output directly influences flow through the heart valves, with functional worsening of stenotic lesions. On the other hand, the drop in peripheral vascular resistance reduces the volume of regurgitation in insufficient valves. For these reasons, the evolution of stenotic lesions is generally worse, and it is correlated to the anatomical degree of the valve lesion, whereas, in patients with regurgitation, it is related to the condition of ventricular function. 146 These initial considerations assist in risk stratification of valve disease, both for adequate family planning counseling and care during gestation. Accordingly, the classification elaborated by WHO was adapted for pregnancy in women with heart valve disease. The WHO considers that patients classified as I and II present acceptable or low risks that do not impose serious restrictions to gestation, whereas risk III would make pregnancy inadvisable, and risk IV would contraindicate it. 147 In this position paper, women with heart valve disease are classified in the following manner: risk I, acceptable; risks II and III, intermediate; and risk IV, high risk to pregnancy (Table 18). It is worth adding that a high-risk situation in heart valve disease does not fulfill the criteria for indicating interruption of gestation (therapeutic abortion), given that these patients may be treated by either surgical or percutaneous intervention following the embryogenesis phase. During family planning, evaluation of heart valve disease should establish etiological, anatomical, and functional diagnosis and investigate the presence of unfavorable factors that are part of the natural history of heart valve disease and previous surgical correction. 148 These factors modify maternal prognosis, and they do not depend on structural cardiac injury per se; the following deserve special emphasis: • AF; • PH; • Ventricular dysfunction; • Associated aortic diseases; • History of HF, thromboembolism, or infectious endocarditis (IE). Cardiovascular evaluation before gestation should be assess the history, physical examination, and subsidiary tests that support in classification of risk of pregnancy, such as the following: • ECG: evaluates rhythm and heart chamber overload; • Echo: informs the type and severity of heart valve disease, degree of ventricular dilatation, presence of ventricular dysfunction, PH, and associated defects; • CMR: useful when heart valve disease is associated with aortic disease; • Ergometric test: valid for estimating functional capacity and arterial pressure in severe aortic stenosis in asymptomatic patients and when there is a dissociation between symptoms and the anatomical degree of mitral stenosis, indicated only during pregnancy planning; • Biomarkers: a controversial application in heart valve disease. • The recommendations put forth by Brazilian 149,150 and International 151 Guidelines for practice during family planning and pregnancy in cases of acquired, congenital, and prosthetic heart valve disease are shown in Tables 19 to 22. 3.1.1. General Considerations for Treatment Moderate restrictions on salt and physical activity, weight gain control (not exceeding 10 kg), and iron supplementation after week 20 of gestation are initial recommendations, taking care to rule out factors such as anemia, infection, hyperthyroidism, and cardiac arrhythmias. Prevention of rheumatic attacks should be maintained with 1,200,000 IU benzathine penicillin every 21 days or, for patients who are allergic to penicillin, 500 mg erythromycin stearate every 12 hours. Sulfadiazine is contraindicated. Prevention of IE for delivery is done with 2 g intravenous ampicillin associated with 1.5 mg/kg intramuscular gentamicin (with a maximum dose of 120 mg) 1 hour before delivery. The safety and efficacy of pharmacological treatment requires periodic dose adjustments. Before conception, drugs with recognized teratogenic effects should be substituted. In women with mitral stenosis, the use of propranolol or metoprolol in doses that do not exceed 80 and 75 mg, respectively, stand out for preventing 875