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 20 – Recommendations for clinical practice in congenital or acquired heart valve disease due to infectious endocarditis 149,150 Heart valve disease Preconception counseling intervention Gestation Maternal risk Fetal risk Intervention Structural TI Ebstein anomaly Severe symptomatic TI Significant RV dilatation/dysfunction consider conservative surgery (plasty) or BPV implant Moderate/severe lesions Right HF Supraventricular arrhythmias Low risk Diuretic Digoxin If Severe right HF consider conservative surgery (plasty) BPV implant Severe pulmonary stenosis Effort dyspnea/fatigue Hypoxemia Atypical angina Right HF (secondary TI) BCV or CPB Syncope Right HF Atrial arrhythmia Hypoxemia Low risk If Hypoxia/severe HF Consider BCV BCV: balloon catheter valvuloplasty; BPV bioprosthetic valve; CPB: cardiopulmonary bypass; HF: heart failure; IE: infectious endocarditis; TI: tricuspid insufficiency. Table 21 – Valve prosthesis with normal function and risks to gestation Biological prosthesis with normal EF Mechanical prosthesis with normal EF Maternal risk Fetal risk Maternal risk Fetal results Patient does not require anticoagulation Low risk Low risk Patient requires anticoagulation Intermediate risk High risk Warfarin embryopathy Miscarriage Prematurity Stillbirth Perinatal Hemorrhage Anticoagulation favors Hemorrhage Systemic embolism If Prosthesis thrombosis consider Emergency treatment Thrombolysis or CPB CPB: cardiopulmonary bypass; EF: ejection fraction. LMWH is due to fluctuations in anti-Xa factor that occur over 24 hours, 158 even with the therapeutic value (0.6 to 1.2 IU/ml) during peak action 4 hours after application, 159 resulting in a suboptimal anticoagulation level. Regarding UFH, prolonged use is associated with thrombocytopenia and osteoporosis; 154,155 its efficacy is inferior to that of LMWH, and its subcutaneous use for anticoagulation practice has been prohibited. Owing to the high incidence of thromboembolism with heparins (UFH and LMWH), there is a tendency to prioritize the use of warfarin throughout the entire pregnancy, as it is believed to be safer for maternal-fetal outcomes. 154-157 3.1.5. Fetal Risks In all anticoagulation regimes, the obstetric risks of hemorrhage, placental abruption, prematurity and fetal death are very high. 155-157 The warfarin cross the placental barrier, it is teratogenic when used in the first trimester of pregnancy and causes embryopathy in 0,6 a 10% of cases, 160 even at doses less than 5 mg. 161-163 The anticoagulation regime for women with MPV who wish to become pregnant or who are in the course of gestation during the first consultation continues to be controversial. Factors that should be taken into consideration when deciding on the best anticoagulation treatment include the patients’ preferences, the attending physician’s expertise, and availability of adequate coagulation control. Recommendations for preventing thromboembolism in mechanical prostheses intend to meet to the ideal requirements of a position based on documentation in the literature and on the authors’ experience, in a manner that is effective for the reality which different healthcare services face. It is understood that permanent anticoagulation should be divided into five different stages, including preconception, each trimester, and the postpartum period, as explained hereafter. First Stage: Preconception. Patient/couple awareness. Advice regarding early diagnosis of pregnancy . Patients in pregnancy planning should receive clarification regarding the need to maintain anticoagulation, the regimes available, and their risks during all phases of gestation, childbirth, and the 878