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 22 – Clinical practice in prostheses with dysfunction during gestation 149,150 Biological prosthesis Mechanical prosthesis Maternal risk Fetal risk Maternal risk Fetal risk Dysfunction with predominance of insufficiency, FC I/II and normal EF Pharmacological measures Low risk Dysfunction with mild to moderate “paravalvular” insufficiency without significant hemolysis or severe HF consider Pharmacological measures for HF and anemia If Severe insufficiency or significant hemolysis consider Intervention If symptomatic HF and/or hemolysis consider Percutaneous paravalvular leak closure by means of a plug device or CPB (high risk of relapse) High fetal risk if CPB Dysfunction with predominance of valve stenosis with calcification (mitral, aortic, or tricuspid) Risks of severe HF, shock, sudden death Always consider Emergency Percutaneous implant or new transapical valve-in-valve* BPV or CPB High fetal risk Fetal loss Prematurity Stillbirth Aortic or mitral MPV stenosis due to intravalvular endothelial growth – “Pannus”: Need for intervention is rare If indicated, consider CPB MPV stenosis (generally aortic) “mismatch” Need for intervention is rare If indicated, consider CPB High fetal risk if CPB BCV: balloon catheter valvuloplasty; BPV: bioprosthetic valve; CPB: cardiopulmonary bypass; HF: heart failure; MPV: mechanical prosthesis. postpartum period. In order to achieve this, frank dialogue with the couple is fundamental. Counseling also includes information regarding the importance of early diagnosis of pregnancy in order to reduce the occurrence of embryopathy. During this consultation, the patient receives an examination request for chorionic gonadotropin beta dosage, which should be taken at the first sign of delayed menstruation. Second Stage: First trimester. Anticoagulant substitution (avoiding teratogenesis). Substituting warfarin with heparin makes it possible to reconcile the benefits of preventing maternal thrombosis and the harmful effects of embryopathy. During this period, there are different options, which are shown in Figure 6. The first choice is to use LMWH, which requires weekly anti-Xa factor control. If this option is not available, intravenous UFH is indicated between the sixth and ninth week of gestation. In patients whose first medical consultation takes place after week 6 of gestational, warfarin should not be suspended. In these cases, the couple should be informed regarding the possibility of embryopathy and that the risks of substituting with heparin are no longer justified. Third Period: Second and third trimesters. Resuming oral anticoagulant, and anticoagulation control. Resuming warfarin use is justified by the assumption that shortening the use of heparin reduces adverse effects to the mother and leads to a lower risk of embryopathy. The proposal is to maintain warfarin doses in accordance with pre-gestation goals, with weekly or biweekly INR control. Reintroduction of warfarin should follow the dynamics of transition, or be it, simultaneous with subcutaneous LMWH or intravenous UFH until INR target value has been reached (Figure 6). Fourth Stage: Delivery planning. Consider hospitalization, redirect to parenteral anticoagulation, control anticoagulation and plan delivery. Hospitalization should be scheduled at week 36 of gestation for use of subcutaneous LMWH or intravenous UFH in therapeutic doses (Table 23). Route of delivery must be discussed with the obstetrician; vaginal delivery is considered safer due to the fact that there is less bleeding and to the advantages of analgesic techniques. In cases of premature delivery under anticoagulation, route of delivery is cesarean, and the use of prothrombin complex concentrate may be considered. Fifth Stage: The postpartum period. Reintroduction of oral anticoagulation and hospital discharge . Six hours after delivery, in the absence of maternal complications, intravenous UFH or subcutaneous LMWH may be reintroduced in therapeutic doses. Warfarin should be prescribed 48 hours after delivery, following the dynamic of transition, in conjunction with heparin, until INR value reaches 2.0, at which point the patient is discharged from the hospital. 3.1.6. Key Points • BPV do not require anticoagulation, except in patients with AF or previous thromboembolic accident; • Pregnancy does not influence structural degeneration of BPV; • Calcified, stenotic BPV are indicated for surgery regardless of gestational age; • MPV require anticoagulation with permanent adjustments seeking to meet conventional goals; 879