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 Figure 6 – Recommendations for anticoagulation in patients with mechanical valve prostheses during gestation. CGH: chorionic gonadotropin hormone; INR: international normalized ratios; LMWH SC: subcutaneous low molecular weight heparin; UFH IV: intravenous unfractionated heparin; VKA: vitamin K antagonists. LMWH SC every 12 hours = 1 mg/kg/dose; UFH IV = 18 IU/kg/h. Dose targets and controls: LMWH SC = anti-Xa factor between 0.6 and 1.2 U/ml, weekly; UFH IV APTT: 2 times normal value, daily; VKA = INR 2.5 to 3.5, biweekly. Women with mechanical valve prosthesis Before pregnancy: patient/couple awareness Maintain VKA until beta-CGH is positive Pregnancy confirmed Replace VKA with LMWH SC or or Hospitalization Replace VKA with UFH IV Maintain VKA in patient who start evaluation during the first trimester Replace LMWH SC with VKA Hospitalization Replace UFH IV with VKA Maintain VKA Week 36 of gestation Hospitalization – change to UFH IV or LMWH SC 24 h before delivery → maintain UFH IV Withdraw UFH IV at 4-6 h before delivery and reintroduce it 4-6 h afterwards, if no bleeding Reintroduce VKA 48h after delivery with UFH IV Hospital discharge with adequate INR Stage First Sateg Second First trimester Stage Third Second and third trimesters Stage Fourth Delivery planning Stage Fifth Delivery/postpartum • MPV thrombosis requires immediate intervention with a thrombolytic agent or emergency surgery with CPB, regardless of gestational age; • Choice of BPV as a preferable substitute for a woman who plans pregnancy, considering that it does not requires anticoagulation and the future perspective of percutaneous valve-in-valve replacement; • Percutaneous valve-in-valve procedures require a specialized center with a heart team and resources for valve and arterial tomography, 3-dimensional esophageal echo, and an interventional hemodynamic and surgery team on standby; • Patients with MPV should be referred to tertiary services and reference centers in valve disease for follow up during pregnancy; • Permanent anticoagulation in patients with mechanical prostheses or mitral valve disease with AF should follow the algorithm which divides the pregnancy and postpartum into five stages; • Notwithstanding adequate and effective anticoagulation control at all times, there are still uncertainties regarding the success of pregnancy in women with MPV; • A multidisciplinary team should discuss choice of valve prosthesis and prospects for future pregnancy together with the patient. 3.2. Congenital Heart Disease Advances in clinical and surgical cardiology treatments have demonstrated that a progressively higher number of women with congenital heart disease are able to reach childbearing age 164 then they wish to become pregnant with a great likelihood of successful maternal-fetal outcome. 165 In Brazil, a growing tendency has been observed in the percent of pregnant women with congenital heart disease, similar to European countries. They are considered the second‑leading indirect cause of maternal mortality, accounting for up to 20% of deaths due to heart disease. 166 Preconception assessment risk should be based on following variables: (1) time of heart disease diagnosis; (2) prior palliative or corrective surgery; (3) NYHA functional class; (4) laboratorial tests such as: hematocrit, hemoglobin, oxygen saturation, natriuretic peptide values; and liver and thyroid function tests. Structural and functional diagnosis is defined by electrocardiography, transthoracic echo, magnetic resonance and cardiopulmonary testing. The WHO classification has been very well accepted as a parameter for evaluating maternal-fetal risk according to structural cardiac injury. In addition to this classification, there are clinical conditions that are predicted over the natural history of congenital heart disease (which modify the prognosis of pregnancy and are independent of structural cardiac injury), which are shown in Table 24. 880