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 23 – Recommendations for anticoagulation dose and control in patients with mechanical prostheses during pregnancy Gestational age( week) Anticoagulant Control Between 6 th and 9 th LMWH 1.0 mg/kg SC every 12 hours UFH IV 18 IU/kg/h infusion pump (< 30,000 IU IV) AntiXa: 0.6 to 1.2 U/ml APTT 1.5 to 2.0 times/NV 12 th to 36 th Warfarin according to INR Aortic INR between 2.5 and 3.0 Mitral INR between 3.0 and 3.5 After week 36 th until delivery LMWH 1.0 mg/kg SC every 12 hours UFH IV 18 IU/kg/h infusion pump (< 30,000 IU IV) AntiXa: 0.6 to 1.2 U/ml APTT 1.5 to 2.0 times/NV The postpartum period LMWH 1.0 mg/kg SC every 12 hours UFH IV 18 IU/kg/h infusion pump (< 30,000 IU IV) Warfarin reaching target INR for hospital discharge AntiXa: 0.6 to 1.2 U/ml APTT 1.5 to 2.0 times/NV INR between 2.0 and 2.5 APTT: activated partial thromboplastin time; INR: international normalized ratio; IU: international units; IV: intravenous; LMWH: low molecular weight heparin; NV: normal value; SC: subcutaneous; UFH: unfractionated heparin. Table 24 – Factors associated with maternal prognosis in congenital heart disease Pulmonary arterial hypertension Cyanosis Severe obstructive lesions Ventricular dysfunction Permanent anticoagulation requirement Symptomatic patients indicated for intervention in heart disease Eisenmenger syndrome: It is considered to have a high risk for maternal death, which reaches 50% during the pregnancy e postpartum. 167 Pulmonary arterial disease restricts circulatory adaptation to the variations in cardiac output and to the drop in peripheral vascular resistance during pregnancy and postpartum period. This leads to the main complications that cause death, such as HF, hypoxia crises, and arrhythmias. The risk during the postpartum period is as high as during gestation, due to hemorrhage and thromboembolism. 168 Patients with Eisenmenger syndrome appear to be predisposed to thrombocytopenia, deficiency in vitamin K-dependent coagulation factors, and bleeding. The fetal risks of spontaneous abortion, prematurity, and perinatal mortality are proportional to the degree of cyanosis. Cyanosis: Almost 30% of patients with cyanotic congenital heart disease, whether or not they undergo previous surgery, present complications during gestation, such as: HF, systemic- pulmonary thrombosis, arrhythmias, and hypoxemia, are presumptive. The degree of arterial oxygen saturation is a prognostic factor for maternal-fetal survival, and the hypoxia has a significant correlation with maternal death, spontaneous abortion, and perinatal death. 169 The indication of phlebotomy in maternal erythrocytosis is only been performed with hematocrit above 65% in patients with symptoms of headache, fatigue, visual or cognitive impairment, and myalgia. Fetal outcome, including miscarriage, prematurity, and perinatal death, is related to the degree of arterial oxygen saturation. It is estimated that oxygen saturation < 85% is associated with only 12% live newborns. 170 HF: dyspnea is a clinical parameter used to aid practice and estimate prognosis of congenital heart disease, however, have limitations when applied to pregnancy. Dyspnea may be consequence of hypoxemia or pulmonary congestion, which is related to congenital heart disease involving the left heart. 52 Cardiac arrhythmias: Frequent in adults with congenital heart disease, arrhythmias are the result of sequelae of cardiac defects such as ventricular dysfunction, myocardial hypertrophy, fibrosis or surgical injure, conduction tissue trauma, and the presence of endocardial grafts. Previous intervention of pregnancy: Surgical or percutaneous correction of congenital heart disease is associated with better maternal-fetal prognoses in comparison with patients who have not undergone operation for heart disease. The eventual need for intervention should be taken into account before conception. 3.2.1. Pregnancy Management Giving continuity to preconception evaluation, initial prenatal visit should include (1) history; (2) type of corrective or palliative surgery; (3) immediate or late postoperative evolution; (4) current clinical and functional situation; and (5) periodic laboratory examinations (hematocrit, hemoglobin, oxygen saturation, and natriuretic peptide). 171 Attending during gestation, delivery, and the postpartum period for patients with congenital heart disease should rely on a team of specialists, a tertiary hospital, and periodic attendance. It is worthwhile to recall that the hereditary nature of congenital heart disease makes routine fetal echo necessary from the second trimester of gestation on. 171 Pregnant women classified as WHO risks III/IV should receive advice regarding routine hospitalization starting between 28 and 32 weeks of gestation, for compensation of maternal condition, continuous fetal monitoring, therapy adjustment, and delivery planning. Decisions regarding the management of delivery and anesthesia should be made jointly, in accordance with the mother’s clinical situation and fetal vitality and maturity. Congenital heart diseases associated with PH: It is recommended the interruption of pregnancy in women with 881