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 The syndrome results in mutations in the genes that codify components of the transforming growth factor beta (TGF-beta) signaling pathway. Aortic pathology is particularly concerning in this condition, but other vascular abnormalities may also be present. 258 Significant maternal morbimortality has been described in patients with Loeys-Dietz syndrome, but it is possible for pregnancy to be successful and free of complications. 258 Nonetheless, all patients with this condition should, at present, be treated as high-risk during pregnancy and the postpartum period, until reliable risk prediction tools become available. 258 There are no studies on the benefits and risks of cesarean delivery in comparison with vaginal delivery in patients with hereditary aortic disease. Cesarean delivery is, nonetheless, recommended, according to the aortic dilatation thresholds shown in Table 26. Vaginal delivery may be considered in cases below these limits. 3.6.4.2. Key Points Aortic diseases constitute an important cause of maternal death during the pregnancy-postpartum cycle; Pregnancy increases women’s susceptibility to aortic dissection and rupture; Pregnancy planning includes diagnosis of the underlying disease, magnetic resonance of the aorta and base vessels, eventual corrective aortic surgery in accordance with limits for risk of dissection, and genetic counseling; The occurrence of dissection of the aorta with a viable fetus (> 28 weeks of gestation) indicates emergency cesarean delivery; if, however, the fetus is not viable, the case should proceed to cardiac surgery and maintain the pregnancy; Women with Ehlers-Danlos, Turner, or Loeys-Dietz syndrome, in addition to the high risk of dissection of the aorta, are exposed to complicated events, such as hypertension, diabetes, and other aneurysms, which, in conjunction, represent a significant increase in maternal death during pregnancy. 3.6.5. Chagas Disease 3.6.5.1. Prevalence Global estimated prevalence of T. cruzi infection in pregnant women has varied from 1% to 40%, with approximately 1.8 million women of fertile age infected in Latin America. 259 In Brazil, the prevalence of infection in pregnant women is accepted to be 1.1%, with a vertical transmission rate of 1.7%. 259,260 3.6.5.2. Diagnosis and Practice for Cases with T. cruzi Infection during Gestation Serological evaluation for T. cruzi infection is recommended during prenatal care in pregnant women who reside in or come from endemic areas and in those who have received blood transfusions in these regions. 259,261 The most frequently used tests are based on higher sensitivity and specificity for detecting T. cruzi infection. They include enzyme-linked immunosorbent assay (ELISA); indirect hemagglutination (IHA), and indirect immunofluorescence (IF). Transmissionmay occur at anymoment during pregnancy, but specific antiparasitic treatment for T. cruzi infection is contraindicated during gestation and breastfeeding, owing to teratogenicity in animals. Accidental exposure to benzonidazol does not indicate adverse effects in the newborn, and it is not a criterion for interrupting gestation. 259 Elevated maternal parasitemia is associated with a greater risk of vertical transmission and miscarriage. 261 For this reason, during the acute phase of Chagas disease, pregnant women should be individually evaluated, and the decision to initiate antiparasitic treatment should be based on the risk-benefit ratio. Evidence of T. cruzi infection does not justify indicating cesarean delivery, even though congenital T. cruzi infection may result in uterine growth restriction and prematurity. 259,261 It is worth emphasizing the importance of proceeding to recommended evaluations during prenatal care, including anti-HIV tests. Simultaneous infection with T. cruzi and HIV represents an increased risk of congenital transmission of T. cruzi owing to elevated parasitemia, which also implies higher perinatal morbimortality. 260,261 After delivery, women should be referred for clinical evaluation and specific treatment. Figure 7 shows indications for practice in Chagas disease during pregnancy. 259 3.6.5.3. Chronic Chagas Heart Disease Chagas heart disease, in its indeterminate form, does not present any additional risks to pregnancy, whereas forms with ventricular or arrhythmogenic dysfunction are associated with complications such as HF, thromboembolism, and complex arrhythmias. In these cases, pregnancy is considered high-risk, and it is advised against at times, depending on the degree of cardiac involvement, which may be established by echo with 24-Holter monitoring. 3.6.5.4. Vertical Transmission of Trypanosoma cruzi Vertical transmission (from mother to child) of T. cruzi depends on the degree of parasitemia; transplacentally, it may occur at any stage (acute or chronic) of the disease, which requires treatment prior to gestation in infected women of fertile age. It is worth emphasizing that vertical transmission may recur during the reproductive period, and detection of vertical transmission in practice is complicated, given that most congenital cases are asymptomatic. Cases of congenital Chagas disease are considered acute, and it is compulsory to notify them within disease surveillance programs. 259,262,263 During the acute phase of Chagas disease, there exists a possibility of transmission through breast milk, whereas, during the chronic phase, transmission occurs during lactation in cases of bleeding from fissures in the nipple rather than throughmilk itself. 3.6.5.5. Reactivation of Chagas Disease During gestation, mechanisms and immunological alterations in the maternal organismmay favor the reactivation of chronic Chagas disease in previously infected cases. Reactivation is defined by positivity on the following examinations, regardless of other signs and symptoms: 893