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 • Presence of the parasite in direct microscopic examination of blood or biological secretions, such as cerebrospinal fluid, pleura, pericardium, and ascitic fluid; • Histopathological examination of tissue lesions (panniculitis, myocarditis, encephalitis, enteritis, colpitis) with parasite nests found in acute inflammatory infiltrates. 3.6.5.6. Breastfeeding Suspending lactation is not recommended in women in the postpartum period with chronic Chagas disease, except in cases with breast fissure, in situations with elevated parasitemia, or in women in the acute phase of the disease. 259 If a breastfeeding child is exposed to milk from an infected mother, either in the acute or chronic form, with nipple fissures, the child should be monitored for acquisition of T. cruzi infection during the exposure period. In some cases, it is possible to consider thermal treatment of breast milk before administration to the child. 259,262,263 Lactation should be suspended in cases of T. cruzi and HIV coinfection, given that lactation, regardless of association with Chagas disease, is associated with a 7% to 22% additional risk of HIV transmission. Similarly, in cases of acute maternal HIV infection, natural breastfeeding increases the probability of vertical transmission of the virus to 29%. In Brazil, mothers have the right to receive infant milk formula until their children are at least 6 months old. 259,263 3.6.5.7. Key Points • Serological evaluation is recommended for all pregnant women who are positive for the disease; • The risks to gestation depend on the clinical form of Chagas disease; • Pregnancy may favor reactivation of the disease; • Breastfeeding should not be advised against; • Antiparasitic treatment is contraindicated during gestation and breastfeeding; • Route of delivery is indicated by the obstetrician. Figure 7 – Flowchart for approaching Trypanosoma cruzi infection in the mother/child binomial. ELISA: Enzyme Linked Immunosorbent Assay; IF: indirect immunofluorescence; IHA indirect hemagglutination. Adapted from: Second Brazilian Consensus on Chagas Disease. 259 Pregnant women reside or come from endemic areas for Chagas disease Routine prenatal care Refer the mother for medical control of the disease and evaluation of treatment Perform anti- T. cruzi serology tests in other children (if there are any) Investigate T. cruzi infection in the newborn Refer for high-risk prenatal care – assess involvement of the mother (clinical evaluation and ECG) During delivery During the postpartum period Absence of clinical alterations suggestive of congenital infection Presence of clinical alterations suggestive of congenital infection Positive investigation Investigate T. cruzi again (1 week after birth) Positive investigation Congenital T. cruzi infection confirmed (according to diagnostic flowchart) Congenital T. cruzi infection ruled out (according to diagnostic flowchart) Treatment for T. cruzi infection Negative investigation Investigate other causes of congenital infection Serology of the child (2 tests after 9 months of life) Negative investigation without clinical alterations Negative investigation with clinical alterations Investigate T. cruzi T. cruzi infection confirmed (according to diagnostic flowchart) T. cruzi infection ruled out (according to diagnostic flowchart) First prenatal consultation Two serological tests for anti-T. cruzi – different methods (ELISA, IF, IHA) 894