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 4. Hypertensive syndromes 4.1. Introduction Hypertensive syndromes during gestation are considered to be a public health problem, with an expressive rate of maternal and fetal mortality, in both developed and developing countries. It is the most common medical complication, and it affects 5% to 10% of pregnancies worldwide. Preeclampsia occurs in approximately 3% of all pregnancies in the United States, where it is responsible for 9% of maternal deaths. 264 Its incidence has shown a 25% increase over the past 2 decades. In recent years, an increase has been registered in the proportion of women with preeclampsia. In 2009, it was 2.2%; in 2013, it was 5.58%, and over the past 5 years, 22.5% suffered a severe general complication. 265 Although research has evolved in the area of hypertensive syndromes during gestation, its etiology remains unknown. The methodological challenges to research related to preeclampsia are numerous; they include defining hypertension, level of severity, and physiopathology during pregnancy. These data probably interfere with research and outcomes, which justifies the following recommendations. 4.2. Recommendations for Measuring Arterial Pressure • Blood pressure measurement devices in pregnant women must be accurate and validated for this special population. The cuff should be appropriately sized 1.5 times the circumference of the arm. • Blood pressure should bemeasuredwith the patient sitting. The patient should rest for at least five minutes before measurement. Measurement may also take place in the left lateral decubitus position, while resting, and it should not differ from the measurement taken in the seated position; • It is necessary to consider Korotkoff phase V to determine diastolic arterial pressure (DAP); 266 • White coat hypertension and masked hypertension are considered to be relatively common presentations during pregnancy. They occur in at least 1/3 of pregnant women, to the extent that ABPM and home blood pressure monitoring (HBPM) are useful complementary examinations for making the clinical decisions which are fundamental to avoiding treatments which are unnecessary and potentially harmful to the fetus; 33,267 • Pregnant women with SAP ≥ 140 mmHg and/or DAP ≥ 90 mmHg are considered hypertensive; • Severity of hypertension during pregnancy is assessed based on the occurrence of target organ involvement, as well as arterial pressure level; 268 • Severe hypertension is defined based on pressure levels ≥ 160/110 mmHg, which are associated with increased risk of stroke in pregnant women. 52,266,268 4.3. Classification The most widely used classification for hypertensive syndromes during gestation is the one adopted by the Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy, 269 which is also applied in the Brazilian Cardiology Society’s Guidelines on Pregnancy in Women with Heart Disease (Figure 8). 270 In accordance with this classification, syndromes are classified in the following manner: • Chronic, preexisting hypertension (due to any cause); • Preeclampsia/eclampsia; • Chronic hypertension with superimposed preeclampsia; • Gestational hypertension. Based on this position, classification into 4 categories will be maintained, emphasizing the importance of other presentations of arterial hypertension, such as the following: • White coat hypertension; • Masked hypertension; • Transitory gestational hypertension occurs without the development of preeclampsia; arterial pressure normalizes within 12 weeks postpartum and it is resolved without treatment; 267,270 • Postpartumhypertension generally arises between 2 weeks and 6 months after delivery. It is mild and labile, and it normalizes within the first year. It may be related to persistent gestational hypertension, preeclampsia, or chronic hypertension, or it may be secondary to other causes; 269 • Unclassified prenatal hypertension is the term used when the first pressure measurement is recorded after week 20, and it is not clear if it is chronic or preexisting; diagnosis is only established during postpartum reevaluation between weeks 6 and 12. 52 4.3.1.Chronic,Preexisting(EssentialorSecondary)Hypertension This occurs when arterial pressure is ≥ 140/90 mmHg (preexisting hypertension; in general, essential hypertension or hypertension diagnosed before week 20 of pregnancy). It is commonly diagnosed around the first trimester or right at the beginning of the second. It is associated with adverse maternal and fetal outcomes; there should, therefore, be more rigorous control of maternal arterial pressure (110 to 140/85 mmHg), monitoring fetal growth and repeatedly evaluating the development of preeclampsia and maternal complications. 267 Hypertension may not be diagnosed in many women whose first prenatal consultations occur during the second trimester. Pregnant women may be considered normotensive during the initial phase of gestation, due to the physiological decrease in arterial pressure during the first trimester of pregnancy, in the same manner that an increase in arterial pressure may be diagnosed as gestational hypertension, because pressure levels were not verified before week 20 of gestation. Chronic hypertension usually persists until 42 days postpartum. 268 Diagnosis of chronic hypertension can only be made correctly once arterial pressure has been reevaluated after 6 to 12 weeks postpartum. 271 4.3.2. Preeclampsia/Eclampsia This is a complex hypertensive syndrome, and it may deteriorate rapidly and without warning; classifying it as “mild” 895