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 • Define as severe hypertension when blood pressure levels ≥ 160 x ≥ 110 mmHg. These levels are associated with increased risk of stroke in pregnant women; • Pre-existing Chronic Hypertension (Essential or Secondary) should have tighter control of maternal blood pressure (BP = 110 - 140/85 mmHg), monitoring fetal growth and repeatedly evaluating the development of preeclampsia and maternal complications; • Preeclampsia/Eclampsia – complex hypertensive syndrome, may deteriorate rapidly and without warning. Not recommend classifying it as "mild" or "severe"; • Proteinuria is not mandatory for diagnosis and may occur for the first time during the intrapartum period or early postpartum. 4.4. Treatment of Gestational Hypertension Syndrome 4.4.1. Non-pharmacological Treatment 269 Considering pregnant women with SAP ≥ 140 mmHg or DAP≥90mmHg hypertensive, the following recommendations are applied: • Routinely, there is no indication for rest in pregnant womenwith gestational hypertension syndrome (GHS); 274 • Physical exercise is recommended for at least 3 days per week, with an average of 50 min per session, including aerobic, strength, and flexibility training; • Physical activity withmoderate exercisemay be continued in women who are already accustomed to practice; 112 • Diet should be healthy, rich in nutrients, proteins, fibers, and cereals; • Calcium supplementation, between 1.5 and 2.0 g daily, is necessary, especially in areas with low dietary calcium ingestion; • Weight gain in pregnant women is based on pre- gestational body mass index (BMI): 131 – BMI of 25 kg/m 2 (normal): weight gain from 11.2 to 15.9 kg; – BMI of 25 to 29.9 kg/m 2 (overweight): weight gain from 6.8 to 11.2 kg; – BMI ≥ 30 kg/m 2 (obese): weight gain of 6.8 kg. The following are not recommended: • Any type of low-calorie diet, even in obese women, because low-calorie diets may lead to fetal growth retardation; • Salt restriction during gestation with the intention of preventing GHS or low sodium (less than 100 mEq daily) diets inpregnant womenwith chronic arterial hypertension; • Use of dietary supplements (magnesium; vitamins C, E, and D; fish or algae oil; or garlic) with the goal of preventing GHS. 4.4.2. When to Treat – Target Arterial Pressure In international consensuses, there are points of divergence regarding the beginning of pharmacological treatment for GHS. 131,275-279 This notwithstanding, the prevailing recommendation is to begin oral anti-hypertensive drugs in GHS when SAP is 140 to 155 mmHg and DAP is 90 to 105 mmHg, measured during a consultation, or when arterial pressure is ≥ 135/85 mmHg at home. Specifically, in cases of chronic hypertension, gestational hypertension, or preeclampsia, anti-hypertensive therapy is recommended if SAP is ≥ 140 mmHg or DAP ≥ 90 mmHg. 273,280 Treatment with anti-hypertensive drugs should maintain arterial pressure at 110 to 140/80 to 85 mmHg, and treatment should be reduced or ceased if DAP is ≤ 80 mmHg. An abrupt drop in maternal arterial pressure, by more than 25% of the initial value, increases the risk of hypoperfusion in maternal target organs and low blood flow to the fetus. The primary objective of treating hypertension in GHS is to prevent stroke, progression of preexisting kidney disease, or other lesions in target organs, while preserving uteroplacental circulation. Pressure levels should be correlated to the gestational period in course, observing the physiological changes that occur with each gestational trimester, 281 such as the increased glomerular filtration rate, which interferes in bioavailability of drugs during gestation. 61,282 In women with chronic hypertension, to date, there is not enough evidence to demonstrate that, by reaching or maintaining a specific (ideal) arterial pressure level or by using a specific anti-hypertensive drug, it is possible to decrease the risk of developing superimposed preeclampsia. 279-282 The latest systematic review by Cochrane 283 concluded that data are insufficient to determine the benefits of anti‑hypertensive medications for mild to moderate hypertension (SAP from 140 to 169 mmHg and DAP from 90 to 109 mmHg) during gestation; more research is, therefore, necessary. Treatment with anti-hypertensive drugs, however, decreases the risk of severe arterial hypertension, but not of preeclampsia, IUGR, premature placental detachment, or adverse neonatal outcomes. The international multicenter randomized clinical trial Control of Hypertension in Pregnancy Study (CHIPS) with pregnant women who were non proteinuric and whose hypertension was “non severe” (arterial pressure = 140 to 159/90 to 109 mmHg), demonstrated that “less tight” pressure control, with DAP target of 100 mmHg versus “tight” control with DAP target of 85 mmHg showed a correlation with a higher incidence of severe hypertension (arterial pressure ≥ 160/110 mmHg), with preeclampsia, fetal loss, low birth weight, prematurity, and hospitalization in neonatal ICU. 284,285 4.4.3. Oral Anti-hypertensive Drugs- Chronic Hypertension /Gestational Hypertension All anti-hypertensive medications cross the placental barrier; for this reasons, the use of pharmacological therapy during pregnancy requires risk-benefit analysis with individualized treatment. 278,282 In Brazil, the available oral medications that are usually used are methyldopa, beta-blockers (except atenolol), hydralazine, and CCB (nifedipine, amlodipine, and verapamil). 275 Initial anti-hypertensive therapy to pregnant women with gestational hypertension or chronic 897