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 hypertension should be with monotherapy, with first-line drugs, 67-276 such as methyldopa, CCB, long-acting oral nifedipine, and beta‑blockers (except atenolol). If ideal blood pressure levels are not achieved, the association with second-line oral medications: clonidine, hydralazine and thiazide diuretics should be considered. 271,274 The potential of diuretics to cause depletion of intravascular volume and therefore compromise placental uterine circulation, IUGR or oligohydramnios, is not supported in more recent randomized studies and in a systematic review of diuretics for the prevention of preeclampsia. 71,286-287 1st line drugs should be considered: • Sympathetic nervous system inhibitors (centrally acting alpha-2-adrenergic receptor agonist): decrease blood pressure by reducing peripheral vascular resistance. They can change the heart rate and output. A -Methyldopa is the best studied antihypertensive drug in pregnancy. 67,68 However, methyldopa has only a mild antihypertensive effect, with a slow onset of action (3 to 6 h) and with an average duration of 6 hours. to 8 hours. The most common dose-dependent maternal side effects are drowsiness and dry mouth. Dose independent agents include elevated liver enzymes in up to 5% of women and autoimmune hemolytic anemia. 68 The recommended starting dose is 250 mg, 2 or 3 times a day (maximum dose 3 g/day); • Calcium channel blockers (BCC): oral nifedipine does not appear to be teratogenic. 64-66,81-83,288,289 Clinical trials demonstrate that blood flow in the umbilical artery is not affected. Maternal side effects with the use of BCC include tachycardia, palpitations, peripheral edema, headaches and facial flushing. Experience with nifedipine has been favorable. 276 Although not specifically licensed for pregnancy, it is recommended and its use together with labetalol and methyldopa. The maximum daily dose of nifedipine is 120 mg, divided into three or four doses or 30-60 mg once daily (prolonged release). 270-273 Administration by sublingual route is contraindicated because it determines an unpredictable hypotensive response, excessive autonomic activation and acute myocardial ischemia; • The exposure to amlodipine in early pregnancy does not appear to be associated with an increased rate of fetal malformations compared to other antihypertensive agents 290,291 and the antihypertensive effect is slow (± 8 hours); • Beta-blockers: none of the beta-blockers have been associated with teratogenicity 76-79 IUGR and low placental weight have been associated with the use of atenolol. 79,80,271 The exposure to any beta-blocker is associated with the risk of bradycardia and neonatal hypoglycemia, which can cause sedation, sleep disorders and depression in pregnant women. In the case of propranolol, there are reports of IUGR, bradycardia and neonatal hypoglycemia, especially with high doses (160 mg/day). 81 Labetalol is not marketed in Brazil. Drugs of second line are: • The following are second-line drugs: • Clonidine shows an exaggerated increase in arterial pressure (rebound effect) when treatment is discontinued abruptly. It has a greater hypotensive effect than methyldopa; • Hydralazine is predominantly used intravenously for treatment of severe hypertension in preeclampsia; • Diuretics: the use of diuretic therapy during pregnancy continues to be controversial, mainly due to theoretical concerns regarding reduced maternal plasma volume. Thiazide diuretics may be continued in pregnant women with chronic SAH, provided that they do not promote volume depletion. Chlorothiazide may increase the risk of congenital anomalies and neonatal complications. 276,286 The following oral anti-hypertensive are contraindicated during gestation: 290 • ACEI and ARB, which are associated with fetal acute kidney injury and oligohydramnios and which should be suspended before conception; 291 • Atenolol (beta-blocker), which leads to IUGR and low placental weight; 292,293 • Spironolactone, which has an antiandrogenic effect during fetal development; 287 • Chlorothiazide, which may increase the risk of congenital anomalies and neonatal complications. 4.4.4 Anti-hypertensive Drugs for Severe Hypertension in Preeclampsia 275,276,278,279,298-300 The maternal and fetal prognosis in severe hypertension is correlated to i nitial care provided to these pregnant women. 292 Severe hypertension in preeclampsia is when systolic arterial pressure ≥ 160 or diastolic arterial pressure ≥ 110 mmHg; or both during pregnancy, intrapartum or postpartum period. 277 It is an obstetric emergency, and it requires immediate anti‑hypertensive treatment. The goal is not to normalize blood pressure, but to reach levels of 140-150 / 90-100 mmHg 277 or to reduce 15% to 25% of BP. 275 Severe preclampsia grave is associated with reversible encephalopathy syndrome (PRES) characterized by headache, visual symptoms, impaired consciousness, epileptic crises, and, occasionally, focal neurological defects. 301 Pregnant women with severe preeclampsia should be attended or transferred to tertiary healthcare centers. Prior to inter-hospital transfer, blood pressure (BP) must be stabilized and other measures initiated, such as magnesium sulfate for eclampsia prophylaxis. 293 It is recommended that magnesium sulfate should be used for the prevention and treatment of seizures in women with gestational hypertension and pre-eclampsia with severe characteristics or imminence of eclampsia. Maternal stabilization should occur before delivery, even in urgent circumstances. Admission to the ICU should be considered, in accordance with the following criteria: pregnant women with severe preeclampsia (SAP ≥ 160 mmHg and DAP ≥ 110 mmHg), respiratory insufficiency requiring mechanical ventilatory assistance, eclampsia, HELLP syndrome, oliguria, acute pulmonary edema, and neurological complications, such as stroke or PRES. 294 898