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 Table 27 – Recommendations for acetylsalicylic acid use in preeclampsia prophylaxis Risk level Risk factor Recommendation High Preeclampsia with adverse fetal outcomes Multifetal gestation Chronic SAH Diabetes mellitus type 1 or 2 Kidney disease Autoimmune disease (lupus/APAS) A low dose of ASA is recommended if the patient meets one or more of these criteria Moderate Nulliparity Obesity (BMI ≥ 30) Family history of preeclampsia (mother or sister) Age ≥ 35 years Poor previous obstetric history (SGA, prematurity, low birth weight, an interval of more than 10 years between gestations) Consider using a low dose of ASA if the patient has more than one risk factor APAS: antiphospholipid antibody syndrome; ASA: acetylsalicylic acid; BMI: body mass index; SAH: systemic arterial hypertension; SGA: small for gestational age. preeclampsia. Doppler ultrasound should be performed between weeks 20 and 22, although there is a good correlation between late preeclampsia (>34 weeks) and IUGR. In contrast, Doppler ultrasound performed at the end of the first trimester has lower accuracy; nonetheless, in conjunction with clinical history and comorbidities, it may be useful for identifying pregnant women with higher risks and selecting those who will require prophylaxis for preeclampsia. 305 Diverse substances have been tested to reduce the incidence of preeclampsia. Studies on diet, weight loss, physical activity, vitamins, antioxidants, nitrates, dipyridamole, heparins (LMWH and UFH), and antiplatelet agents have been conducted; of these, only calcium replacement and acetylsalicylic acid (ASA) have shown some benefit. Calcium replacement (1.5 to 2.0 g daily) reduces the risk of preeclampsia effectively only in the subpopulation with calcium ingestion below 600 mg daily. 306 Studies have shown the benefits of ASA in low doses (between 75 and 150 mg) for preeclampsia prevention, 307 and it has recently been included in the recommendations of important international guidelines. 278,308,269 Study 309 with 1,776 patients, using 150-mg doses of ASA versus placebo, starting between weeks 11 and 14, demonstrated that the total of preeclampsia events was significantly reduced in the ASA group compared to placebo group, reinforcing the protective effect of ASA in pregnant women with high risks. The precise indication of ASA is for patients classified as high-risk for preeclampsia (Table 27), and it should be initiated between weeks 12 and 16. 4.7.1. Key Points • Predicting preeclampsia in low-risk patients is difficult and depends on joint assessment of clinical history and Doppler US; • Calcium replacement in patients with low intake reduces the risk of preeclampsia; • The use of low dose AAS in moderate to high risk pregnant women reduces the risk of preeclampsia and should ideally be started between 12 and 16 weeks. 4.8. Arterial Hypertension during the Postpartum Period Arterial hypertension during the postpartum period has been little studied, because there is still a belief that once the placenta has been removed the problem is solved. To a certain extent, placental delivery marks the moment when the stimulation of the production of inflammatory and vasoconstrictive substances ceases, leading to a gradual return in arterial pressure to pre-gestation levels; nevertheless, some of these inflammatory and vasoconstrictive alterations may remain in the maternal organism for a few days. 4.8.1. Recommendations Hypertension normally improves within the first week (5 to 7 days); however, during this period, there continues to be a risk of related complications, especially in patients with preeclampsia, in addition to the possibility of preeclampsia itself manifesting only during the postpartum period. There is also a risk of eclampsia during this period, and 32% to 44% of convulsions may occur during the postpartum period. Hypertension during the postpartum period may be aggravated or prolonged by situations such as volume overload (hydration) and use of pain medication, such as non-steroidal anti-inflammatory drugs (vasoconstriction and sodium retention), in addition to cases of stroke with reactive vasoconstriction and in patients with previously undiagnosed chronic hypertension. In postpartum women with preeclampsia, a new elevation in arterial pressure may occur between 3 and 6 days postpartum, probably due to reabsorption of accumulated edema in the third space, which is a rather common syndrome of preeclampsia. 310 The treatment objective is to decrease the risk of target organ injury due to hypertensive emergency (acute pulmonary edema, stroke, dissection of the aorta, acute kidney disease). Thus, postpartum women with mild to moderate hypertension (SAP < 160 mmHg and/or DAP < 110 mmHg), who are asymptomatic, may receive follow up without anti‑hypertensive medication. 901