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 Women may receive any anti-hypertensive medication during the postpartum period. The factor that limits use is breastfeeding; thus, preference should be given to anti‑hypertensive medications which pass through breast milk in lower quantities. In 2013, a review from the Cochrane Library 311 suggested that the use of furosemide might assist in more effective control and shorten hospitalization time in patients with preeclampsia. The review recommends that each service use its routine medication without giving preference to any class of anti-hypertensive drug. Diuretics should become part of the anti-hypertensive regime after the second day, when the reabsorption of peripheral edema begins. The consultation site https://toxnet.nlm.nih.gov , reviews publications and updates recommendations for use of medication while breastfeeding. 312 The ACEI captopril and enalapril, which are contraindicated during gestation, are permitted during breastfeeding, as they pass through breast milk in very small quantities. Regarding ARB group II, there is not a sufficient number of studies for liberating the use of this class of medication. The most utilized CCB is nifedipine, which also passes through breast milk in small quantities. Amlodipine and other CCB, such as ARB, lack studies to liberate them without restrictions. Beta-blockers should be individualized on a case-by-base basis. Propranolol and metoprolol are compatible with breastfeeding, whereas atenolol should be avoided. Diuretic drugs, such as hydrochlorothiazide and furosemide, may deplete intravascular space and decrease milk production; for this reason, they should be used in low doses. Spironolactone may be administered without restriction, and it may be used in patients with resistant hypertension (primary hyperaldosteronism). Treatment of hypertensive peaks in postpartum women may be done conventionally. A study comparing captopril and clonidine for controlling hypertension (SAP ≥ 180 mmHg and DAP ≥ 110 mmHg) verified that there was no significant difference between the substances, only a tendency for clonidine to be better during the third day of the postpartum period. Both were considered effective and safe for treating postpartum women with hypertensive emergencies. 313 We recommend hospital discharge after at least 24 hours in cases of SAP < 160 mmHg and DAP < 110 mmHg. After that they should receive close outpatient follow up, with brief reevaluation 1 to 2 weeks after discharge. 314 4.8.2. Key Points • Hypertension usually improves in the first five to seven days, but after this period there is still a risk of complications, including preeclampsia/eclampsia; • Priority should be given to medications low-releasing for breastfeeding; • Outpatient follow-up is important as most of these patients leave the hospital still on medication. 4.9. Hypertension During Gestation and Future Cardiovascular Risk Preeclampsia is an established risk factor for coronary artery disease, chronic hypertension, peripheral vascular disease, and stroke. Possible mechanisms behind the increase in cardiovascular disease include endothelial, vascular, and metabolic dysfunctions found during preeclampsia, which have a common link to other traditional risk factors, such as dyslipidemia, obesity, diabetes mellitus, and kidney disease. The CHAMPS Study, 315 conducted retrospectively with more than one million women with cardiovascular disease after their first gestation, showed an increase in the risk of myocardial revascularization and hospitalization due to cardiovascular disease, stroke, and peripheral arterial vascular disease; this risk was 2 times higher in patients who had had preeclampsia, gestational hypertension, placental rupture, or infarction. Another large review 316 including more than 3 million women and nearly 200,000 pregnant women showed increased relative risks of 3.7 for chronic SAH, 2.16 for ischemic heart disease and 1.81 for stroke after 10.4 years, in women whose had preeclampsia. In this manner, hypertension during gestation should be seen as a sex-related marker of future cardiovascular risk. Furthermore, although it is not one of the main factors used for calculating cardiovascular risk, it is necessary, as part of clinical routine, to include precautions when counseling women after delivery and to intensify control of other modifiable factors with the aim of decreasing their cardiovascular risks. 317 4.9.1. Key Points • Preeclampsia is a risk factor for coronary artery disease, chronic hypertension, peripheral vascular disease and stroke; • Patients who have high blood pressure during pregnancy should intensify control of other modifiable factors to reduce future cardiovascular risk. 5. Treatment and Prevention of Cardiac Complications 5.1. Cardiac Arrhythmias 5.1.1. Epidemiology Arrhythmias are very frequent complications during pregnancy, whether or not they are associated with structural or electrical heart disease. The first manifestation may occur during gestation, or an aggravation of preexisting arrhythmias may occur. 318 The occurrence of arrhythmias during gestation requires investigation with special attention to definition or exclusion of structural or electric cardiac injury; this practice is fundamental to determining treatment and prognosis for the patient. 52,318 902