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 A study in hospitalized pregnant women has shown that: 60% of arrhythmias correspond to sinus bradycardia or tachycardia; 19% to supraventricular or ventricular extrasystoles; 14% to supraventricular tachycardia (SVT); 5% to VT or VF; and 2% to other disorders. 319 AF and paroxysmal supraventricular tachycardia (PSVT) are the most frequently diagnosed sustained SVT during gestation; bradyarrhythmias, conduction disorders, other atrial tachycardias, VT, and VF are relatively rare. 320 The accepted risks of antiarrhythmic drugs affecting organogenesis and fetal development should be considered during pregnancy, given that most diagnosed arrhythmias do not require specific treatment. Nevertheless, recurring or persistent arrhythmias that cause important symptoms or hemodynamic repercussion should be treated in the same manner they would be for non-pregnant women. 321 The risks inherent to ionizing radiation used to perform catheter ablation may by minimized with electromechanical mapping and, in some cases of device implantation (pacemaker, ICD, and resynchronizer), with the use of 2-dimensional echo. 322 5.1.2. Clinical Presentation Palpitations occur frequently during pregnancy. They may be related to arrhythmias, or they may be consequent to hemodynamic alterations during gestation. Diagnostic evaluation of palpitations in pregnant women does not differ from diagnosis in non-pregnant women, and it has been demonstrated that palpitations are associated with the presence of arrhythmias in only 10% of cases. 323 Symptomatic sinus bradycardia is rare, and it is generally associatedwith gestational supine hypotensive syndrome, which is treated by placing pregnant patients in left lateral decubitus. Syncope linked to atrioventricular blocks is, similarly, infrequent, and congenital complete atrioventricular block, especially supra‑hisian, with narrow QRS, presents favorable evolution during gestation. Sudden Cardiac Death (SCD), which is rare during gestation, presents a greater risk of occurring inwomenwith VT associated with structural heart disease, and, during gestation and the postpartum period, in women with channelopathies (especially women with long‑QT syndrome). 319,320 5.1.3. Maternal-fetal Risks Sustained cardiac rhythm disorders may lead to maternal hemodynamic impairment, the risk of thromboembolism, and SCD. They may also compromise fetal development, leading to low birth weight, premature delivery, fetal abnormalities, and other indications for cesarean delivery. For this reason, these disorders should be diagnosed and adequately treated. The modified WHO classification for maternal risk considers isolated supraventricular and ventricular extrasystoles as class I (in which there is no detectable risk of increased maternal mortality, but there is a mild increase in maternal morbidity); supraventricular arrhythmias are in class II (in which there is a mild increase in maternal mortality and a moderate increase in maternal morbidity), andVT are included in class III (inwhich there is a significant increase in maternal mortality and morbidity). 324 Current recommendations suggest that arrhythmias be classified during gestation, in accordance with potential hemodynamic impairment, as the following: low-risk of SCD (PSVT and AF with hemodynamic stability, idiopathic VT, low-risk long QT syndrome, and Wolff-Parkinson-White syndrome); medium-risk of SCD (unstable SVT, VT in patients with structural heart disease, Brugada syndrome, long QT syndrome, and moderate-risk catecholaminergic polymorphic VT); high-risk of SCD (unstable VT in patients with structural heart disease, torsades de pointes in patients with long QT syndrome, short QT syndrome, and high-risk catecholaminergic polymorphic VT). 52,320 For the low-risk group, a cardiologist should participate in delivery planning, and delivery should be indicated by the obstetrician. In the medium-risk group, delivery continues to be indicated by the obstetrician; nevertheless, the multidisciplinary team that accompanies the pregnant patient should include an electrophysiologist, and, during delivery, the team should be prepared to use drugs such as adenosine and beta-blockers, as well as cardioverter-defibrillator (CD). In the high-risk group, there is an indication for cesarean delivery, during which it is necessary to be prepared to use CD and antiarrhythmic drugs, in addition to beta-blockers; patients in this group may require admission to the ICU during the postpartum period. 52 5.1.4. Treatment Treatment of arrhythmias in pregnant women is similar to that in non-pregnant women. 325 According to indication, the following methods may be used: electrical cardioversion, vagal maneuvers, antiarrhythmic drugs, device implantation (pacemaker, ICD, and cardiac resynchronizer), and catheter ablation (Table 28). Treatment of cardiac arrhythmias in the emergency room will be discussed in section 5.7. Due to a lack of randomized clinical trials, the indication or contraindication of a given method is based on experimental data from animal studies, registries of side effects of medications used in clinical practice, and case reports or case series. This means that these treatments should only be used when there is maternal and fetal hemodynamic impairment as a result of arrhythmia and/or when there is a risk of maternal SCD during pregnancy and the postpartum period. Whenever possible, all treatments should be postponed to the second or third trimester (thus avoiding the organogenesis period); in the event that medications are used, it is necessary to utilize the lowest dose for the shortest time necessary. Synchronized electrical cardioversion, which is indicated for reversion of unstable SVT (AF, atrial flutter, atrial tachycardias, PSVT), and unstable or stable VT in the presence of heart disease, is safe during all phases of gestation; it does not compromise fetal blood flow. The pads should be placed in the anterolateral position, with the lateral pad below the mother’s left breast and fetal rhythm monitoring. 326 During gestation, vagal maneuvers, such as the Valsalva maneuver, carotid sinus massage, immersing the face in 10ºC water, placing a wet towel on the face, may be used safely for acute reversion of PSVT (caused by nodal reentry or by an accessory route, the latter being characteristic 903