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 of Wolff‑Parkinson-White syndrome). 52,325 The Valsalva maneuver is typically more effective than carotid sinus massage. Eyeball compression is potentially dangerous and should never be used. When vagal maneuvers fail in the attempt at acute reversion of PSVT, adenosine (6 mg initially; maximum dose of 24 mg) is the drug of first choice for pregnant women, because there is no evidence of negative effects on the fetus, and the maternal effects (chest discomfort and flushing) have short duration. 52,325,327 Even though they are not first-choice drugs, beta-blockers (metoprolol, propranolol), verapamil, procainamide, and amiodarone may also be used in the attempt at reversion. In acute management of other sustained supraventricular arrhythmias (AF, flutter, atrial tachycardia), beta-blockers, verapamil and digitalis drugs are indicated for controlling ventricular response, and other drugs, including flecainide, ibutilide, and propafenone, may be used for acute reversion to sinus rhythm. 52,325,327 For reversion to sinus rhythm in stable idiopathic VT, beta-blockers, sotalol, flecainide, procainamide, lidocaine are indicated. For SVT, overdrive ventricular pacing is an alternative that should be considered (Table 29). Permanent treatment of SVT and VT should be the same as that applied to non-pregnant women, with the exception of restrictions to the use of amiodarone due to fetal implications (hypothyroidism, hyperthyroidism, growth retardation, and prematurity). It should also be considered that bradycardia, fetal hypoglycemia, and low birth weight might be associated with the chronic use of beta-blockers; nevertheless, this fact appears to be dose-dependent. Prescription of beta-blockers should contemplate the benefits, which should exceed the risks; the exception is atenolol, which has recognized teratogenic effects and should, therefore, be avoided during gestation. There are also reports of teratogenicity with the use of diltiazem. Sotalol should not be permanently used in pregnant women with Wolff-Parkinson-White syndrome to prevent episodes of PSVT (Tables 30 and 31). 52,325,327 In general, catheter ablation and device implantation, whenever possible, should be performed outside of the gestational period, due to the risks inherent to these procedures, including the risk related to exposure to ionizing radiation. Catheter ablation during gestation has been indicated only for pregnant women who present recurring or persistent severe tachycardias with severe hemodynamic impairment and who do not respond to the usual treatments. There are case reports and small case series of patients with SVT who underwent catheter ablation with the use of mapping strategies that use increasingly smaller amounts of ionizing radiation, thus increasing maternal and fetal safety regarding the future risks of this exposure. 328 There are no reports of catheter ablation for VT to date. Women with pacemakers and ICD show positive evolution during gestation; this notwithstanding, the complications inherent to underlying heart disease and devices appear to be present, leading to the need for specialized care. 329 In the event that they are absolutely indispensable, these devices may be implanted safely during gestation with or without minimal fluoroscopy. 330 Devices (pacemakers and ICD) should be reprogrammed before cesarean delivery, due to functional interference caused by the electric scalpel. In the event of emergency cesarean delivery, a magnet is placed over the pacemaker generator pocket while the electric scalpel is in use, and the cautery plate is placed far away from the thoracic region. For vaginal delivery, reprogramming is not necessary. For pregnant women with chronic AF or atrial flutter that are not associated with structural heart disease risk stratification should be performed for thromboembolic phenomena, by means of the CHA 2 DS 2 -VASc risk score, 331 including indication for anticoagulation when the score is ≥ 2. It is controversial whether the state of hypercoagulability increases the risk score for indication of anticoagulants during gestation. It is necessary to emphasize that new oral anticoagulants (dabigatran, rivaroxaban, apixaban, and edoxaban) should not be used in pregnant women. 332,333 5.1.5. Key Points • Initial practice for arrhythmias during pregnancy is to investigate structural cardiac injury; • “New” arrhythmias, in the absence of structural cardiac injury, should be treated according to maternal symptoms or the complexity of the arrhythmia; • A 24-hour Holter monitor examination is essential to therapeutic decision making; • Device implantation (pacemaker, ICD) and radiofrequency ablation with electroanatomical mapping are safe during pregnancy, and they should be indicated when a case is refractory to pharmacological treatment; • Devices such as pacemakers, ICD, and cardiac resynchronizers should be reprogrammed after cesarean delivery. 5.2. Thromboembolism 5.2.1. Epidemiology Venous thromboembolic events are important causes of maternal mortality and they are potentially preventable. 131,334 They are the main direct cause of maternal death in developed countries and in Brazil; in 2013, 335 they were the sixth leading cause, behind severe hemorrhage, hypertension during gestation, infection, delivery complications, and abortion. Furthermore, they are a relevant cause of morbidity due to post-thrombotic syndrome. Late diagnosis, delayed or inadequate treatment, and inappropriate prophylaxis are responsible for approximately 3.5% of maternal deaths. 336 Thromboembolism includes both deep vein thrombosis (DVT) and PTE; 75% to 80% of cases of pregnancy-associated thromboembolism are DVT, and 20% to 25% are PTE. The real incidence of the disease associated with gestation is unknown, but it appears to be between 7 and 25 cases per 10,000 pregnancies, and the clinical impression is that chances are increased 5- to 10-fold during this period. The risk appears to be greater during the third trimester, but it is elevated since the first. During the postpartumperiod, the risk reaches 20 times that of non-pregnant women, and it decreases gradually until 904