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 Figure 10 – Flowchart for diagnostic investigation of pulmonary thromboembolism during gestation. PTE: pulmonary thromboembolism; US: ultrasound. Suspeita clínica de TEP US vascular bilateral com iliacas Positivo Tratamento Alta Probabilidade Negativo Normal Normal Inconclusiva Buscar outro diagnóstico Cintilografia de Perfusão AngioTomografia pulmonar Anormal Rx Tórax DVT in lower limbs should be differentiated fromosteomuscular diseases, such as tendinitis, muscular distension, popliteal cyst, popliteal aneurysm, hematoma, cellulitis, lymphangitis, and post-thrombotic syndrome (Figure 10). 5.2.5. Treatment 5.2.5.1. General Approach Faced with strong clinical suspicion of thromboembolism, full permanent anticoagulation should be initiated before confirmation of diagnosis, unless it is contraindicated. Heparin is the preferred anticoagulant, whereas “new” oral anticoagulants, such as dabigatran, rivaroxaban, and apixaban, have not been approved for use during gestation and lactation. In cases of allergy or thrombocytopenia induced by heparin, fondaparinux may be indicated, and it seems to be safe during the second and third trimesters of pregnancy. 5.2.5.2. Heparin Use LMWH and UFH are the options for treating PTE during gestation. LMWH is easy to use, and it seems to be safer and more efficacious than UFH, with data extrapolated from studies that did not include gestation. Intravenous UFH is indicated in patients with increased risk of bleeding or persistent hypotension during PTE. Prolonged heparin use, i.e., for more than 7 weeks, is associated with the risk of osteoporosis, hemorrhage, allergic reactions, skin necrosis, and thrombocytopenia, which are less frequent with the use of LMWH. Suspension is indicated when platelet count drops below 150,000 or the equivalent of 50% of the initial count. In this case, although it is controversial, substitution with fondaparinux may be indicated. Anticoagulation should be continued throughout the pregnancy and at least during the first 6 weeks postpartum. Platelet count should be performed daily to investigate thrombocytopenia during the first 3 days of treatment and weekly thereafter. 5.2.5.2.1. Recommended Doses • Subcutaneous LMWH: dalteparin 200 units/kg daily or 100 units/kg every 12 hours, or enoxaparin 1 mg/kg every 12 hours. The heparin dose should be controlled by anti-Xa factor in the therapeutic range between 0.6 and 1.0 IU/ml, when it is applied every 12 hours, and in the range of 1 to 2 IU/ml, when it is applied in a daily dose; • Intravenous UFH: UFH bolus of 80 units/kg followed by an infusion of 18 units/kg/h, adjusted every 6 hours to maintain APTT between 1.5 and 2.5 times baseline. Stabilization of the therapeutic range allows for daily APTT control; • Subcutaneous UFH: It is reasonable to initiate with 17,500 IU every 12 hours, adjusted every 6 hours to maintain APTT between 1.5 and 2.5 times control. Stabilization of the therapeutic range allows for daily APTT control. 5.2.5.2.2. Labor and Delivery Delivery planning in patients under anticoagulation requires the involvement of a multidisciplinary team, as risks of bleeding and thrombosis should be weighed during the stages of labour, delivery and postpartum period. In cases of spontaneous labor, heparin should be suspended immediately; in planned induced or cesarean delivery, LMWH should be suspended 24 hours in advance; this practice makes neuraxial anesthesia possible. In cases when it is judged risky to suspend heparin for 24 hours, it should be substituted by intravenous UFH, which should be interrupted 4 to 6 hours before delivery. Neuraxial anesthesia may be performed when 909