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 APTT returns to normal. In the event of planned preterm delivery (triplet gestation, premature rupture of membranes, significant cervical dilatation, preeclampsia, or IUGR), LMWH or subcutaneous UFH should be discontinued at week 36 and substituted with intravenous UFH. In the occurrence of delivery in patients under full anticoagulation, more bleeding is predicted during the intrapartum and postpartum periods; in addition to this, the risk of spinal hematoma contraindicates neuraxial anesthesia. Accordingly, oxytocin use is suggested during the third stage of labor. 342 5.2.5.2.3. The Postpartum Period Heparin should be reinitiated 12 hours after cesarean delivery or 6 hours after vaginal delivery, once it has been verified that there is no significant bleeding. Warfarin, when it is indicated, should be initiated on the second day postpartum, in conjunction with heparin, until INR is between 2 and 3 IU. It is indispensable for patients to be on heparin when an oral anticoagulant is initiated, because the oral anticoagulant can stimulate coagulation andmay cause vascular purpura during the first days. Oral anticoagulant use does not contraindicate lactation. 5.2.5.2.4. Duration of Anticoagulation Duration of anticoagulant treatment should be individualized. According to studies in the general population, total duration should be from 3 to 6 months in patients with only transitory risk factors. Anticoagulation should be extended for at least 6 weeks postpartum; patients with persistent risk factors, however, may require more prolonged duration of anticoagulation. 131,342 5.2.5.3. Inferior Vena Cava Filters Temporary removable inferior vena cava filters may be used during gestation with indications similar to non-pregnant patients. This means that they are contraindicated in cases of conventional anticoagulation, such as the following: hemorrhagic stroke, active bleeding and recent surgery; thromboembolism in spite of full anticoagulation; need to interrupt anticoagulation; or when pulmonary circulation is significantly impaired. The use of vena cava filters is limited, because it is associated with risks of insertion and removal, such as filter migration in more than 20% of cases, filter fracture in more than 5%, perforation of the inferior vena cava in 5%, and mortality in 0.12% to 0.3%. 131 5.2.5.4. Thrombolysis Thrombolysis is reserved for patients with massive PTE and associated hypotension. Maternal mortality is estimated at 1%, fetal loss at 6%, and maternal hemorrhage at 8%. Intravenous UFH should be initiated immediately after thrombolysis, and LMWH should only be initiated once the clinical picture has stabilized. 5.2.6. Prophylaxis Proposed prophylaxis regimes (Table 36) against thromboembolic phenomena during gestation in diverse clinical situations are the following: 131,336,338,342 • Prophylactic UFH: 5,000 units of subcutaneous UFH, every 12 hours; • Intermediate dose of UFH: 10,000 units of subcutaneous UFH, every 12 hours; • Adjusted UFH: subcutaneous UFH, every 12 hours with APTT adjusted to 1.5 to 2.5 times baseline; • Prophylactic LMWH: dalteparin (5,000 units subcutaneous daily), enoxaparin (40 mg or 0.5 mg/kg subcutaneous), or tinzaparin (4,500 units subcutaneous); • Intermediate dose of LMWH: dalteparin (5,000 units subcutaneous, every 12 hours) or enoxaparin (40 mg subcutaneous, every 12 hours); • Adjusted dose of LMWH: dalteparin (200 U/kg or 100 U/kg every 12 hours) or enoxaparin (1 mg/kg every 12 hours) in doses adjusted to 0.6 to 1.2 anti-Xa factor; • Postpartum: Initiate with intravenous UFH or subcutaneous LMWH + warfarin until INR reaches 2.0. Subsequently, maintain warfarin for 4 to 6 weeks with INR between 2.0 and 3.0. 5.2.7. Key Points • Thromboembolism is an important cause of morbimortality during gestation; • Gestation and other related factors may increase the risk of the disease; • Diagnosis of thromboembolism should be confirmed in order to justify treatment of the disease, which is prolonged, requires prophylactics measures, and has future therapeutic implications; • When thromboembolism is suspected during gestation, venous ultrasound should be the first complementary examination solicited; • While normal D-dimer dosage appears to have a negative predictive value, it has not been validated during gestation; • Pulmonary V/Q scintigraphy or CTPA are examinations of choice for diagnosing PTE during gestation; • Treatment of DVT or low-risk PTE during gestation is based on the use of LMWH or UFH; • Treatment should be maintained throughout the entire gestation and at least for 6 weeks postpartum; • Thromboembolic prophylaxis should be used in pregnant women with past history of thromboembolism. It should also be considered in the presence of other risk factors; • Investigation of thrombophilia should be individualized; • The absence of factors such as deep vein thrombosis, hemoptysis, PTE as the most likely diagnosis and, D-dimer not exceeding 1000 ng/ml, makes the diagnosis of PTE unlikely. 5.3. Therapy and Prevention 5.3.1. Heart Failure HF stands out as the main cause of complications associated with maternal mortality in women with heart disease. 910