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 Table 36 – Proposed prophylaxis regimes Clinical history Practice during pregnancy Practice during postpartum History of thromboembolism with transitory RF unrelated to estrogen use or the current pregnancy* Observation Anticoagulant prophylaxis with a prophylactic or intermediate dose of UFH/LMWH for 6 weeks History of idiopathic thromboembolism Prophylactic or intermediate dose of UFH/LMWH Anticoagulant prophylaxis with a prophylactic or intermediate dose of UFH/LMWH for 6 weeks Patients with high risk** thrombophilias with history of thromboembolism Prophylactic or intermediate dose of UFH/LMWH Prophylactic or intermediate dose of UFH/LMWH for 6 weeks Patients with lower risk of thrombophilia, without prior thromboembolism or family history of the disease Observation or prophylactic dose of UFH/LMWH Prophylactic or intermediate dose of UFH/LMWH for 6 weeks High-risk patients, without previous thromboembolism and positive family history Prophylactic or intermediate dose Prophylactic or intermediate dose of UFH/LMWH for 6 weeks Pregnant women with previous thromboembolism Elastic socks Elastic socks Pregnant women with ovarian hyperstimulation syndrome Prophylactic dose of LMWH during the first trimester * The British Society for Haematology recommends prenatal prophylaxis in this situation. ** High-risk thrombophilias: antithrombin deficiency, positive antiphospholipid antibody, homozygous for factor V Leiden, or mutation G20210A (prothrombin gene), double heterozygosis (factor V Leiden or mutation G20210A). LMWH: low molecular weight heparin; RF: risk factor; UFH: unfractionated heparin. Table 37 – Heart failure during pregnancy Obstetric causes Preeclampsia Peripartum cardiomyopathy Amniotic fluid embolism Non-obstetric causes Cardiomyopathy Pulmonary embolism + right ventricular dysfunction Obstructive valve disease (mitral and aortic stenoses) Valve prostheses (calcification or thrombosis) Cardiomyopathies due to cardiotoxicity (drug use) Adapted from: John Antony and Karen Sliwa. 346 It has a prevalence of 0.04% in the general population of pregnant women and 12.5% among women with heart disease. It is important to emphasize that approximately 60% of cases of HF occur during the postpartum period. 344 Although they are asymptomatic, 0.85% of women in Brazil may eventually present ventricular dysfunction during the postpartum period. 345 The most frequent situations that should be considered in diagnosis of HF during the pregnancy- postpartum cycle are shown in Table 37. 346 HF associated with PPCM has been discussed in section 3.3.7. Diagnosis of HF during gestation is difficult, because adaptive physiological changes during pregnancy cause signs/symptoms, which should be considered when they are exacerbated. In this manner, interface in interpretation of physiological symptoms of pregnancy versus those of HF, as shown in Table 38, requires the application of specific knowledge in order to make the most appropriate decision regarding eventual therapeutic intervention. From initial evaluation to clinical follow up, the physician should pay attention to personal and family history of heart disease, gestational age at the time when FC progressed from I/II to III/IV, and identification of factors such as cardiac arrhythmias, anemia, and infections (Figure 11). Pregnancy is generally poorly tolerated in women with LVEF < 40% and FC III/IV (NYHA), both of which are considered predictive factors of mortality, 347 and pregnancy should be advised against. In cases with LVEF < 20%, pregnancy should be contraindicated, and, during the first trimester, interruption should be considered. The routine for pregnant women with suspicion of HF should include basic subsidiary examinations, namely, the following: laboratory tests (blood count, serum electrolytes, renal function, fasting blood glucose, glycosylated hemoglobin, lipid profile, thyroid function and liver function); 12-lead ECG to identify arrhythmias, cardiac chamber overload, and conduction disorders; chest X-ray to detect pulmonary congestion; and 2-dimensional transthoracic Doppler echo with Doppler flow analysis, which is the preferred diagnostic imaging test, not only due to its wide availability, but also to the fact that it does not require ionizing radiation. Echo identifies structural cardiac alterations, including myocardial, valve, and pericardial abnormalities, in addition to evaluating hemodynamic aspects. 345 Studies have confirmed the value of BNP as a marker for HF during gestation as well. 348 Values above 100 pg/ml contribute to sustaining clinical diagnosis of HF, and they facilitate the implementation of appropriate therapeutic measures. It may be useful to incorporate serum levels of BNP into clinical practice, especially when assessing cardiac events during pregnancy. Evaluation of prognosis of HF during pregnancy is similar to conventional evaluation; the following invasive examinations, however, should be postponed until after pregnancy: transesophageal echo, CMR, myocardial perfusion spect, PET scan , coronary angiotomography, and cardiopulmonary test. HF prevention during gestation requires multidisciplinary counseling with the obstetrician, and it should observe the 911