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 The literature is lacking in data on target doses for reaching therapeutic goals during gestation, which should not be the same as those considered for the general population of women with heart disease. This is because reduced heart rate and decreased arterial pressure resulting from high doses, which are usually factors applied to the population of patients with HF, can impair uteroplacental circulation. It is generally prudent for doses of drugs used during pregnancy to be fractionated; they should initially be low and gradually increase, with caution, seeking the highest dose tolerated by the mother and the fetus. The following are thus recommended: an initial dose of bisoprolol of 1.25 mg daily, carvedilol of 3.125 mg 2 times daily, and metoprolol succinate of 12.5 mg 2 times daily, in accordance with the recommendations for the population of patients with HF. 345 Vitality (biophysical profile and cardiotocography) and fetal maturity should be assessed more frequently when compared to the population of healthy pregnant women. During the neonatal period, supervision should last from 24 to 48 hours after birth, considering the most frequent symptoms and signs, such as respiratory depression, bradycardia, hyperbilirubinemia, and hypoglycemia. For this reason, when a patient is close to delivery, a prudent measure is to reduce the beta-blocker progressively, seeking the lowest dose with maternal efficacy. 344 The occurrence of pulmonary congestion requires the use of loop diuretics, preferably furosemide and thiazide diuretics, in the attempt to optimize preload. In the event that there is no congestion, they should be avoided, due to the risk of causing reduced uteroplacental flow. 346 Attention should be paid to the deleterious effects of the permanent use of diuretics, such as worsened placental flow, increased uric acid (early marker of preeclampsia), appearance of maternal-fetal electrolytic disorders, and IUGR. Hydralazine may be used to treat symptoms of HF, with or without nitrates, as an alternative treatment in the event that SAP is > 110 mmHg, especially in cases with associated arterial hypertension, severe left ventricular dysfunction, and/or evidence of congestion. 52,345 Nevertheless, during pregnancy, the association between hydralazine and nitrates has been related to low maternal tolerance due to the usual arterial hypotension. Digoxin may be used when volume overload persists, notwithstanding therapy with vasodilators and diuretics. When it is necessary in patients with HFrEF, digitalis plays an important role in controlling maternal heart rate, especially in the presence of AF. 345 Anticoagulation in HF during pregnancy is controversial. LMWH or UFH may be considered in patients in the most common situations, such as dilated cardiomyopathy with LVEF < 35%, prolonged hospitalization and history of thromboembolic events. It is worthwhile to consider that the postpartum period adds a higher risk of thromboembolism; for this reason, anticoagulation is indicated during this phase of the pregnancy-postpartum cycle. Regarding arrhythmias in HF, AF if the most common, and it may be treated with beta-blockers; if necessary, digoxin is added to control heart rate. Regarding frequent ventricular arrhythmias or sustained ventricular tachyarrhythmia, treatment includes the use of amiodarone and, when risks are higher, ICD are indicated. When hemodynamic instability and cardiogenic shock occur, the patient should initially be transferred to the ICU, if possible, with MCS. 346 Urgent cesarean delivery should be considered, with MCS immediately available; in the event of elective delivery, however, it is at the obstetrician’s discretion whether the route of delivery is vaginal or cesarean, considering maternal parity, existing comorbidities, and the severity of cardiac injury. During the postpartum period, it is necessary to avoid volume overload as a result of infusion of fluids during the intrapartum and postpartum periods. The use of oxytocin in low doses should be considered, in spite of its vasoactive properties, and ergometrine should be avoided due to its peripheral vasoconstrictive effect. 5.3.2. Key Points • The physiological symptoms and signs of pregnancy may delay diagnosis of HF; • BNP (≤ 100 pg/ml) is a marker of HF that is also valid during pregnancy; • Serial BNP during gestation assists in HF diagnosis and therapy; • Beta-blockers are considered first-line drugs, and they should be maintained during gestation in cases of HFrEF; • During family planning, pregnancy should be advised against in women with chronic HF who present LVEF < 40% and contraindicated in those in FC III/IV with LVEF < 20%. 5.4. Therapy and Prevention 5.4.1. Infective endocarditis IE is rare during pregnancy; it occurs in 0.006% of the general population. However in patient with valve disease or congenital heart disease, this percentage reaches 1.2%. 270,350 Patients with valve prostheses and complex cyanotic heart disease, as well as those who use illicit drugs, constitute a higher-risk group. IE is a severe disease with maternal mortality close to 33%, consequent HF, and thromboembolic phenomena. 350,351 During pregnancy, special attention should be paid to fever without an apparent cause and new precordial heart murmur, given that it appearance is very common during normal pregnancy. The approach to IE requires multidisciplinary care in a tertiary cardiology center, with decisions supported by a heart team that is qualified to offer the resources available for diagnosis, treatment, and follow up, according to conventional recommendations. 350 Prophylaxis for IE during pregnancy follows the same recommendations that apply non-pregnant patients. 350,351 Given that the oral cavity is the entryway for the most frequent etiological agents, basic orientations for preventing IE include 913