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 promotion of oral health, advice on hygiene, and periodic dental consultation for surveillance of gingivitis, which favors periodontal disease. Antibiotic prophylaxis for dental treatment is controversial; nonetheless, when it is indicated, 2 g of oral amoxacillin or 600 mg of oral clindamycin are used for patients who are allergic to penicillin, 1 hour before dental intervention. Antibiotic prophylaxis for IE at the moment of vaginal or cesarean delivery is also controversial, 350 and the lack of evidence regarding disease prevention with antibiotic use at the moment of delivery renders their indication fragile. Nevertheless, it is necessary to consider that the occurrence of IE during the postpartum period is severe, given that, during this period, complications that elevate bacteremia (manual extraction of the placenta, curettage, or placental retention) 352 are not predictable, and postpartum infection in Brazil is one of the leading obstetric causes of maternal death. For this reason, the decision to use antibiotic prophylaxis for IE at the moment of delivery should be at the discretion of the team caring for the parturient patient, with individualization of each case. Although it is still controversial, clinical situations at a high risk of IE that may require routine antibiotic prophylaxis are shown in Table 39, 350 and recommendations regarding means of application are shown in Table 40. Clinical diagnosis of IE reviews history of fever; chills; decline in general condition; embolic, peripheral, or central phenomena; vascular or immunological phenomenon; glomerulonephritis; and new murmur. Regarding complementary examinations, transthoracic Doppler echo should be performed whenever clinical suspicion exists; transesophageal echo is indicated when transthoracic echo is negative for IE and in cases of prosthetic valve. Blood cultures should be collected prior to the introduction of antibiotics. A minimum of 3 samples should be taken at 30-minute intervals, by means of sterile peripheral venipuncture, regardless of fever peak. Treatment should be initiated following blood culture collection, and it should be based on epidemiology, clinical history, and blood culture and antibiogram results, in accordance with conventional guidelines. 350,351 It is worth remembering that the most common etiological agent of IE in Brazil is Streptococcus viridans in the oral cavity. The choice of antibiotic, intravenous administration, and duration of antibiotic therapy are the same as in non-pregnant patients, considering the possible toxic effects of antibiotics on the fetus. 52,350,351,353 There are, accordingly, 3 groups of antibiotics classified regarding risks to gestation: (1) the safest, which include ampicillin, penicillin, amoxacillin, oxacillin, erythromycin, daptomycin, and cephalosporins; (2) those which present intermediate risk and should thus be monitored, such as vancomycin, imipenem, rifampicin, and teicoplanin; and (3) those that are contraindicated, namely, aminoglycosides, quinolones, and tetracycline. 354 Surgical treatment in cases of IE follows conventional indications, such as failure of etiological treatment, refractory HF, repeat embolic phenomena, periprosthetic complications, abscess, or prosthetic dehiscence. It is recommended that delivery take place before cardiac surgery in cases where the fetus is viable. 351,353 5.4.2. Rheumatic Disease Rheumatic fever (RF) is an autoimmune disease which occurs following infection of the oropharynx by Lancefield Group A beta-hemolytic Streptococcus . 355 The first rheumatic outbreak affects children in early childhood, and it contributes to an important number of women with valve disease in reproductive age and, therefore, during pregnancy. Acute RF is rare during pregnancy, but its diagnosis should be considered in pregnant adolescents without previous prophylaxis or those who present a clinical picture of severe HF that does not correspond to the degree of valve involvement. Diagnosis is guided by the Jones criteria and complementary examinations. 355 Both major (carditis, Sydenham’s chorea, migratory arthritis, erythema marginatum, and subcutaneous nodules) andminor (fever and arthralgia) criteria are valid during gestation; however, acute phase reagents, such as alpha acid- glycoprotein, C-reactive protein, and protein electrophoresis, may be influenced by pregnancy. For this reason, diagnosis is strongly based on the patient’s clinical presentation and history. Accordingly, it is worth considering that Sydenham’s chorea is a common cause of chorea in patients who have prior history, and there should be differential diagnosis with chorea gravidarum, which may be associated with morbidities other than RF. Both manifestations of chorea are linked to high obstetric risks, such as fetal loss, and they require differential treatment. 355 Table 39 – High-risk heart diseases for infectious endocarditis 350 Prosthetic valves Transcatheter valve prostheses Prosthetic material used for valvuloplasty, such as rings for annuloplasty and artificial chord Prior infectious endocarditis Congenital heart disease Unoperated cyanotic Complex heart disease with residual lesion (shunts, valve regurgitation in the graft location, valve tubes) Table 40 – Antibiotics and doses used one hour before delivery Antibiotic Doses Ampicillin 2.0 g IV or IM Associated with gentamicin 1.5 mg/kg O, IV, or IM Patients allergic to penicillin/ampicillin/amoxacillin Vancomycin 1.0 g IV for 1 h Associated with gentamicin 1.5 mg/kg IV or IM IM: intramuscular; IV: intravenous; O: oral. 914