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 41 – Precautions for cardiac surgery with cardiopulmonary bypass during pregnancy Control of hemodilution, which should not be below 25% hematocrit level Use of flow 30% to 40% above usual flow, maintaining mean arterial pressure above 60 mmHg Use of mild hypothermia or normothermia, in order to avoid fetal arrhythmias in cooling and warming and to decrease uterine contractions Use of added glucose in the perfusate, in order to avoid fetal bradycardia and improve fetal energy conditions Adequate control of acid-base balance, avoiding acidosis The same applies to the distinction between HF consequent to rheumatic carditis and chronic heart valve disease; both increase the risk of maternal death, and they have very different forms of treatment. 356 Treatment of rheumatic outbreak, which is rare during pregnancy, should be the same as in the general population. Hospitalization is indicated in all cases of suspected carditis, incapacitating arthritis, or severe chorea, and home rest should last for a minimum of 4 weeks and, eventually, until delivery. 357 Secondary prophylaxis for RF should be maintained during gestation in accordance with the following recommendations: penicillin G benzathine 1,200,000 IU intramuscular every 21 days or phenoxymethylpenicillin 250mg orally 2 times daily. In patients who are allergic to penicillin, erythromycin 250mg orally 2 times daily or clindamycin 600 mg daily are recommended. 357 The use of sulfadiazine is contraindicated during pregnancy. Duration of prophylaxis does not depend on occurrence during pregnancy, and it is related to the following factors: RF without prior carditis (for 21 years or 5 years after the latest outbreak, applying whichever covers the longer period); RF with prior carditis, mild residual heart valve disease, or resolved valve lesion (for 25 years or 10 years after the latest outbreak, applying whichever covers the longer period); moderate to severe residual valve lesion (for 40 years or lifelong); after valve surgery (for 40 years or lifelong). Patients with risk of repeat pharyngitis, such as those who work in daycare centers or nursing homes, should use secondary prophylaxis for the rest of their lives. 353,358 5.4.3. Key Points • Antibiotic prophylaxis for IE at the moment of delivery should be performed in patients at a high risk for IE; • Prophylaxis for RF should be maintained during pregnancy. 5.5. Cardiovascular Surgery During Pregnancy Worldwide experience in cardiac surgery during pregnancy has shown controversial results. Studies are characterized by retrospective nature and heterogeneity of procedures, associated with difficulties to standardization of surgical techniques, which render difficult the judicious analysis of prognostic variables and their reflexes in practice during pregnancy. 359,360 It is accepted that the risk of maternal death due to cardiac surgery is not greatly modified by pregnancy. 359 For emergency surgery, however, the risk of maternal mortality increases. 361 The maternal mortality rate verified of 7.5% to 13.3% is relatively high, in comparison with that of cardiac surgery in the population of young women of fertile age, which encompasses the age range of pregnancy. 359,361,362,363 Another important aspect for indication of cardiac surgery is gestational age. This is because, the earlier complications appear in patients with severe lesions, the greater the tendency to indicate early surgery, because there is a very high tendency for hemodynamic deterioration to progress during pregnancy, leading to an increase in emergency surgery and maternal death. This logic justifies the notion that the best period to plan cardiac surgery is during the second trimester of gestation, given that the fetus is still not viable, and the physiological and mechanical modifications pregnancy are still not very significant; furthermore, it provides the mother with a reasonable postoperative recovery period. One of the highest risk variables associated with worse maternal-fetal outcomes is emergency. 362,363 Surgery during pregnancy requires specific precautions; the following stand out: choice of anesthetic drug, continuous maternal-fetal monitoring , and adequate control of anticoagulation. The obstetric team should initiate both maternal and fetal monitoring simultaneously, by means of cardiotocography, in order to control uterine dynamics and fetal heartbeat. Induction of anesthesia should be cautious to avoid periods of hypoxia and hypotension, and drugs without teratogenic effects should be chosen. 52 Cardiovascular surgery techniques during pregnancy do not differ from those for non-pregnant patients; the surgical team’s experience, however, is fundamental in order to reduce duration of surgery, especially of CPB, in addition to specific precautions which are shown in Table 41. Typically, a drop in fetal heart rate occurs during initial installation of CPB, which returns to normal by completion. 359 This is mainly due to the change to continuous flow, embolic effect of microbubbles, initial hypotension, hemodilution, stacking of red cells, and alterations in peripheral vascular resistance. This “acute dysfunction” of the placenta as a result of impaired uteroplacental flow is the cause of the high incidence of fetal loss, prematurity, neonatal death, and malformations. 361,364 It has been recommended to indicate delivery before cardiac surgery if the fetus is viable. Nevertheless, it is worth highlighting that corticoid use for fetal pulmonary maturation is very risky for pregnant women with unstable, severe hemodynamic conditions, which are very frequent in this situation. This is because corticoid use in recommended doses (2 doses of betamethasone, 12 mg intramuscular, 12 hours before delivery), associated with delivery, whether cesarean or vaginal, may lead to aggravation of HF, cardiogenic shock, and maternal death. 915