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 A protocol with low-dose thrombolytic therapy in slow infusion (rT-PA 25 mg, intravenous infusion for 6 hours, repeated after 24 hours and, if necessary, up to 6 times, reaching a maximum dose of 150 mg, without bolus or concomitant use of heparin) has recently been proposed for pregnant women with prosthesis thrombosis. The results have shown that thrombolysis was efficacious, with no maternal deaths, and fetal mortality rate was around 20%, which is better than the routinely used strategies. 403 With the enhancement of surgical techniques, however, it is not possible to infer that thrombolysis is superior to surgery during pregnancy. The issue with surgery is due to high perioperative mortality (between 5% and 18%), which is closely associated with NHYA FC, which is the main predictor variable. Patients in NHYA FC I/III present 4% to 7% mortality, whereas those in FC IV present 17.5% to 31.3%. In contrast, surgery presents a higher rate of success than thrombolysis (81% versus 70.9%). 399 In this scenario, it should be considered in urgent or emergency cases, depending on the patient’s clinical condition. Surgical procedures are associated with maternal and fetal risks, when performed during pregnancy. In patients with non-obstructive thrombi, who are stable from the hemodynamic point of view and who have no signs of decompensated HF, parenteral anticoagulation at therapeutic doses, with heparin according to APTT and echocardiographic imaging control, is the option. In cases that fail to respond to treatment, thrombolysis or conventional surgery should be indicated. 151,402 5.7.6. Cardiorespiratory Arrest Cardiorespiratory arrest (CRA) in pregnant women is one of the most dramatic and challenging situations in the emergency room. Although the steps for cardiopulmonary resuscitation (CPR) in pregnant women are very similar to those related to the conventional protocol stipulated by advanced cardiac life support (ACLS), there are different details that require due attention, which are summarized in Figure 13. 404 It is worthwhile to remember that many episodes of CRA are preceded by signs of hemodynamic instability. For this reason, teams providing care should receive training regarding not only prompt recognition and evaluation of these findings, but also complete performance of CPR in a synchronous manner. 405 The mechanical effects of the pregnant uterus can aggravate desaturation and hypotension in aortocaval compression, favoring cardiorespiratory collapse.In the attempt to reduce aortocaval compression by the gravid uterus, manual left uterine displacement should be performed throughout attendance and during care following CRA. 406 When indicated, defibrillation should be performed promptly, without delay or questioning. It is known that it does no harm to the fetus; it is completely safe, and the energy doses established by current protocols should be maintained. 407 In the same manner as the indications for defibrillation regarding energy doses, medications and their doses should be the same as those defined by protocols used in adults in general. 405,407,408 Attention should be paid to venous access above the diaphragm, thus minimizing the effects of aortocaval compression caused by the gravid uterus, which would make it difficult to recirculate the medication. 409 For pregnant women, in addition to considering the classic causes of CRA established by the ACLS protocol, which makes use of a mnemonic device with letters A to H , there are other diverse conditions which may favor cardiorespiratory collapse, and which may be corrected 409 (Table 44). As soon as CRA is identified in a pregnant patient, the performance of perimortem cesarean delivery should promptly be considered if the patient’s uterus is above her umbilicus. 410 This measure is characterized by performing cesarean delivery and birth of the fetus after maternal CRA, in most cases during the period of CPR. A review of the last decade has shown that perimortem cesarean delivery is related to maternal survival in 31.7% of cases, and it has no harmful effects on the mother. 411 One of the purposes of performing this type of delivery is to facilitate CPR, because it possible to release aortocaval compression by the gravid uterus completely, seeing that lateralizing it to the left is not sufficient. The other purpose is to deliver the child, reducing the risk of anoxia during the period of CRA, thus minimizing definitive neurological sequelae. 412 The decision to perform urgent cesarean delivery should be made within the first 4 minutes after CRA. Delivery should be in the same place as attendance for CPR, given that patient transfer may lead to delays that increase risks to the fetus and compromise resuscitation maneuvers. 409 It is worth highlighting that the entire CPR protocol should be maintained during performance of the procedure. In situations where the maternal clinical picture is considered irreversible, perimortem cesarean delivery should be performed immediately. 5.7.7. Key Points • In emergency cases, practice should prioritize the mother’s life. It is not justified to omit any treatment that is essential to the mother on account of concerns regarding potentially harmful effects to the fetus; • Practice for cardiac emergencies during pregnancy should follow conventional protocols, such as ACLS. • Cesarean section is considered “perimortem” in pregnant women with uterine height above the umbilical scar, in order to improve the maternal-fetal prognosis. 6. Family Planning 6.1. Pregnancy Counseling and Maternal Risk Stratification Preconception counseling is essential for women of reproductive age with heart disease, with emphasis on maternal and fetal risks related to gestation and information regarding the safety and efficacy of contraception. The criteria of functional evaluation for approving or contraindicating pregnancy include anamnesis, clinical examination, and subsidiary examinations, such as ECG, chest X-ray, transthoracic or transesophageal echo, CMR, ergospirometry 921