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 Figure 13 – Flowchart for guiding intra-hospital care for cardiorespiratory arrest in pregnant women. ACLS: advanced cardiology life support; CRA: cardiorespiratory arrest; IV: intravenous; OTI: orotracheal intubation; PMCS: postmortem cesarean section. * Causes are shown in Table 44. CRA identified in a pregnant woman Basic life support • Give attention to good quality of compressions • Defibrillation, when indicated • Perform left uterine displacement • Always monitor quality of compressions Advanced attendance team Consider etiology of CRA* Obstetric care (for patients with uterus above umbilicus) Maternal care Airway management • Predict difficult airway • Consider OTI by the most experienced provider Venous access above the diaphragm • Drugs and doses recommended by ACLS • Pay attention to hypovolemia and consider volume replacement and blood transfusion, when indicated If the patient is receiving magnesium IV, in addition to stopping the infusion, either 10 ml of calcium chloride 10% or 30ml of calcium gluconate 10% should be applied IV Maintain left uterine displacement Consider and prepare emergency cesarean delivery Neonatal care If spontaneous circulation does not recover during the first 4 minutes, consider PMCS test, and other more specific tests. Invasive intervention for eventual treatment of cardiac lesions, if indicated, should be performed before gestation. Once a diagnosis of heart disease (anatomical, functional, and syndromic) has been determined, the risk of pregnancy is weighed together with the couple or relatives. 270 Identification of risk predictors for pregnancy contributes to determining maternal prognosis and decision making, such as approving or advising against conception. The prospective multicenter study known as CARPREG 190 considered a study population composed 75% of women with congenital heart disease and 25% of women with acquired heart disease, verifying cardiovascular complications in 13%, including 3 cases of maternal death. The predictors of maternal mortality proposed by this study are shown in Table 45. Subsequently, the ZAHARA study 413,414 defined independent predictors of mortality for women with congenital heart disease, generating a very specific risk estimate. The event rate in the 1,300 women studied was 7.6%, and the most frequent complications were arrhythmia (4.7%) andHF (1.6%) (Table 46). The classification for theWHOwhich divides heart diseases by increasing level of severity: (1) risk I includes low-risk heart diseases (accepted as equal to that of the general population); (2) risk II denotes a slight risk of mortality and moderate risk of morbidity; (3) risk III, there is a significant risk of mortality or severe morbidity, (4) risk IV denotes a high risk of mortality that contraindicates pregnancy (Table 47). 415 Comparison between the 3 studies, 324 considering the CARPREG, ZARAHA, andWHO scores, revalidated the WHO classification as the most accepted and reliable for predicting risks of heart disease to pregnancy (Tabela 47). Patients included in the IV-WHO risk should be advised against pregnacy. 324 The Registry of Pregnancy and Cardiac Disease (ROPAC) validated the modifiedWHO classification, 416 which includes an intermediate category (risk II/III-WHO) which means moderate risk of morbidity and mortality. This study also showed differences between developed and emerging countries regarding the characteristics of heart diseases and the complication rates that can lead to distortions in the interpretation of the risk score. The ESC 52 Guidelines suggest using the modified WHO classification to establishment maternal risk. This Brazilian Statement understand that WHO classification is themost accepted, and it should be applied to risk stratification of heart diseases for pregnancy. It is worth considering that complicating factors that are expected throughout the natural history of heart diseases, such as complex arrhythmias, prior HF, thromboembolism, or IE, aggravate maternal risk. The resources for care and the availability of amultidisciplinary team should also be considered and individualized during pregnancy counseling. The ESC Guidelines 52 added aortic diseases associated with the following to WHO risk IV category: Turner syndrome (aortic size index of 25 mm/m 2 ); tetralogy of Fallot (aorta diameter > 50 mm), Ehlers-Danlos vascular syndrome; and Fontan circulation with complications. 922