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 45 – Predictors of maternal events and risk score from the CARPREG study 1. Previous cardiac event (HF, transitory ischemic attack, pulmonary stroke prior to gestation, or arrhythmia) 2. NYHA FC > II or cyanosis 3. Left heart obstruction (mitral area < 2 cm 2 , aortic valve area < 1.5 cm 2 , or peak left ventricular outflow gradient > 30 mmHg on echo) 4. Reduced systolic ventricular function (< 40%) CARPREG risk score (each predictor is worth 1 point) • 0 points – 5% risk • 1 point – 27% risk • More than 1 point – 75% risk FC: functional class; HF: heart failure; NYHA: New York Heart Association. Table 46 – Predictors of maternal risk from the ZAHARA study History of arrhythmia before gestation – 1.5 points HF with NYHA FC > II – 0.75 points Left heart obstruction (aortic valve stenosis with peak gradient > 50 mmHg or valve area < 1 cm 2 ) – 2.5 points Mechanical prosthetic valve – 4.25 points Moderate to severe systemic atrioventricular valve regurgitation (possibly due to ventricular dysfunction) – 0.75 points Moderate to severe subpulmonary atrioventricular valve regurgitation (possibly due to ventricular dysfunction) – 0.75 points Cardiovascular medication use before gestation – 1.5 points Repaired or unrepaired cyanotic heart disease – 1 point ZAHARA risk score: 0 to 0.5 – 2.9% risk 0.51 to 1.5 – 7.5% risk 1.51 to 2.5 – 17.5% risk 2.51 to 3.5 – 43.1% risk > 3.5 – 70% risk FC: functional class; HF: heart failure; NYHA: New York Heart Association. In order to choose a contraceptive method, should be considerer 1) safety supported on the into medical eligibility criteria of available methods 2) clinical condition of patiente; 3) effectiveness, determined by the number of failures (i.e. pregnancies) that occur in every 100 women utilizing the method for 12 months, which is known as the Pearl index 417 (Figure 14). Patients with severe diseases that contraindicate pregnancy or patients who wish to postpone or avoid pregnancy should receive adequate counseling regarding contraception. 418 Furthermore, patients with contraindications to gestation have higher surgical risks; for this reason, permanent methods (laparotomic, laparoscopic, or hysteroscopic tubal ligation) are not any more recommended than any other highly efficacious methods. In recent years, special attention has been given to long- acting reversible contraception (LARC) methods. These methods have greater adherence because they do not depend on the user remembering them; furthermore, they have greater contraceptive efficacy, with a lower number of failures, and they do not contain estrogen. This category includes both types of IUD (copper and levonorgestrel) and etonogestrel subdermal implant. 419,420 6.2.2. Medical Eligibility Criteria TheWHO has analyzed the safety of different contraceptive methods, taking each clinical condition and their relevant characteristics into consideration, including the following: whether the method worsens a preexisting condition or adds additional health risks; and whether the condition renders the contraceptive method less effective. 421 Safety should always be weighed when comparing the risk of an unplanned pregnancy. It is fundamental to remember that refusing patients access to all contraceptive methods due to concerns related to diseases they have increases the risk of decompensating these diseases should pregnancy occur. Table 48 shows a summary of the categories of medical eligibility criteria for contraceptive choice. 924