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 47 – Modified WHO classification Risk I • Pulmonary stenosis, PDA, and mild to moderate uncomplicated mitral valve prolapse • IAC, IVC, PDA, and uncomplicated, successfully repaired pulmonary vein drainage anomalies • Isolated atrial or ventricular extrasystoles Risk II (uncomplicated): • Unoperated uncomplicated IAC and IVC • Repaired tetralogy of Fallot • Most arrhythmias Risk II-III (individualized evaluation) • Mild left ventricular impairment • Hypertrophic cardiomyopathy • Native or tissue valvular heart disease (not considered WHO risk I or IV) • Marfan syndrome without aortic dilatation • Bicuspid aortic valve with aorta diameter < 45 mm • Repaired coarctation of the aorta Risk III • Mechanical prosthetic valve • Systemic right ventricle • Fontan circulation • Cyanotic heart disease (unrepaired) • Complex congenital heart diseases • Marfan syndrome with aorta diameters between 40 and 45 mm • Bicuspid aortic valve with aorta diameters between 45 and 50 mm Risk IV (pregnancy contraindicated): • Pulmonary arterial hypertension of any etiology • Severe systemic right ventricular dysfunction (LVEF < 30%, NYHA FC III/IV) • Peripartum cardiomyopathy with ventricular dysfunction • Severe mitral stenosis, severe symptomatic aortic stenosis • Marfan syndrome with dilated aorta > 45 mm • Aortic dilatation associated with bicuspid valve > 50 mm • Turner syndrome with aortic index > 25 mm/m 2 • Tetralogy of Fallot with aorta > 50 mm • Ehlers-Danlos syndrome • Fontan procedure with any complication • Severe coarctation of the aorta FC: functional class; IAC: interatrial communication; IVC: interventricular communication, LVEF: left ventricular ejection fraction; NYHA: New York Heart Association; PDA: patent ductus arteriosus. Accompanying women of fertile with heart disease requires decisions on the application of family planning methods and, therefore, contraception counseling. A pioneering study on the efficacy and safety of contraceptives that included low-dose combined oral contraceptives, quarterly injection of progestin, and IUD in women with heart disease showed good tolerance and safety for patients who followed the eligibility criteria. 422 6.2.3. Contraception in Adverse Conditions 6.2.3.1. Hypertension In patients with hypertension, the use of combined contraceptive methods may worsen blood pressure control. Ethinylestradiol increases the hepatic synthesis of angiotensinogen, which leads to an increase in angiotensin II and aldosterone, with higher systolic volume and greater cardiac output, as well as increased peripheral vascular resistance, thus resulting in greater arterial pressure. In susceptible patients, this increase may be considerable, causing clinical decompensation. 423 For this reason, patients with hypertension, even if it is controlled, should not use combined methods; there is, however, no contraindication to the use of progestin-only methods in patients with controlled hypertension, and, in patients with uncontrolled hypertension, only quarterly injections should be avoided. Table 49 shows the medical eligibility criteria for different types of contraception in relation to patients with SAH. 6.2.3.2. Diabetes Melittus Patients with diabetes are at a greater risk of cardiovascular events than healthy women, and they are more exposed to unfavorable outcomes during pregnancy. 424 For this reason, contraception in patients with diabetes should be guided by the best available evidence. 425 Table 50 summarizes the eligibility criteria for different contraceptive methods in patients with diabetes. There is a theoretical concern that, due to its glucocorticoid effect, quarterly depot injections of medroxyprogesterone acetate may worsen glycemic control, and, in patients with vasculopathy, theymay increase the risk of thromboembolic and cardiovascular events; for this reason, it is classified as category 3. 6.2.3.3. Heart Valve Disease Complicated heart valve diseases are included in the WHO list of conditions that expose women to greater health risks due to undesired pregnancy. 415,426 Nevertheless, several studies have shown expressively low rates of use of contraceptive methods in women with heart disease. 422,427 To comprehend the criteria summarized in Table 51, heart valve diseases are divided into complicated and uncomplicated. Those that are accompanied by PH, risk of AF, and history of subacute bacterial endocarditis are considered complicated. Table 51 shows the medical eligibility criteria for different types of contraception in relation to patients with heart valve disease. Currently, the indication for antibiotic prophylaxis during IUD insertion is controversial, and the available evidence does not seem to justify making it mandatory. Deciding whether or not to use it is at the attending physician’s discretion, considering associated risks and benefits. It is, however, indispensable to remember that the best way to avoid pelvic infection is by performing adequate antisepsis. 6.2.3.4. Previous Cardiovascular Events Women with ischemic coronary disease or stroke may safely initiate progestin-only contraceptive methods, with the exception of the quarterly injection. However, if events 925