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 49 – Medical eligibility criteria for different types of contraception in relation to patients with systemic arterial hypertension Combined hormonal contraception Progestin-only contraception Intrauterine device Oral Patch Vaginal ring Monthly injection Oral Quarterly injection Subdermal implant Copper Levonorgestrel History of SAH where blood pressure is not known 3 3 3 3 2 2 2 1 2 Controlled SAH 3 3 3 3 1 2 1 1 1 SAH with elevated blood pressure – SAP 140 to 159 mmHg and/or DAP 90 to 99 mmHg – SAP ≥ 160 mmHg and/or DAP ≥ 100 mmHg 3 3 3 3 1 2 1 1 1 4 4 4 4 2 3 2 1 2 Target organ disease 4 4 4 4 2 3 2 1 2 DAP: diastolic arterial pressure; SAH: systemic arterial hypertension; SAP: systemic arterial pressure. Adapted from the World Health Organization, 2015. 421 Table 50 – Medical eligibility criteria for different types of contraception in relation to patients with diabetes Combined hormonal contraception Progestin-only contraception Intrauterine device Oral Patch Vaginal ring Monthly injection Oral Quarterly injection Subdermal implant Copper Levonorgestrel Without vascular lesion 2 2 2 2 2 2 1 2 2 Nephropathy, neuropathy, or retinopathy 3 / 4 3 / 4 3 / 4 2 3 2 1 2 3/4 Other vascular disease 3 / 4 3 / 4 3 / 4 2 3 2 1 2 3/4 or > 20 years’ disease duration Adapted from the World Health Organization. Medical Eligibility Criteria for Contraceptive Use. 5th ed. Geneva: World Health Organization; 2015. 421 Table 51 – Medical eligibility criteria for different types of contraception in relation to patients with heart valve disease Combined hormonal contraception Progestin-only contraception Intrauterine device Oral Patch Vaginal ring Monthly injection Oral Quarterly injection Subdermal implant Copper Levonorgestrel Uncomplicated 2 2 2 2 1 1 1 1 1 Complicated 4 4 4 4 1 1 1 2 2 Adapted from the World Health Organization. Medical Eligibility Criteria for Contraceptive Use. 5th ed. Geneva: World Health Organization, 2015. 421 the physiopathology of each group of heart disease and the risk of unplanned pregnancy (Table 53). Complex congenital heart diseases present diverse structural lesions which complicate risk stratification of contraceptive use. 415,427 In any event, cyanotic heart diseases, diseases with PAH, Eisenmenger syndrome, and diseases with an elevated risk of thromboembolism have an absolute contraindication to the use of combined methods. For these groups of patients in WHO classes III and IV, the use of progestin-only methods is recommended, and monthly injections are recommended in cases with low risks of tromboembolism. 432-434 Due to pain issues, when patients have more delicate heart conditions that occur with the risk of arrhythmias, the IUD should be inserted in a hospital environment, with the possibility of prompt relief provided by an anesthesiologist with experience in women with heart disease, due to the risk of vagal reaction following IUD insertion. 6.2.3.7. Pulmonary Hypertension As the literature is very limited, eligibility criteria for patients with PAH are not included. For this reason, contraception should be effective, tolerable, and non‑harmful, because all patients with PAH should be advised against becoming pregnant. For this reason, barrier methods or “fertility‑awareness” based methods are not recommended, because they have very elevated failure rates. Among reversible hormonal contraceptives, estrogen-containing compounds are not recommended due to the risk of PTE, leaving progestin-only methods, which may be injectable, oral, or via subcutaneous implantation, which is the most indicated. 419,420 927