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 Copper-T IUD pose a risk of metrorrhagia, while long-acting reversible contraceptive (LARC) methods with levonorgestrel may be recommended when the patient does not present structural cardiac injury. Unplanned pregnancy is very frequent in women with heart disease, especially due inadequate contraception counseling. In fact, myths about the eventual risks and lack of knowledge about the efficacy and application of eligibility criteria are factors which favor maternal mortality. Faced with this reality, contraception counseling regarding preferences, contraindications, and efficacy of methods should be initiated during the immediate postpartum period, even before hospital discharge. 435 6.2.4. Contraception and Adolescence Age alone does not represent a contraindication to different methods of contraception; nevertheless, during adolescence, doubts may arise regarding strategies for presenting and prescribing contraceptives. Indication of methods should be based on eligibility criteria and, when attending adolescents, it is necessary to consider ethical and legal aspects, which are not always known. Article 226 of the Brazilian Constitution guarantees the right to family planning free of coercion, and the Child and Adolescent Statute (Law Number 8069, July 13, 1990) clearly addresses important issues in providing care to adolescents who require contraceptivemethods, basedonprivacy and confidentiality rights. Adolescent patients have the right to privacy, i.e., to be attended alone, in a private consultation space. Confidentiality is defined as an agreement between physicians and patients, meaning that information discussed during and after consultation may not be disclosed to adolescents’ parents or guardians without their express consent. 420 Confidentiality is supported by rules of medical bioethics, through moral principles of autonomy (article 103 of the Code of Medical Ethics). In this manner, adolescents have the right to sexual education, access to information about contraception, confidentiality and secrecy regarding their sexual activity, and the prescription of contraceptive methods; there are no ethical infractions when medical professionals proceed in this manner. Table 52 – Medical eligibility criteria for different types of contraception in relation to patients with previous cardiovascular events Combined hormonal contraception Progestin-only contraception Intrauterine device Oral Patch Vaginal ring Monthly injection Oral Quarterly injection Subdermal implant Copper Levonorgestrel Ischemic heart disease 4 4 4 4 I: 2, C: 3 3 I: 2, C: 3 1 I: 2, C: 3 Stroke 4 4 4 4 I: 2, C: 3 3 I: 2, C: 3 1 2 I: initiation; C: continuation. Adapted from the World Health Organization, 2015. 421 Table 53 – Recommendations for contraceptive use in patients with congenital heart disease OC Progestin- only pill Implant Depo-Provera IUD Barrier 1. Surgically corrected defects: Without residual lesions: IAC/IVC/PDA 1 1 1 1 1 Shunt and/or residual obstruction 3 1 1 1 3 1 Prosthetic valve, tubes, patches 2 1 1 1 2 1 Pulmonary and/or systemic hypertension 4 2 2 2 3 1 2. Uncorrected, residual, or postoperative defects: Small IVC 2 1 1 1 4 1 Mild to moderate shunt (IAC, IVC, PDA) 4 1 1 1 4 2 Residual pulmonary or systemic hypertension (CoA) 2 1 1 1 4 3 Complex cyanotic defects 4 1 1 1 4 1 3. Complicated defects due to: Cyanosis 4 1 1 1 - 1 Ventricular dysfunction 3 1 1 1 - 1 Atrial fibrillation/flutter 4 2 2 2- 4 2 Eisenmenger syndrome 4 2 2 2 4 4 CoA: Coarctation of the aorta; IAC: interatrial communication; IUD: intrauterine devices; IVC: interventricular communication; OC: oral contraceptives; PDA: patent ductus arteriosus. 928