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 Contraceptive counseling involving short-lasting methods such as pills is generally applied without problems following these precepts. On the other hand, in relation to long‑lasting methods (intrauterine methods and implants), as they require medical procedure for insertion, doubts may arise. The Brazilian Federation of Gynecological and Obstetric Associations (FEBRASGO, acronym in Portuguese) suggests that, for these methods, the consent of adolescents and their legal guardians should be considered, reinforcing contraceptive counseling. 436 With respect to adolescents with heart disease, contraception should be safe and effective; there is, however, a great barrier to the knowledge of different options and their access, often due to the high initial costs. During contraception counseling for adolescents with WHO risks III/IV for pregnancy, it is necessary to present all available methods with low Pearl indexes, good tolerance, and acceptance for continuity of the method, such as IUD and implants. Nevertheless, the most popular forms of contraception in adolescents continue to be condoms and withdrawal, which represent a high rate of unplanned pregnancy and high risk. Lack of knowledge, inadequate counseling, social-cultural taboos, legal restrictions, andmoralistic attitudes regarding sexuality during adolescence are common, even in patients who choose or wish to use a contraceptive method. Although long‑acting methods (IUD and implant) are prioritized by medical entities, 419 difficulties in access and acceptance by adolescents demonstrate that traditional methods, such as combined oral contraceptives and condoms, should receive focus during counseling, with the aimof improving rates of continuity and, in final analysis, reducing the possibility of high-risk pregnancies and maternal mortality due to heart disease. 6.2.4.1. Key Points • There are numerous contraceptive methods (behavior- based, barrier, IUD, hormonal, and surgical) that may be prescribed to women with heart disease; • Choice of contraceptive methods should consider patients individually, including their wishes and tolerance, as well as the eligibility criteria proposed by the WHO; • Ethical and legal aspects should be considered regarding contraception in adolescents. 6.3. Ethical Considerations The advances in medicine transformed Michel Peter’s proverb, “Women with heart disease, don’t get married, and, if you do, don’t get pregnant,” outdated. That was the case two centuries ago for preserving the lives of young women with heart disease. We are currently living in a new era, in which the risk of pregnancy is generally lower, with resources to cope with most complications that may eventually occur. Heart disease and pregnancy should be a comprehensive topic based on medical ethics, integrating several moments during which the multidisciplinary interface is stablished in the care of pregnant women and her child. Physicians should apply scientific rigor, based on validated clinical recommendations, clarify the benefits and possible risks and respect the patient's right to participate freely and actively in the decision-making process, obtaining consent informed for all decisions. From moments before conception there have been situations related to maternal and fetal safety. Heart evaluation may reveal different degrees of risk due to pathological, clinical and therapeutic situations. Decision-making results in possible conflicts in the doctor-patient relationship, which require the application of bioethics fundamentals. Prudence must prevail. Therapeutic measures should consider the informed consent of the patient, which is based on their right to answer yes or no. Furthermore, qualification of multidisciplinary teams is fundamental to family planning in young women with heart disease, based on maternal risk stratification, regarding the article 226 of the Brazilian Constitution, which states the following: “Based on the principles of human dignity and responsible parenthood, family planning is a free choice of the couple, it being within the competence of the State to provide educational and scientific resources **for the exercise of this right, any coercion by official or private agencies being forbidden” (our emphasis added). This norm refers to other items: a) dignity of the human person (Article 1, III) and b) right to liberty (Article 5, Heading).” During pregnancy, the doctor-patient relationship requires total reception by the doctor and adherence by the patient, obviously with adequate availability of institutional resources and the health system. Interdisciplinary team is desirable at all times of pregnancy and postpartum period; however, it expands its value in the approximation of childbirth, when it is essential the professional competence of the care team. The decision of moment and type of delivery, the search for technological and infrastructure support in general are well assisted by the application on bioethics fundaments. The puerperium has specific peculiarities and the mother with heart disease demands a higher level of care than usual, while the newborn already has a life of her own, with her particular demands. Thus, there are conflicts, such as non‑consent for a medical instruction, it is up to the doctor – or the Service – to make a critical reassessment, based on bioethics at the Bedside for the specific case. The agreement made with the patient must be strictly adhered to by the doctor. Erratum In the Statement “Brazilian Cardiology Society Statement for Management of Pregnancy and Family Planning in Women with Heart Disease – 2020”, with DOI number: https://doi.org/10.36660/abc.20200406 , published in the periodical Arquivos Brasileiros de Cardiologia, 114(5): 849-942, on page 851, in the conflict of interests of Dr. Fernando Souza Nani, in the item “ Spoke at events or activities sponsored by industry related to this statement”, consider the company CSL Behring to be correct instead of Boehringer. 929