CONTRACEPTION FOR PATIENTS WITH CONGENITAL HEART …



CONTRACEPTION FOR PATIENTS WITH CONGENITAL HEART DISEASE

Unplanned pregnancy can be disastrous for patients with congenital heart defects. It is vital that they are given adequate and accurate advice about which forms of contraception are suitable for them. The contraceptive efficacy of each different method must be given consideration.

EMERGENCY ‘MORNING AFTER’ CONTRACEPTION

No cardiac contra-indication to the morning after pill. Those on warfarin should have their INR checked after 48 hrs.

BARRIER METHODS

Contraceptive failure rate 15 -30% / year

Can be used for any cardiac condition

COMBINED ORAL CONTRACEPTIVE PILL

Contraceptive failure rate 3 - 8% / year

Avoid in Cyanotic heart disease

Bjork Shiley or Starr Edwards mechanical valves

Tricuspid valve prosthesis

Pulmonary hypertension

Fontan circulation

Pulmonary AV malformations

Previous coronary arteritis (Kawasakis disease)

Systemic ventricular dysfunction (EF < 30%)

Use with caution in Bileaflet mechanical valves

Hypertension (eg repaired coarctation)

Previous thromboembolism

Atrial arrhythmia

Dilated left atrium

Potential reversal of left to right shunt (eg unoperated ASD)

ORAL PROGESTERONE ONLY METHODS

Can be used in any heart defect. Can induce menstrual irregularities, particularly in the first few months of taking.

Various preparations;

Standard Progesterone only pill

Contraceptive failure rate 5-10% / year

‘Cerazette’ (new anovulatory POP)

Contraceptive failure rate 0.4% / year

INJECTABLE PROGESTERONE ONLY METHODS

Can be used in any heart defect. Can induce menstrual irregularities initially. With prolonged use many women become amenorrhoeic. Caution with depo Provera IM injection in those taking warfarin.

Depo Provera (3 monthly IM injection)

Contraceptive failure rate 3% / year

Implanon (3 yearly sub dermal implant)

Contraceptive failure rate 0.05% / year

MIRENA COIL

Contraceptive failure rate 0.1% / year

If a woman with a congenital heart defect opts to have an intra-uterine device, a Mirena coil has certain advantages over the traditional copper IUD. More effective contraception than sterilisation. Usually induces amenorrhoea. Needs antibiotic prophylaxis at the time of insertion. Insertion induces vasovagal response in about 5% of women. Therefore avoid in patients with pulmonary vascular disease, Eisenmengers syndrome or Fontan circulation, unless other forms of contraception are unacceptable.

FEMALE STERILISATION

Contraceptive failure rate 0.5% / year

Given the efficacy of Implanon, Cerazette and Mirena coil, female sterilisation is rarely indicated. Late failures are more common in younger women and increase the risk of ectopic pregnancy. The surgical procedure can carry risks for women with congenital heart defects.

MALE STERILISATION

Contraceptive failure rate 0.15% / year

Rarely appropriate. Assuming the sterilisation is performed to protect the health of his partner - the male partner may well outlive his female partner with congenital heart disease and may wish to start a family later on.

PREGNANCY IN WOMEN WITH CONGENITAL HEART DEFECTS

It is perfectly possible for many women with congenital cardiac defects to have normal pregnancies and deliveries. It is important that Pre-conception counselling and assessment be available.

Patients can be divided into mild, moderate and severe risk groups. Attention should be paid not only to maternal risk but also to fetal risk.

LOW RISK

The risk of maternal morbidity and mortality is not detectable higher than that of the general population

Uncomplicated, small or mild

Pulmonary stenosis

Ventricular septal defect

Patent ductus arteriosus

Mitral valve prolapse with trivial mitral regurgitation

Successfully repaired

Ostium secundum ASD

VSD

PDA

TAPVD

MILD RISK

Small increased risk of maternal morbidity and mortality

Repaired coarctation with no hypertension, no significant obstruction and no aneurysm formation (as assessed by MRI)

Mild aortic stenosis or regurgitation

Repaired tetralogy of Fallot (good surgical result and no arrhythmias)

Unoperated atrial septal defect

Mild to moderate mitral regurgitation

Ebsteins anomaly (depends on degree of cyanosis)

Moderate pulmonary stenosis

MODERATE RISK

Maternal morbidity expected in up to 25 %. Mortality expected in up to 10%

Unrepaired coarctation

Repaired coarctation with residual obstruction and hypertension

Repaired tetralogy of fallot with poor haemodynamic result, severe PR and RV dysfunction

Very severe PS

Moderate to severe aortic stenosis

Transposition of the great arteries (Mustard or senning operations)

ccTGA

Well balanced single ventricle (depends on degree of cyanosis, and presence or absence of pulmonary hypertension)

Fontan circulation

Mechanical heart valves

SEVERE RISK

Maternal mortality expected in up to 50%

Pulmonary hypertension

Severe left heart obstruction

>moderate systemic ventricular impairment (Ej # < 30%)

Marfans syndrome with dilated aortic root >40mm

Women with congenital heart defects in class 1 or class 2 should attend the ACHD specialist centre or the local ACHD centre for pre-pregnancy assessment and counselling. This will sometimes involve extensive investigations including cardiac catheterisation, exercise testing, and imaging. Occasionally it is advisable that a woman undergoes surgery or intervention prior to embarking on a pregnancy. In women with moderate risk pregnancies, care should take place in a combined high risk cardiac obstetric clinic

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