Download contraception for patients with congenital heart disease

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
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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.
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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
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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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