Birth Control in Patients with Congenital Heart Disease

Transcription

1 Birth Control in Patients with Congenital Heart Disease Arwa Saidi MB. BCh. MEd. FACC University of Florida Departments of Pediatrics and Internal Medicine Gainesville, FL

2 There are an increasing number of adult women with congenital heart disease Although pregnancy is tolerated in most patients with CHD, contraception has to be addressed on an individual basis Prevention of pregnancy is disease and patient specific Each unique patient should be counselled

3 Current guidelines for the care of the ACHD patient recommend: Proactive counseling regarding issues of contraception and pregnancy There are significant gaps in knowledge regarding birth control and pregnancy in patients with CHD Warnes et al ACC/AHA 2008 Guidelines JACC;52:23: e Kaemmerer et al. Clin Res Cardiol 2012:101; Van Deyk et al. Am J Cardiol 2010;106c:

4 For the cardiologists When recommending birth control, must consider: Risk of pregnancy/birth control given patients cardiac anatomy and status Available contraceptive options Risks and benefits of various contraceptive options Failure rate of contraceptives and consequences of pregnancy Patient preference

5 For the cardiologists PEARL INDEX: The most common technique used in clinical trials to calculate the effectiveness of birth control methods For example: Surgical sterilization <1 IUD 1-3 Hormonal 1-5 Barrier 3-20

6 For the gynecologists Understand the cardiac anatomy Cardiac defects are classified as: Simple: ASD, VSD, pulmonary stenosis Moderate: TOF, AVSD Complex: Single ventricle Is the patient at an increased risk of a paradoxical embolus? If residual shunts or intra-cardiac lesion

7 For the gynecologists Is the patient at an increased risk of thrombosis? If cyanosed or has single ventricle physiology Is the patient at an increased risk of fluid retention and heart failure? Remember anesthesia concerns (sterilization) Consider high risk of pregnancy in some cardiac lesions as you weigh the risks/ benefits

8 Clinical question 32 year old G1P1 with mechanical mitral valve and dilated left atrium with EF 35% on warfarin. Clinic appointment to discuss birth control options and possible second pregnancy What is risk of pregnancy? Which contraceptive is reliable? Which contraceptive is safe? If pregnancy is high risk, should her husband consider vasectomy?

9 Contraceptive options Combined hormonal contraceptives Progestin only formulation Intra-uterine devices Barrier methods Sterilization/ permanent forms ACOG Practice bulletin 73: 2006 Silversides et al. Current Cardiol Reports 2009;11:

10 WHO Risk Classification WHO CLASS Risk for Contraceptive method Risk for Pregnancy 1 No restriction No increased risk of mortality or morbidity 2 Advantages outweigh risks Small increase M & M 3 Risk outweigh advantages: use alternative unless patient accepts risks and risk of pregnancy is high Significant increased M & M 4 UNACCEPTABLE HEALTH RISK Extremely high risk of M & M Thorne et al. J Fam Plann Reprod Health Care 2006;32: 75-81

11 Combined hormonal contraceptives Inhibit ovulation Low dose if 35 µg or less of Ethinylestradiol Usually oral but may be transdermal or vaginal ring Failure rate 3 to 8% during first year Interferes with drug metabolism and must monitor INR

12 Combined hormonal contraceptives Adverse cardiac effects: Increased risk of thromboembolic complications Reduce HDL and increase LDL Increased BP Contraindicated if : Cyanosis related to shunt (R to L or L to R) Fontan Cirrhosis (risk if Fontan or hepatic infection)

13 Combined hormonal contraceptives Consider other risk factors: obesity, smoking, DM and hypertension Questions : What about patients on warfarin? British Working group: even if anticoagulated should not prescribe COC Prior thromboembolic event and now on Warfarin Should we check for coagulopathy such as Factor V Leiden? ACOG Practice bulletin 73: 2006 Silversides et al. Current Cardiol Reports 2009;11:

14 Progestin only formulation Acts on cervical mucus ± inhibits ovulation Less thrombotic so more suitable for CHD But high failure rate (5 to 10% in first year) If high risk pregnancy: injectable (3 months) or implantable forms (3 years) Side effects: Fluid retention and effect INR Hematomas if on anticoagulants Bosentan may reduce effectiveness

15 Intrauterine devices Prevent fertilization and implantation Very effective Copper and hormone releasing May have amennorhea Theoretical risk of pelvic infections Contraindicated : Pulmonary hypertension or Fontan Vagal reaction with device placement

16 Barrier methods Include male and female condoms, diaphragms and cervical caps Used with spermicides Can protect against STD Safe for women with CHD but potentially high failure rate (15 to 32% first year failure)

17 Sterilization/ permanent forms Tubal ligation, intra-tubal stents or vasectomy Permanent Increased risk of GA, increased intra-abdominal pressure and vagal response Vasectomy? May be an issue for partner and future relationships Must be discussed in detail with patient, partner and cardiologists / gynecologist

18 Emergency forms Progestin only or combined pills Must be used within 72 hours Side effects include nausea and vomiting Caution if DVT or ischemic heart disease Monitor INR if on warfarin If on Bosantan, may need higher dose

19 Cardiac risks of contraceptives Intra-cardiac shunt Cyanosis Heart failure Specific Precautions Combined OCP C/I C/I C/I Thrombosis Progestin only OK OK C/I Fluid retention IUD OK Caution Vagal Barrier methods OK OK OK Decrease STD Sterilization OK OK OK GA and vagal

20 Clinical question 32 year old G1P1 with mechanical mitral valve and dilated left atrium with EF 35% on warfarin. Clinic appointment to discuss birth control options and possible second pregnancy What is risk of pregnancy? Which contraceptive is reliable? Which contraceptive is safe? If pregnancy is high risk, should her husband consider vasectomy?

21 Clinical questions Patient with small residual defect with no cyanosis. Is it OK to use combined OCP? Patient on anticoagulation for Fontan. Is it OK to use estrogen? Should we check for coagulopaty and factor V Leiden in high risk cardiac patients?

22 In Conclusion Counselling should be on an individual basis and dependent on patients cardiac risks and personal preferences Communication with patient / partner and cardiologist/ gynecologist to ensure safe and effective contraceptive therapy Permanent sterilization may be considered if very high risk pregnancy

23 Thank you