Contraception and Heart Disease

Pregnancy in cardiac disease can cause heart failure, arrhythmia, thrombosis and death, particularly with pulmonary hypertension, Eisenmenger syndrome, severe mitral stenosis, severe left ventricular dysfunction and mechanical valves on anticoagulation. Contraception must be highly effective and must not worsen the heart disease.

Assessment. Lesion and severity, functional class, pulmonary hypertension, ventricular function, arrhythmia, cyanosis, anticoagulation, history of endocarditis, hypertension, thrombosis risk, other arterial risk factors, and cardiac medicines (ACE inhibitors, angiotensin receptor blockers, warfarin, statins are teratogenic).

Valvular disease. Uncomplicated valvular disease has no pulmonary hypertension, atrial fibrillation or history of endocarditis. Complicated disease has any of these.

Ischaemic heart disease and stroke. Hormonal methods that raise thrombotic risk are avoided.

Effectiveness. First-year pregnancies per 100 women with typical use: implants 0.05, intrauterine devices 0.2 to 0.8, injectables 3, combined pills 8.

Eligibility.

Method comparison. Implants and the levonorgestrel device are preferred in most heart disease; they are effective, have no oestrogen, and often reduce bleeding in anticoagulated patients. The copper device is category 1 but may increase bleeding on warfarin. DMPA is avoided in ischaemic disease and stroke.

Pulmonary hypertension and Eisenmenger syndrome. Maternal mortality in pregnancy is very high; the most effective methods (implant, device, sterilisation) are advised, and combined methods are avoided because of thrombosis.

Insertion risks. Intrauterine insertion can trigger vasovagal reactions, which are dangerous in cyanotic disease and severe stenosis; insert in a monitored setting with atropine available.

Special groups. Patients on warfarin need highly effective contraception because of embryopathy risk. Patients with peripartum cardiomyopathy and persistent left ventricular dysfunction are advised against future pregnancy.

Regimen lines.

• Etonogestrel 68 mg rod: 3 years; levonorgestrel two 75 mg rods: 5 years or 3 years by system; backup 7 days if inserted after day 7 of bleeding.

• Levonorgestrel 52 mg device: 5 years; copper T 380A: up to 12 years; insertion within 12 days of the start of bleeding or at any time if reasonably not pregnant; no backup. Give antibiotic prophylaxis for insertion in patients at risk of endocarditis, where the cardiology service advises it.

• Progestin-only pill: one tablet daily without a break; late window 3 hours for the traditional pill, 12 hours for desogestrel and 24 hours for drospirenone; backup 2 days after a late or missed pill.

• DMPA 150 mg intramuscularly every 13 weeks, up to 4 weeks late: not in ischaemic heart disease or stroke.

• Combined methods: not used in complicated valvular disease, ischaemic heart disease, stroke or multiple risk factors.

Anticoagulation. Warfarin does not need to be stopped for implant insertion; the INR should be in range for intrauterine insertion.

Follow up. Review at cardiology visits, including medicines and pregnancy intention.

Vasovagal reaction at insertion. Stop the procedure, lay the patient flat, give oxygen and atropine 0.5 to 1 mg intravenously if bradycardic, and monitor.

Endocarditis. Fever after intrauterine insertion in valvular disease needs blood cultures and urgent assessment.

Heavy bleeding on anticoagulation. Use the levonorgestrel device; tranexamic acid is avoided with mechanical valves and thrombosis risk.

Pregnancy with cardiac disease. Urgent cardio-obstetric review; stop teratogenic medicines and plan delivery.

Red flags. Chest pain, breathlessness, syncope, palpitations, fever, new heart failure.

Referral and escalation. Refer severe lesions, pulmonary hypertension, mechanical valves and any pregnancy to a cardiologist and obstetrician.