Cardiac disease is the leading cause of maternal death in pregnancy, and many women with underlying heart conditions express concern over choosing the right contraceptive method. Here the options are explored and discussed
Dr Louise Newson, Shirley Medical Centre, Solihull
Mrs TH is a 25-year-old lady who comes to see you one morning for advice regarding contraception. She is worried about which type of contraception is suitable for her. She has a history of coartcation of the aorta, which was repaired when she was a baby. She is otherwise fit and well. She takes warfarin and her INR is usually well controlled. She and her boyfriend have been using condoms, but she would prefer a more effective contraception.
Cardiac disease is the leading cause of maternal death in pregnancy in the UK. Cardiac conditions are associated with higher risks of complications for the foetus such as preterm delivery, growth restriction, stillbirth or death in infancy.
The cardiovascular risk of pregnancy among women with a history of congenital heart disease is heterogeneous, ranging from negligible to prohibitively high. Nonetheless, many of these patients are still not being counseled about the potential risks, and the incidence of unintended pregnancy is high.1 These women should be given accurate information on safe and effective contraceptive options.
Provision of information regarding effective and appropriate contraception is therefore of paramount importance to avoid pregnancy or to allow time for preconception planning and minimisation of pregnancy risks.
The ideal contraception is safe, effective, free from side effects, cost-effective, easily available, independent of intercourse, acceptable to all cultures and also protects against sexually transmitted infections. This ideal contraceptive is not yet available. However, there is a wide choice of contraception available for women, which are both very effective and safe.
Current recommendations are for children with a history of congenital heart disease to be given information about the significance of their cardiac disease in terms of pregnancy, contraception and sexual function via the cardiology clinic. The age at which this is initiated should be judged according to the individual’s level of maturity, but will generally be between the ages of 12 and 15 years.2
Choice of contraception
Contraception should be individually tailored to the patient. Any personal preference, and the efficacy and safety of each method, should be considered.
In the period of time when a woman is deciding the most suitable type of contraception for her, it is recommended that she should be given a progestogenonly pill containing 75µg desogestrel.2 However, women taking an enzyme-inducing medication, such as bosentan, which is a treatment for primary pulmonary hypertension, cannot be given this.
For many women with more severe cardiac disease, barrier methods or natural family planning should not be recommended, as they are associated with higher failure rates than other methods of contraception.
Combined hormonal contraception (CHC)
The use of the combined oral contraception is associated with an increased risk of venous thromboembolism (VTE). The risk of VTE among those women taking the combined oral contraceptive pill is around twice the risk compared to those not taking it.
The type of progesterone makes a difference – COCs containing desogestrel, gestodene, drospirenone and cyproterone acetate appear to be associated with a higher risk of VTE than those containing levonorgestrel, norethisterone and norgestimate.3 The number of extra cases of venous thromboembolism per year per 10,000 treated women appears to be lowest for levonorgestrel and norgestimate and highest for desogestrel and cyproterone.4
Interestingly, the transdermal route does not reduce this risk of VTE as it does in those taking HRT.5 Some studies have shown there to be a greater risk of VTE compared with non-oral CHC preparations when compared with the combined oral contraceptive pill.
It has previously been unclear as to whether taking the CHC actually increases the risk of myocardial infarction or not. However, a recent Cochrane metaanalysis showed that the risk of myocardial infarction or ischaemic stroke was only increased in women using COCs containing =50µg of oestrogen.6 This review summarised that regarding myocardial infarction or ischaemic stroke, prescribing COCs with <50µg of oestrogen seems to be safe.
There is an increased risk of stroke in those women who have a history of migraine with aura and so the CHC is contraindicated in these women. However, the results are still conflicting regarding the risk of stroke in those other women taking the CHC.
CHC can also lead to a rise in blood pressure and fluid retention. These may both exacerbate any preexisting heart disease.
Women with coronary heart disease who are at particular risk for thromboembolic events (i.e., presence of cyanosis and an obligatory right-to-left intracardiac shunt, pulmonary hypertension, Fontan circulation – a variety of surgical procedures designed to overcome the absence of two distinct ventricular chambers – sustained arrhythmias, mechanical heart valves and/or significant ventricular dysfunction) should avoid oestrogen-containing contraception.7 In addition, those women with a history of stroke or myocardial infarction should not receive combined oral contraception.8
Progestogen-only contraceptives Long-acting reversible contraceptives, including the intrauterine devices and the implant, are highly effective and safe for all cardiac patients. These are good options for pregnancy planning for women at elevated risk of cardiovascular complications during pregnancy, who are taking potentially teratogenic medications, or who have contraindications to oestrogen-containing methods.1
There is only limited data regarding the association between VTE and progesterone-only contraceptive use. The majority of evidence suggests that there is no increased risk of thrombosis.9 However, although a statistically significant increased risk of VTE with use of the progestogen-only injectable has been reported.10 Initiation of the progestogen-only pill, implant or levonorgestrel intrauterine system (LNG-IUS) in a woman with a history of stroke is UKMEC category 2 (a condition where the advantages of using the method generally outweigh the theoretical or proven risks). Initiation of the progestogen-only injectable in a woman with a history of stroke is UKMEC3 (a condition where the theoretical or proven risks generally outweigh the advantages of using the method).8
Women with a history of cardiac disease are no different to those women without a history regarding their risk of sexually transmitted infections (STIs). Therefore, all women should be offered screening and treatment for STI infection prior to insertion of an intrauterine method.
Prophylactic antibiotics are no longer necessary for the insertion or removal of intrauterine contraception in those women with an increased risk of infective endocarditis.11
The insertion and removal of an intra-uterine device can lead to a vasovagal reaction. Therefore, it is recommended that the intrauterine method should be fitted in a hospital setting if a vasovagal reaction presents a particularly high risk, for example, women with single ventricle circulation, Eisenmenger’s physiology (any untreated congenital cardiac defect with intracardiac communication that leads to pulmonary hypertension, reversal of flow, and cyanosis), tachycardia or pre-existing bradycardia.
Risks associated with pregnancy
The amount of risk associated with a pregnancy in women with cardiac disease depends on the nature of their condition and also on other factors such as valvular function, cardiac rhythm, chamber enlargement, cardiac medication and also lifestyle factors.
Current guidelines state that the presence ofthe following is an indicator of a low-risk cardiac condition:2
- Patient discharged from cardiology follow up or only seen at intervals of two years or more
- Normal oxygen saturation levels
- Patient not taking any cardiac medication (including aspirin or warfarin).
The following are considerations for reducing the risk of unintended pregnancy in women with a cardiac history:2
- Advance provision of emergency contraception
- Awareness of the emergency copper intrauterine device
- Long-acting reversible contraception and sterilisation are the most effective methods
- Dual use of condoms with other contraceptive method
- Condom demonstrations and information regarding free supplies
- Diaphragms, caps and fertility awareness methods are not considered sufficiently effective
- Sole use of condoms not advisable, particularly if pregnancy poses a high risk to health.
Women taking anticoagulants
Women taking anticoagulants can still have a progestogen-only implant, injectable contraception or an intrauterine device as the risk of bleeding is extremely small. It is recommended that to minimise risks, an experienced clinician should perform the procedure. In addition, a pressure bandage should be applied after an implant is inserted.
Progestogens have been reported to affect international normalised ratio (INR) levels in warfarinised women.12 However, current advice is that INR levels should be monitored as usual without any special or different measures being undertaken.2
Mrs TH was given information about the different types of contraception available to her and decided to take the progestogen-only pill, desogestrel. She has not noticed any change in her INR levels and has found that it suits her really well. She decided against a long acting reversible contraception as she is considering trying to conceive in the near future. She also did not want to take the combined oral contraceptive as she had a history of migraine with aura as a teenager.
1. Lindley KJ, Conner SN, Cahill AG, Madden T. Curr Treat Options Cardiovasc Med. 2015, 17(11):50
2. Faculty of Sexual & Reproductive Healthcare Clinical Guidance. Contraceptive Choices for Women with Cardiac Disease. Clinical Effectiveness Unit June 2014 - http://www.fsrh.org/pdfs/CEUGuidanceContraceptiveChoicesWomenCardiacDisease.pdf
3. Faculty of Sexual & Reproductive Healthcare. Combined Hormonal Contraception. 2011. www.fsrh.org/pdfs/CEUGuidanceCombinedHormonalContraception.pdf
4. Vinogradova Y, Coupland C, Hippisley-Cox J. BMJ. 2015 26;350:h2135. doi: 10.1136/bmj.h2135
5. L’Hermite M. Climacteric. 2013, 16 Suppl 1:44-53
6. Roach RE, Helmerhorst FM, Lijfering WM, Stijnen T, Algra A, Dekkers OM. Cochrane Database Syst Rev. 2015 27;8:CD011054. doi: 10.1002/14651858.CD011054.pub2
7. Wald RM, Sermer M, Colman JM. Paediatr Child Health. 2011, 16(4):e25-9
8. Faculty of Sexual & Reproductive Healthcare Clinical Guidance. UK Medical Eligibility Criteria for Contraception Use. 2009. http://www.fsrh.org/pdfs/UKMEC2009.pdf
9. Mantha S, Karp R, Raghavan V, Terrin N, Bauer KA, Zwicker JI. BMJ 2012; 345: e4944
10. Van H, V, Helmerhorst FM, Rosendaal FR. Arterioscler Thromb Vasc Biol 2010; 30: 2297–2300
11. National Institute for Health and Clinical Excellence. Prophylaxis Against Infective Endocarditis. 2008. http://www.nice.org.uk/nicemedia/live/11938/40039/40039.pdf
12. Zingone MM, Guirguis AB, Airee A, Cobb D. Ann Pharmacother. 2009, 43(12):2096-102