– adequate time to conceive
– maternal, graft and fetus potential issues discussed
Class of recommendations: I, is indicated; IIa, should be considered; IIb, may be considered; III, is not recommended
Level of evidence: A, data from multiple randomized clinical trials or meta-analyses; B, data from a single randomized clinical trial or large nonrandomized studies; C, consensus of opinion of the experts and/or small studies, retrospective studies, registries
ECG = electrocardiography; HBV = hepatitis B virus; ISHLT = International Society of Heart and Lung Transplantation; MMF = mycophenolate mofetil
All pregnancies in HT and LT recipients should be considered high risk and followed by a multidisciplinary team of healthcare providers. A baseline evaluation of the patient’s graft status should be performed before pregnancy, as recommended by the ISHLT guidelines. Before transplantation, immunization status should have been checked and vaccination administered as required.
Assessment of kidney and liver function should be performed early in pregnancy, and careful screening for obstetric complications including systemic hypertension, preeclampsia, gestational diabetes, and urinary tract infection are recommended. Close monitoring of rejection is mandatory in pregnant solid organ transplant recipients.
In HT recipients, myocardial biopsy should be done if possible under echocardiographic guidance.
Calcineurin inhibitors and corticosteroids should be continued in a pregnant heart or lung recipient, but mycophenolate mofetil (class D), and possibly azidothymidine should be discontinued. Blood levels of calcineurin inhibitors should be monitored closely during pregnancy and treatment adapted according to the results. Immunosuppressive therapy should be continued throughout delivery and postpartum. A detailed fetal scan should be done to screen for birth defects according to standard obstetric practice.
As for high-risk pregnancies in all cardiac patients, vaginal delivery is recommended if possible and a cesarean section should be performed only for obstetric indications. A delivery plan should be made at the end of the joint cardiac/pregnancy clinic to allow good coordination of all specialists involved. Noninvasive cardiac monitoring is recommended for pregnant women with cardiothoracic transplantation because of their increased risk of arrhythmias and the stress induced by labor. Epidural anesthesia is recommended to reduce pain-induced sympathetic response and acute blood pressure changes. For HT recipients, fluid balance should be closely monitored and controlled to prevent heart failure.
Breastfeeding is still controversial; it was previously discouraged because immunosuppressive medication is passed in expressed milk to a variable extent. However, according to the NTPR data, 126 children were breastfed by recipients taking various immunosuppressive drugs, with no specific health problems reported. The ISHLT guidelines do not recommend breastfeeding, but this has a low level of evidence. Contraception should be started again soon after delivery.
Depression is associated with heart transplantation and predicts mortality independently of other risk factors in the HT population. Moreover, depression is a risk factor for nonadherence to therapy. Postpartum depression is a well-recognized clinical entity and should be screened for routinely and thoroughly in this specific population. Every heart transplantation team should have a psychologist who can follow these patients routinely, and perhaps particularly in the context of a pregnancy and puerperium.