5

 

Termination and Contraceptive Options for the Cardiac Patient

 

Blake Zwerling and Rachel Perry

 

Introduction

All patients of reproductive age should be counseled on family planning and contraception as part of routine health care. This is particularly crucial for women* with cardiac conditions given their potentially heightened risk of pregnancy-associated morbidity and mortality. When a patient with a cardiac condition is faced with an unintended pregnancy, clinicians are tasked with risk assessment and subsequent options counseling, including pregnancy continuation and induced abortion. This chapter explores contraception and induced abortion options for women with cardiac conditions.

 

Contraception Considerations for Women with Cardiac Disease

The U.S. Medical Eligibility Criteria (MEC) for Contraception Use details the recommendations from the U.S. Centers for Disease Control and Prevention (CDC) on contraceptive choices for various medical conditions. These classifications are referenced in this chapter for select cardiac conditions. Noncardiac contraindications to methods are not addressed here; however, the MEC (available online and in a mobile application) should be referenced for women with other medical comorbidities or special considerations such as the postpartum period or during concomitant breastfeeding. (See Box 5.1).

How Do You Counsel Women of Reproductive Age with Cardiac Conditions about Contraception?

Despite increased risks of pregnancy, many women with cardiac disease do not receive adequate contraceptive counseling. Over half of patients with congenital heart disease report receiving no cardiac-specific contraception counseling [4], and many leave medical visits with unanswered questions about contraception and pregnancy [5]. One study found that 63% of women reported no knowledge of contraindications to particular contraceptive methods specific to their heart disease [4].

Building a trusting, nonjudgmental dynamic is key: observational studies have shown that the interpersonal quality of family planning counseling is associated with higher patient satisfaction in their contraceptive method as well as overall contraceptive use [6]. More effective forms of contraception should be emphasized while still respecting patient autonomy. In addition, women should be counseled on dual protection for sexually transmitted infections (STIs), and clinicians may offer advance provision of emergency contraception [6].†

Ideally, patients with cardiac conditions should receive joint counseling with their cardiologists and obstetrician-gynecologists to streamline recommendations for contraceptive methods along with information on maternal and fetal prognosis during pregnancy. This multidisciplinary approach prevents conflicting advice from different providers and patient concerns can be answered simultaneously [2].

For hormonal methods of contraception, unique considerations include:

•Does the method have thrombogenic potential?

•Could it affect blood pressure, volume status, blood glucose levels, or lipid profiles?

•Does it affect metabolism of anticoagulants or cardiac medications?

For contraceptive methods requiring procedures such as permanent surgical contraception or intrauterine devices, considerations include [3]:

•Potential risk of bacteremia/endocarditis

•Anesthesia risk

•Risk of Vasovagal reaction

All of these possibilities must be weighed against the potential risk of pregnancy.

 

Contraceptive Methods

Highly Effective Methods

Intrauterine Devices

Intrauterine devices (IUDs) are a highly effective form of long-acting reversible contraception (LARC) that include hormonal (levonorgestrel) and nonhormonal (copper) options.

•Mechanism of action: Multiple mechanisms of action contribute to the effectiveness of IUDs. The levonorgestrel in hormonal IUDs thickens cervical mucus, which acts as a barrier to sperm. Secondary progestin effects include slowed tubal motility and endometrial decidualization and atrophy [7]. Copper impairs sperm migration, viability, and the acrosomal reaction, thereby preventing fertilization.‡

•Efficacy: All IUDs boast high efficacy. With typical use, first-year pregnancy rates are 0.1%–0.2% for the 52 mg levonorgestrel IUD and 0.5%–0.8% for the copper IUD [8].

•Benefits: include safety,§ quick return of fertility, and ease of use. The 52 mg levonorgestrel IUD causes amenorrhea in 20%–40% of patients. For those who continue to have menses, most report a reduction in menstrual flow and dysmenorrhea. Therefore, hormonal IUDs may be a particularly good choice for women on anticoagulation or with bleeding diatheses (see “Anticoagulation” section). Unscheduled bleeding may occur with any of the devices, though it generally improves with time [9]. The copper IUD does not affect ovulation but may cause increased menstrual flow and dysmenorrhea and therefore should be avoided with those patients at risk for hemorrhage, including women on therapeutic anticoagulation. It is approved for longer term use in the United States (up to 10 years) and acts as a very effective form of emergency contraception if inserted within 5 days of unprotected intercourse.

•Risks of IUDs include infection, uterine perforation, vasovagal reaction during placement, and a theoretical risk of endocarditis [10]. Large epidemiological studies have not identified an increased risk of stroke, myocardial infarction (MI), or venous thromboembolism (VTE) for progestin-only contraceptives such as the hormonal IUD [1]. For Fontan-type circulation, IUDs should be avoided due to the risk of cardiovascular collapse with a vasovagal reaction, which occurs in approximately 2% of patients undergoing IUD insertion [12]. The theoretical concern for endocarditis has not been demonstrated (see section “Pregnancy Contraindicated [WHO Class IV], Endocarditis”). The American Heart Association guidelines do not recommend antibiotic prophylaxis for genitourinary procedures, including IUD insertion [13].

Contraceptive Implant

•The etonogestrel contraceptive implant is a radio-opaque single-rod progestin implant that is placed subdermally in the inner arm. It contains 68 mg of etonogestrel and provides highly effective contraception for at least 3 years with a pregnancy rate of only 0.05% in the first year [8]. Its primary mechanism of action is suppression of ovulation. Secondary progestin mechanisms are similar to the hormonal IUD [14].

•Benefits include reduced dysmenorrhea. Some users report irregular bleeding, which may or may not improve with continued use [14].

•Bosentan—a dual endothelin receptor antagonist commonly used in the treatment of pulmonary artery hypertension—interacts with etonogestrel, reducing its efficacy (see section “Pregnancy Contraindicated [WHO Class IV], Pulmonary Artery Hypertension”).

Permanent Surgical Sterilization

•Female permanent contraception (tubal sterilization) is highly effective, with a 10-year pregnancy risk of less than 1% [15]. It requires a surgical procedure that may involve general anesthesia and therefore risks of anesthesia should be considered when counseling patients.

•Vasectomy (male permanent contraception) is the most cost-effective and safest method of permanent sterilization. It should be recommended to women with cardiac conditions who are monogamous with a male partner. Male sterilization can be performed in the outpatient setting [16].

Moderately Effective Methods

Estrogen-Containing Combined Hormonal Contraceptives: Contraceptive Pill, Patch, and Ring

Combined hormonal contraception (CHC) contains both synthetic estrogen and progestin. Ethinyl estradiol is the estrogen in most CHCs in the United States, but various progestins are used depending on the product formulation. CHCs are available as oral contraceptive pills, contraceptive patches, and contraceptive vaginal rings.

•Mechanism of action: CHCs function by preventing ovulation. Secondary progestin effects also contribute to the mechanism of action.

•Efficacy: The typical use failure rate is 9% in the first year, largely due to inconsistent use [17–19].

•Benefits: Include cycle regularity and decreased dysmenorrhea.

•Side effects: Include irregular bleeding, nausea, bloating, breast tenderness, and headaches, though these often resolve in the first 3 months [20]. The synthetic estrogen component of CHCs increases the production of hepatic pro-coagulation factors (VII, VIII, and X) while simultaneously decreasing the production of fibrinolytic factors (tissue plasminogen activator and antiplasmin), which can result in increased thromboembolic events [3]. However, the risk of venous thromboembolic or arterial thrombotic events are lower with CHCs than during pregnancy or the immediate postpartum period [21,22]. CHC users are at an increased risk of MI and cerebrovascular accident (CVA) [23]. Some progestins are associated with a slight decrease in HDL and increase in LDL cholesterol [24]. Oral, but not transdermal estrogens are associated with an increase in serum triglycerides [25,26]. Potential fluid retention may exacerbate cardiac conditions [3]. Studies in both normotensive and chronic hypertensive patients have shown a small increase in systolic blood pressure of 7–8 mmHg for women using CHCs [27,28].

•Contraindications: CHCs should not be given to smokers over the age of 35, those with known thrombophilias, or a history of VTE or stroke [1]. Other contraindications include those with multiple risk factors for arterial cardiovascular disease (older age, smoking, diabetes, and hypertension), known ischemic heart disease, complicated valvular disease, and migraine with aura (due to increased stroke risk) [1]. The patch (applied weekly) and vaginal ring (inserted monthly) are thought to confer similar benefits and risks as the contraceptive pill but have been less well studied. Patients with contraindications to estrogen should also avoid these methods.

Progestin-Only Oral Contraceptive Pills

The primary mechanism of progestin-only pills (POPs) is thought to be cervical mucus thickening; they do not reliably inhibit ovulation. The effectiveness of POPs is lower than other progestin-only contraceptives as they require daily dosing. National survey data do not distinguish between CHCs and POPs, but the typical failure rate within the first year is likely higher than the 9% cited due to the necessity for strict dosing timing (pills should be considered skipped if they are taken more than 3 hours late) [17]. Studies have not identified an increased risk of MI, CVA, or VTE with the use of POPs [29,30]. They are therefore a safe contraceptive option for a wide range of cardiac patients.

Depot Medroxyprogesterone Acetate Injections

Depot medroxyprogesterone acetate (DMPA) is an injectable intramuscular progestin-only contraceptive dosed every 3 months. It works primarily by suppressing ovulation [31]. The unintended pregnancy rate in the first year of typical use is 6%, with most failures associated with late injections [17].

DMPA can reduce or eliminate menstrual bleeding [32]. Side effects of DMPA include irregular menstrual bleeding, injection site reactions, headache, mood changes, and weight gain [33]. A 2016 systematic review found the mean weight gain for DMPA users was less than 2 kg for most studies, and generally comparable to users of other contraceptive methods [34]. Though DMPA can induce bone mineral density loss, best available data indicate that DMPA does not reduce peak bone mass or increase the risk of osteoporotic fractures later in life for women at average risk of osteoporosis [35]. There may be a delay in return in fertility for up to 1 year after cessation of DMPA use [1].

DMPA should not be used for those with ischemic heart disease as it can decrease HDL levels. It should be used with caution for women with hypertension given concern for increased risk of cardiovascular events (see section “Hypertension”) [1].

Least Effective Methods

Barrier Methods and Pericoital Contraceptives

Barrier and pericoital methods include male and female/receptive condom, the cervical diaphragm, spermicidal agents, and the contraceptive sponge. These methods must be used with each act of intercourse. Therefore, they are prone to reduced effectiveness due to inconsistent or incorrect use. There are few contraindications to the use of barrier methods.

Condoms are the only form of contraception that can help prevent or reduce the risk of transmission of STIs. Given their user-dependent nature, unintended pregnancy with typical use is 18% and 21% for male and female condoms, respectively, within the first year [17].

The diaphragm, contraceptive sponge, and cervical cap function by maintaining a reservoir of spermicide against the cervix. Spermicide creates a chemical barrier by immobilizing sperm. All have high failure rates, making them less optimal choices for women with cardiac conditions for whom pregnancy carries high risk [17].

Fertility Awareness−Based or “Natural Family Planning” Methods

Fertility awareness−based methods of contraception are based on avoiding intercourse on the fertile days of a woman’s cycle [36]. These methods have a 24% pregnancy rate in the first year with typical use [17].

Emergency Contraception

Emergency contraception (EC) is used to prevent pregnancy after unprotected intercourse¶ and includes the copper IUD and oral medications. EC does not disrupt an implanted pregnancy [37].

The copper IUD is the most effective form of emergency contraception. When inserted within 72 hours, it prevents over 95% of expected pregnancies [38,39]. In addition, it has the advantage of providing ongoing contraception.

Oral EC functions primarily by delaying ovulation [40]. In the United States, two formulations are available: ulipristal and levonorgestrel. Of these, ulipristal prevents two-thirds and levonorgestrel one-half of expected pregnancies [38].** Ulipristal is a selective progesterone receptor modulator taken as a single pill within 120 hours of unprotected intercourse, though efficacy is higher with earlier dosing. Levonorgestrel EC (available over the counter), is either a single dose or two tablets taken 12 hours apart. There are no cardiovascular conditions for which the risks of EC outweigh potential benefits [1]. (See Box 5.2).

 

Contraceptive Considerations by Cardiac Disease

Risk of Pregnancy by Cardiac Condition

See Box 5.3.

Low Risk (WHO Class I) Conditions

Small Shunts (ASD, VSD, PDA, PFO)

Women with repaired shunts have no increased thrombogenic risk and therefore are candidates for all forms of contraception. Atrial septal defects confer a risk of paradoxical thromboembolism and stroke, making CHCs Category 3 [42]. However, VSDs and small PDAs do not carry the same risk, so CHCs are not contraindicated [41].†† Two community-based studies have failed to find a consistent independent association between asymptomatic PFOs and thromboembolic events [43,44]. Therefore, CHC use is permissible for women with asymptomatic PFOs, and screening is not indicated prior to initiation [42]. CHCs are Category 3 for those with a previous thromboembolic event [1].

Mitral Valve Prolapse/Mild Pulmonary Stenosis

The MEC does not distinguish between valvular defects: CHCs are Category 2 for all of them [1]. However, other schema that parse out types of valvular defects note that women with mitral valve prolapse and minimal to no regurgitation have no contraindication to CHC use [3].

Isolated Premature Atrial or Ventricular Contractions

All methods of contraception are considered appropriate for isolated premature atrial or ventricular contractions if no underlying structural abnormality exists [3].

Moderate Risk (WHO Class II)

Repaired Tetralogy of Fallot

In the absence of right-to-left shunting, CHCs are safe for women with repaired tetralogy of Fallot. There is a theoretical risk of endocarditis from the copper IUD (Category 2, see section “Endocarditis”), but there are no further restrictions on the forms of contraception these women can receive [3].

Arrhythmia

While CHCs are appropriate for many of women with arrhythmias, they should be avoided for those with atrial fibrillation or flutter due to increased thromboembolic risk [3].

Mild Left Ventricular Dysfunction (Left Ventricular Ejection Fraction 40%–50%)

The risks of thrombosis, fluid retention, and hypertension must all be considered for women with mild left ventricular dysfunction. Recommendations for women in this category are largely based on expert opinion and vary widely. Whereas the MEC rates CHCs as absolutely contraindicated (Category 4), other schema do not rate the risk as highly. Progestin-only methods and IUDs are considered safe [1].

Hypertrophic Cardiomyopathy

Data are very limited on contraceptive safety for patients with hypertrophic cardiomyopathy [45–48]. Classification of contraceptive options is largely based on potential sequalae, including arrhythmias, thromboembolism, and endocarditis. For uncomplicated cases, CHCs are generally considered Category 2, but should be considered Category 3 if sequalae of the disease are present.

Marfan Syndrome

The risk of aortic dissection for patients with Marfan syndrome is proportional to the aortic root diameter, with morbidity increasing sharply with dilatation >4 cm (see section “Aortic Root Dilatation >4 cm”) [3]. Without aortic root dilatation, there are no specific recommendations for contraceptives by the MEC [1].

Ehlers-Danlos and Other Connective Tissue Disorders

There are no specific recommendations for women with Ehlers-Danlos regarding contraception, therefore recommendations are the same as for Marfan syndrome [3].

Repaired Aortic Coarctation

Due to the potential of exacerbating hypertension, CHCs are Category 3 for women with a known aortic aneurysm or persistent hypertension [1].

High Risk (WHO Class III)

Ischemic Cardiovascular Disease

Given its rarity, little data exist on the risks of contraception and pregnancy for women with a history of MI. Those with significant residual left ventricular dysfunction or NYHA class III or IV symptoms should be considered WHO class IV risk [3]. CHCs are generally contraindicated due to concern for thrombosis, hypertension, hyperlipidemia, and glucose derangements [1,42]. DMPA is Category 3 due to reduction in HDL [1]. The MEC labels progestin-only contraceptive methods Category 2 for continuation and Category 3 for initiation due to theoretical concern for lipid profile effects. For women with ischemic heart disease generally, the copper IUD is the ideal method of contraception. However, if this method is not an option, other LARC methods should be encouraged [1].

Mechanical Prosthetic Valve

Women with mechanical prosthetic valves carry an increased risk of thromboembolic events [49]. However, the risk will vary depending on the type of valve, how long it has been in place, and which valvular position it is in. In addition, these patients are often on anticoagulation (see “Women on Anticoagulation”). Overall, CHCs are Category 3–4 [1]. Progestin-only methods are safe for women with mechanical prosthetic valves [1]. LARC methods are preferred. The MEC rates IUDs as Category 4 due to concern for infective endocarditis with insertion, but newer data including a prospective trial of 20 anticoagulated women demonstrated improved bleeding profiles, higher hemoglobin, and no cases of endocarditis for hormonal IUD users, suggesting this method may be safe for use [50].

Complex Congenital Heart Disease

CHCs should be avoided in women with complex congenital heart disease due to risk of pulmonary artery thrombosis and pulmonary emboli [41,51].

Aortic Root Dilatation >4 cm

CHCs are Category 3 for patients with aortic root dilatation >4 cm due to concern for exacerbation of hypertension and potential aortic dissection [1].

Pregnancy Contraindicated (WHO Class IV)‡‡

Severe Pulmonary Hypertension

CHCs are Category 4 for women with severe pulmonary hypertension due to thrombotic and hypertensive risk [1]. Of note, bosentan—a dual endothelin receptor antagonist—can reduce the effectiveness of ethinyl estradiol as well as several progestin-only methods (contraceptive implant and POP). DMPA does not interact with bosentan, but women with pulmonary hypertension are often anticoagulated, which carries the theoretical concern of hematoma. IUDs may be contraindicated due to the potentially fatal consequences of a vasovagal reaction during placement. In cases where no other acceptable method is available, this risk may be mediated with the use of a paracervical block or epidural anesthesia [3].

Significant Left Ventricular Dysfunction

Considerations for contraceptives for women with significant left ventricular dysfunction are the same as for those with mild to moderate dysfunction (see “Mild Left Ventricular Dysfunction”), but with higher risk of morbidity.

Severe or Complicated Mitral or Aortic Stenosis (Coexisting Atrial Fibrillation, Pulmonary Hypertension, or History of Endocarditis)

The MEC lumps valvular heart defects into a single category, considering CHCs “broadly useable” for uncomplicated lesions without sequalae [1,3]. CHCs are Category 4 for those with complicated lesions. Progestin-only methods and IUDs are Category 1 [1], though there is a theoretical concern for infective endocarditis for IUDs [3].

Peripartum Cardiomyopathy with Any Residual Impairment of Left Ventricular Function

A systematic review revealed no primary research articles that addressed the safety of any contraceptive method among women with peripartum cardiomyopathy [45]. The patient’s functional status and time since delivery (less than 6 months vs. greater than 6 months) aids in classifying contraceptive methods. Depending on the time since delivery, CHCs are Category 3 or 4 for women with normal cardiac function. POPs, DMPA, and the implant are all Category 1 with normal or mildly impaired cardiac dysfunction, but Category 2 for women with moderate to severe cardiac dysfunction. Regardless of functional status, all IUDs are Category 2. Though no direct evidence on the safety of IUDs exists, there is theoretical concern for the induction of arrhythmias during IUD insertion. Limited evidence did not demonstrate any cases of arrhythmia or infective endocarditis in women with cardiac disease who received IUDs [1].

Fontan-Type Circulation

Though not specifically mentioned in the WHO classification system, Fontan-type circulation is considered a contraindication to pregnancy [41,52,53]. Contraceptive recommendations are the same as for others with complex congenital heart disease (see “Complex Congenital Heart Disease”).

Hypertension

Estrogen-containing methods may affect blood pressure. Estrogen stimulates angiotensinogen production by the liver and simultaneously increases activation of the renin-angiotensin system [54]. Given the cardiovascular risks of pregnancy, elevated blood pressure reading should not delay the initiation of contraception, though it may affect the choice of method.

CHCs increase systolic blood pressure an average of 8 mmHg and diastolic 6 mmHg [27]. The effect is dose-dependent and increases with age and BMI [55]. The increase in blood pressure is small, but it does confer an increased risk of MI and CVA, particularly for women with preexisting hypertension [56]. CHCs are Category 3 for women with moderate hypertension (140−159/90−99) or adequately treated hypertension. If estrogen-containing methods are used, the lowest possible estrogen dose should be chosen [29]. CHCs are Category 4 for women with severe hypertension >160/100 [1]. Given these risks, blood pressure measurement is recommended before the initiation of CHCs [57].

The MEC does not distinguish between estrogen-containing hormonal contraceptive methods in its recommendations for women with hypertension [1]. There is a paucity of data for the effect of other estrogen-containing contraceptive methods. Systemic estrogen levels for the ring are 50% that of CHCs, but evidence suggests the ring still confers an increased risk of CVA [29,58]. In contrast, the patch has been shown to result in higher estrogen levels than CHCs and is assumed to confer similar risk.

Progestin-only methods do not affect blood pressure [59]. POPs are Category 1 for women with mild or well-controlled hypertension, and Category 2 for women with severe hypertension citing “Limited evidence suggest[ing] that among women with hypertension, those who used POPs or progestin-only injectables had a small increased risk for cardiovascular events” [1].

DMPA is Category 2 for women with moderate or well-controlled hypertension and Category 3 for women with severe hypertension [3].

No studies exist exploring the relationship between progestin-containing implants and IUDs on blood pressure. There is little biological plausibility that the hormonal IUDs would increase blood pressure [3]. The MEC therefore gives these methods the same ratings as POPs: Category 1 for moderate or well-controlled hypertension and Category 2 for severe. There are no limitations on the use of copper IUDs [1].

Multiple Risk Factors for Atherosclerotic Disease

For women with multiple risk factors for atherosclerotic disease (e.g., age >35, smoking, diabetes, hypertension, low HDL, high LDL, or high triglycerides), the copper IUD is Category 1. POPs, the implant, and the hormonal IUD are all Category 2, DMPA Category 3, and CHCs Category 3/4. Evidence backing the recommendation is sparse. Given these women might have a substantially increased risk of cardiovascular disease, CHCs represent an unacceptable risk. DMPA is rated Category 3, as it persists for some time after discontinuation in the case of adverse effects. The MEC states that simple addition of categories for multiple risk factors is not intended (e.g., two Category 2 risk factors does not make a Category 4), however it does not delineate specific guidelines for how many risk factors need be present and to what severity [1].

Known Thrombogenic Mutations

Women with known thrombogenic mutations (e.g., factor V Leiden; prothrombin mutation; or protein S, protein C, or antithrombin deficiencies) can freely use the copper IUD. Progestin-only methods are Category 2. CHCs are Category 4 due to increased risk of thrombosis. Routine screening for these mutations is not appropriate as it is not cost-effective due to the rarity of mutations and the cost of screening [1].

Women on Anticoagulation

CHCs should generally be avoided in women requiring anticoagulation. Beyond prothrombotic effect, CHCs can also interfere with hepatic metabolism of anticoagulants like warfarin, and therefore INR should be closely monitored if CHCs are used [60]. There is a theoretical risk of intramuscular hematoma formation with DMPA injection. Though no studies have specifically looked at this concern, a prospective series of women taking anticoagulation with a history of bleeding complications did not report any intramuscular hematomas [32]. It is thought that subdermal implants carry a lower risk, as hematomas would be more superficial and therefore easier to detect and monitor [3]. (See Box 5.4.)

Stay updated, free articles. Join our Telegram channel

Join