Reproductive counseling, pregnancy planning vital for women with CVD
Most reproductive-age women with CVD are also sexually active; therefore, reproductive counseling and pregnancy planning is of significant importance within this population, according to a review.
According to the review, published in the Journal of the American College of Cardiology on behalf of the ACC Cardiovascular Disease in Women Committee and the Cardio-Obstetrics Work Group, contraception for women with CVD requires special consideration for efficacy and safety, and preconception counseling and pregnancy planning for women are essential to optimize outcomes for both mother and child.
“While most adolescent and young women with CVD are sexually active, pregnancy and contraception counseling is not routinely discussed with them by their cardiologists,” Kathryn J. Lindley, MD, associate professor of medicine in the cardiovascular division of the John T. Milliken Department of Internal Medicine at Washington University School of Medicine in St. Louis, told Healio. “This is an essential part of delivering CV care to this unique patient group. Developing a reproductive plan in conjunction with the patient and her obstetrician can facilitate the use of safe and effective contraception, including the long-acting reversible methods (the IUD and the subdermal implant), thus reducing unintended pregnancies and optimizing maternal and fetal outcomes.”
The authors wrote that many women with CVD are prescribed potentially teratogenic drugs, and pregnancy can potentially contribute to significant morbidity and mortality. Therefore, reproductive counseling and pregnancy planning or prevention may be lifesaving to both the mother and fetus.
Preconception counseling regarding contraceptive options should begin long before a woman conceives; however, only one-half of women with congenital heart disease ever recall discussing contraception with their cardiologist, and even fewer before their first sexual encounter, according to the report.
The frequency of reproductive discussions/preconception counseling with cardiologists among women with acquired CVD is unknown.
“This report is intended to be a resource for cardiologists, obstetricians and primary care providers to identify safe and effective methods of contraception and to increase awareness of the need for incorporation of reproductive planning into routine CV care,” Lindley told Healio. “There are still gaps in understanding how well women with acquired cardiovascular conditions are counseled about reproductive planning, and solutions to overcoming financial, physical and logistical barriers to coordinated multidisciplinary cardio-obstetrics care are still needed.”
Contraceptive options
“Shared decision-making is essential when providing contraceptive counseling to patients, such that autonomy and patient preference can drive the decision-making,” the authors wrote. “When offering contraceptive options to a woman with cardiovascular disease, the risks and benefits of specific contraceptive methods must be weighed against the risks of unplanned pregnancy in the setting of the individual patient’s specific cardiovascular condition. Consideration must be given to both the generalized risks of the contraceptive method, as well as the patient’s individual risk of developing serious morbidity or mortality from the contraceptive method.”
The committee divided the various methods of contraception into three tiers of effectiveness based on their typical-use failure rates:
- Tier I methods, including permanent sterilization and long-acting reversible contraceptives such as intrauterine devices and implants, have typical-use 1-year failure rates of less than 1%.
- Tier II methods, including combined hormonal contraceptives, progestin-only pills and the depot medroxyprogesterone acetate injection, have typical-use failure rates of 6% to 12%.
- Tier III methods, including barrier methods, withdrawal and natural family planning, have typical-use 1-year failure rates of 18% to 28%.
The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) recommend use of long-acting reversible contraceptives in all appropriate candidates, including adolescents and nulliparous women.
According to the report, long-acting reversible contraceptives, given their excellent safety and efficacy profile, should be recommended for women with underlying CVD, especially those at increased risk for CV complications of pregnancy, at increased fetal risks due to teratogenic drug use or women with heritable disorders.
The committee recommends barrier methods of contraception in addition to tier I or II methods for the prevention of sexually transmitted infections.
Pregnancy in high-risk patients
“When women with severe cardiovascular disease become pregnant, or when women develop de novo cardiovascular disease during pregnancy, difficult decisions can arise,” the committee wrote.
Women with cyanotic congenital heart disease, advanced cardiomyopathy or significant pulmonary arterial hypertension, may be especially high risk for maternal and fetal mortality or morbidity, according to the report.
“Treating cardiologists have a primary obligation to treat the woman in the best way they can, to minimize fetal risks where possible, and to engage in honest and sometimes difficult shared decision-making,” the committee wrote. “This may include recommending termination of pregnancy in circumstances where maternal risk is unacceptably high.”
Although pregnancy termination carries some risk, abortion-related mortality is significantly lower than pregnancy-related mortality, and delays should be minimized for patients pursuing pregnancy termination, according to the report.
“If a patient identified to be at increased risk for pregnancy complications is also noted to be using a contraceptive method with low effectiveness, a discussion of reproductive goals and safe and effective methods of contraception is recommended,” the committee wrote. “If the patient desires highly effective contraception, prompt referral should be made to an obstetrician/gynecologist comfortable with the provision of contraception for medically complex patients, with multidisciplinary collaborative efforts made for rapid scheduling given the gravity of unintended pregnancy in high-risk patients.”
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