Safety of contraceptive use among women with peripartum cardiomyopathy: a systematic review

ACOG Practice Bulletin No. 212: Pregnancy and Heart Disease

Maternal heart disease has emerged as a major threat to safe motherhood and women's long-term cardiovascular health. In the United States, disease and dysfunction of the heart and vascular system as "cardiovascular disease" is now the leading cause of death in pregnant women and women in the postpartum period () accounting for 4.23 deaths per 100,000 live births, a rate almost twice that of the United Kingdom (). The most recent data indicate that cardiovascular diseases constitute 26.5% of U.S. pregnancy-related deaths (). Of further concern are the disparities in cardiovascular disease outcomes, with higher rates of morbidity and mortality among nonwhite and lower-income women. Contributing factors include barriers to prepregnancy cardiovascular disease assessment, missed opportunities to identify cardiovascular disease risk factors during prenatal care, gaps in high-risk intrapartum care, and delays in recognition of cardiovascular disease symptoms during the puerperium. The purpose of this document is to 1) describe the prevalence and effect of heart disease among pregnant and postpartum women; 2) provide guidance for early antepartum and postpartum risk factor identification and modification; 3) outline common cardiovascular disorders that cause morbidity and mortality during pregnancy and the puerperium; 4) describe recommendations for care for pregnant and postpartum women with preexisting or new-onset acquired heart disease; and 5) present a comprehensive interpregnancy care plan for women with heart disease.

Contraception and reproductive counseling in women with peripartum cardiomyopathy

OBJECTIVES

Pregnancies following a diagnosis of peripartum cardiomyopathy (PPCM) are associated with increased risk for maternal morbidity and mortality. Yet patterns of contraceptive use and reproductive counseling have received little attention. This nationwide registry-based study sought to evaluate patterns and clinical characteristics associated with contraceptive use, and examine the prevalence of contraceptive counseling in women with PPCM.

METHODS

From December 2015 to June 2016, 177 PPCM patients (mean age of 34.8±5.7years, median time since diagnosis of 3.0±4.3years) completed questionnaires about contraceptive use and counseling at registry enrollment. T Tests, chi-square and logistic regression were used to compare demographic and clinical characteristics among women who reported contraceptive use vs. nonuse.

RESULTS

Tubal ligation (24.3%), condoms (22.0%) and intrauterine devices (IUDs; 16.4%) were the most common forms of contraception. Among sexually active women, 28.9% reported contraceptive nonuse. Contraceptive users had a lower body mass index higher education, and were less likely to be in a dating relationship, have hypertension, wear an external cardioverter-defibrillator, and use antihypertensive medications compared with nonusers (all p<0.05). Two-thirds of women received counseling about risks of subsequent pregnancies and contraceptive strategies.

CONCLUSIONS

This preliminary study indicates that 1 in 4 PPCM patients are sexually active and are not using contraception to prevent PPCM reoccurrence. Although a majority of women did receive reproductive counseling, as many as 25% of patients reported no discussion of contraceptive strategies to prevent unintended pregnancy and heart failure relapse.

Peripartum cardiomyopathy: a contemporary review

Peripartum cardiomyopathy is a rare and potentially fatal disease. Though approximately half of the patients recover, the clinical course is highly variable and some patients develop refractory heart failure and persistent left ventricular systolic dysfunction. It is diagnosed when women present with heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found. Etiology remains unclear, and treatment is similar to other cardiomyopathies and includes evidence-based standard heart failure management strategies. Experimental strategies such as intravenous immunoglobulin and bromocriptine await further clinical validation.

Usefulness of progesterone-only components for contraception in patients with congenital heart disease

The objective of the study is to report the contraceptive methods used by patients with congenital heart disease (CHD) before referral to a specific preconception clinic and evaluate safety and treatment adherence of the alternative contraception method, progesterone-only component (PC), offered. Contraceptive methods in the CHD population reported included estrogen-progesterone combined contraceptives (EPCC), despite the potential risk for thromboembolism. PC has been suggested as an alternative, but, no information on its use has been reported. Retrospective analysis was performed of all patients (n = 237) referred to the preconception clinic of an adult CHD center. Thirty-three percent of patients had used EPCC in the past; 3.8% had had thromboembolic events during its use. Current contraception consisted of barrier methods in 58% of patients, EPCC in 18%, and PC in 1.3%; 21.7% of patients were not using any contraception. PC was offered as an alternative in 146 patients; 73% of patients agreed to start the treatment. At a median follow-up of 1 year, 73% of patients who started PC maintained the treatment. Gynecologic side effects were reported in 25% of patients, with no cardiovascular effects. In conclusion, a significant proportion of patients with CHD were former users of EPCC, although some had formal contraindications, and the rate of PC use before referral to the preconception clinic was low. After being offered as an alternative treatment, the use of PC in its various forms was extensive, with no thrombogenic side effects and an acceptable rate of gynecologic side effects being reported.

Concepts of contraception for adolescent and young adult women with chronic illness and disability

Sexual behavior is common in adolescents and young adults with or without chronic illness or disability, resulting in high levels of unplanned pregnancy and STDs. Individuals with chronic illness or disability should not receive suboptimal preventive health care. These individuals have a need for counseling regarding issues of sexuality and contraception. Sexually active adolescent and young adult women can be offered safe and effective contraception if they wish to avoid pregnancy. Women with chronic illnesses and disabilities who are sexually active should also be offered contraception based on their specific medical issues. Condoms are also recommended to reduce STD risks. Table 36 summarizes basic principles of contraception application for specific illnesses, which have been identified since the release of the combined OC in 1960. Clinicians should also consider the noncontraceptive benefits of this remarkable and life-changing technology that allows all reproductive age women to improve their lives, including those with chronic illnesses and disabilities.

United States medical eligibility criteria for contraceptive use 2010: a review of changes

In the late 1990s, the World Health Organization (WHO) created the Medical Eligibility Criteria for Contraceptive Use (MEC), which provide evidence-based recommendations for safe and effective contraception in women with medical problems. The WHO MEC incorporate the best available evidence, are periodically updated, and are designed to be modified for specific populations. The US Centers for Disease Control and Prevention published US MEC in 2010. Changes to WHO guidelines for use in the US population include the following areas: breastfeeding, intrauterine device use, valvular heart disease, ovarian cancer, uterine fibroids, and venous thromboembolism. Medical conditions not covered by WHO recommendations but added to the US MEC include contraceptive guidance for women with inflammatory bowel disease, history of bariatric surgery, rheumatoid arthritis, endometrial hyperplasia, history of peripartum cardiomyopathy, and history of solid organ transplant. This article reviews the changes and additions to WHO MEC found in the US MEC.