Contraceptive choices for females with congenital heart disease

Experiences of women with cardiac disease in pregnancy: a systematic review and metasynthesis

OBJECTIVE

Cardiac disease in pregnancy is a leading cause of maternal death in high-income countries. Evidence-based guidelines to assist in planning and managing the healthcare of affected women is lacking. The objective of this research was to produce the first qualitative metasynthesis of the experiences of pregnant women with existing or acquired cardiac disease to inform improved healthcare services.

METHOD

We conducted a systematic search of peer-reviewed publications in five databases to investigate the decision-making processes, supportive strategies and healthcare experiences of pregnant women with existing or acquired cardiac disease, or of affected women contemplating pregnancy. Identified publications were screened for duplication and eligibility against selection criteria, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We then undertook a thematic analysis of the data relating to women's experiences extracted from each publication to inform new healthcare practices and communication.

RESULTS

Eleven studies from six countries were included in our meta-synthesis. Four themes were revealed. Women with congenital and acquired heart disease identified situations where they had either taken charge of decision-making, lacked control or experienced emotional uncertainty when making decisions. Some women were risk aware and determined to take care of themselves in pregnancy while others downplayed the risks. Women with heart disease acknowledged the importance of specific social support measures during pregnancy and after child birth, and reported a spectrum of healthcare experiences.

CONCLUSIONS

There is a lack of integrated and tailored healthcare services and information for women with cardiac disease in pregnancy. The experiences of women synthesised in this research has the potential to inform new evidence-based guidelines to support the decision-making needs of women with cardiac disease in pregnancy. Shared decision-making must consider communication across the clinical team. However, coordinated care is challenging due to the different specialists involved and the limited clinical evidence concerning effective approaches to managing such complex care.

Pregnancy and contraception in young women with congenital heart disease: General considerations

Young women with heart disease are increasingly being seen in obstetrical referral centres owing, in large part, to the dramatic improvements in survival of young adults with congenital heart disease in recent years. Although pregnancies in most women with heart disease result in favourable outcomes, there are important exceptions that must be recognized. These exceptions pose significant mortality risk to the mother and/or the fetus. The present article outlines cardiovascular adaptations to pregnancy, general outcomes and management considerations for practitioners caring for pregnant young women with congenital heart disease. A lesion-specific review is published in a complementary article.

Management of pregnancy in women with palliated and unpalliated congenital heart defects

Medical advancements have made it possible for more women with congenital heart defects (CHDs) to carry successful pregnancies. Most CHD surgeries or interventions are palliative with persistent residua and sequelae exacerbated by the physiologic stresses of pregnancy. Preconception assessment, a tailored multidisciplinary approach during pregnancy, and a planned, elective delivery followed by careful postpartum monitoring may improve outcomes. Teratogenic medications should be stopped and changed to safer alternatives. Major hemodynamic changes in pregnancy, labor, and delivery may aggravate the underlying cardiovascular defects. Interventions or surgeries, when anticipated, should be performed before pregnancy. Antibiotic prophylaxis is indicated for nearly all palliated and unpalliated defects.

Repaired tetralogy of Fallot in the adult

The majority of persons living with tetralogy of Fallot are now adults and may face a number of long-term cardiac problems that necessitate reoperation. These problems include pulmonary regurgitation, tricuspid regurgitation, ventricular tachycardia, atrial flutter and/or fibrillation, pulmonary artery branch stenoses, right ventricular aneurysms, right ventricular outflow tract obstruction, residual ventricular septal defects, and coronary artery disease. Management approaches to these potential problems are discussed. Issues related to genetics, pregnancy, infective endocarditis, insurability, and employment are also reviewed with specific reference to the individual with repaired tetralogy of Fallot.