75 J Fam Plann Reprod Health Care 2006: 32(2) REVIEW Introduction Heart disease is the leading cause of maternal mortality in the UK. 1 There is therefore a need to disseminate amongst the medical profession accurate information about contraception and pre-pregnancy counselling for women with heart disease. The risk of pregnancy depends on the specific disease and the individual patient. For example, the risk of maternal death is up to 50% for those with pulmonary arterial hypertension, but there is no anticipated extra risk for those with mild pulmonary stenosis compared to women without heart disease. Similarly, although certain contraceptive methods are associated with unacceptable increases in risk for specific cardiac conditions, it is not the case that “most structural heart disease” is an absolute contraindication for use of the combined oral contraceptive (COC). 2 There is a paucity of published information and very little evidence base about contraception in women with heart disease. Thus health care professionals who offer advice to such women may err on the side of caution, being reluctant to advise some methods that may in fact be appropriate. A lack of knowledge by non-specialists of the range of effective contraceptive measures available may result in the highest-risk women being denied effective contraception and having unplanned pregnancies. 3 Conversely, those with less severe lesions receive inappropriate advice regarding (primarily) oral contraception, again leading to unintended conceptions. 3 In extreme examples, women may even be advised to undergo unnecessary termination of pregnancy for a cardiac condition that has little or no increased risk in pregnancy. The lack of specialist cardiac services for the growing number of adolescents and adults with congenital heart disease (CHD) may compound the problem. Many cardiologists have little knowledge of the interactions between complex heart disease, pregnancy and its prevention. Family planning needs and preconceptual advice for adults with CHD are presently generally poorly provided for. 3 All these women need advice arising from a combined approach between family planning clinicians and cardiologists with relevant special skills and interests. This counselling should always respect the woman’s autonomy. For the above reasons, a group of obstetricians, gynaecologists, experts in contraception, obstetric physicians, cardiologists and specialists in adult CHD was convened. This working group met on several occasions and corresponded over 2 years to produce a consensus document outlining recommendations on pregnancy and contraception for women with heart disease. Since women with heart disease are not a homogeneous group, the aim of this review and the resulting recommendations is to provide risk stratification for both pregnancy and individual contraceptive methods in women with cardiac disease. Pregnancy and contraception in heart disease and pulmonary arterial hypertension Sara Thorne, Catherine Nelson-Piercy, Anne MacGregor, Simon Gibbs, John Crowhurst, Nick Panay, Eric Rosenthal, Fiona Walker, David Williams, Michael de Swiet, John Guillebaud J Fam Plann Reprod Health Care 2006; 32(2): 75–81 (Accepted 16 January 2006) University Hospital Birmingham, Birmingham, UK Sara Thorne, MD, FRCP, Consultant Cardiologist St Thomas’ Hospital, London, UK Catherine Nelson-Piercy, Qualifications, Consultant Obstetric Physician Eric Rosenthal, MD, FRCP, Consultant Paediatric Cardiologist Barts Sexual Health Centre, St Bartholomew’s Hospital, London, UK Anne MacGregor, MFFP, Senior Clinical Medical Officer Department of Cardiovascular Medicine, Imperial College School of Medicine, Hammersmith Hospital, London, UK Simon Gibbs, MD, FRCP, Senior Lecturer Hammersmith Hospital, London, UK John Crowhurst, Dip(Obst) RCOG, FRCA, Consultant Anaesthetist Nick Panay, MRCOG, MFFP, Consultant Obstetrician and Gynaecologist Middlesex Hospital, London, UK Fiona Walker, BM, MRCP, Consultant Cardiologist Elizabeth Garrett Anderson Obstetric Hospital, London, UK David Williams, PhD, MRCP, Consultant Obstetric Physician Institute of Reproductive and Developmental Biology, Imperial College, Queen Charlotte’s and Chelsea Hospital, London, UK Michael de Swiet, MD, FRCP, Emeritus Professor of Obstetric Medicine and Consultant Obstetric Physician University College London and Margaret Pyke Memorial Trust, London, UK John Guillebaud, FRCOG, Hon FFFP, Emeritus Professor of Family Planning and Reproductive Health Correspondence to: Dr Sara Thorne, University Hospital Birmingham, Birmingham B15 2TH, UK. Tel: +44 (0) 121 627 2959. Fax: +44 (0) 121 627 2862. E-mail: sara.thorne@uhb.nhs.uk Table 1 World Health Organization (WHO) risk classifications by medical condition for contraceptive method and pregnancy WHO Class 1 2 3 4 Risk for contraceptive method by medical condition Condition with no restriction for the use of the contraceptive method Always usable Condition where the advantages of the method generally outweigh the risks Broadly usable Condition where the risks of the method usually outweigh the advantages: alternatives are usually preferable. Exceptions if: (i) Patient accepts risks and rejects alternatives (ii) The risk of pregnancy is very high and the only acceptable alternative methods are less effective Caution in use Condition where the method represents an unacceptable health risk Do not use Risk for pregnancy by medical condition No detectable increased risk of maternal mortality or morbidity Small increased risk of maternal mortality or morbidity Significantly increased risk of maternal mortality or severe morbidity. Expert counselling required. If pregnancy is decided upon, intensive specialist cardiac and obstetric monitoring needed throughout pregnancy, childbirth and the puerperium Extremely high risk of maternal mortality or severe morbidity: pregnancy contraindicated. If pregnancy occurs termination should be discussed. If pregnancy continues, care as for Class 3 75-81 - Thorne - Review 3/13/06 4:11 PM Page 1 on December 6, 2021 by guest. 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