ࡱ> 9;8y 2bjbj .0{{tJJJJJ^^^84^v$n JJJ08JJ`εk/F0v^J`#^v : CONTRACEPTION FOR PATIENTS WITH CONGENITAL HEART DISEASE Unplanned pregnancy can be disastrous for patients with congenital heart defects. It is vital that they are given adequate and accurate advice about which forms of contraception are suitable for them. The contraceptive efficacy of each different method must be given consideration. EMERGENCY MORNING AFTER CONTRACEPTION No cardiac contra-indication to the morning after pill. Those on warfarin should have their INR checked after 48 hrs. BARRIER METHODS Contraceptive failure rate 15 -30% / year Can be used for any cardiac condition COMBINED ORAL CONTRACEPTIVE PILL Contraceptive failure rate 3 - 8% / year Avoid in Cyanotic heart disease Bjork Shiley or Starr Edwards mechanical valves Tricuspid valve prosthesis Pulmonary hypertension Fontan circulation Pulmonary AV malformations Previous coronary arteritis (Kawasakis disease) Systemic ventricular dysfunction (EF < 30%) Use with caution in Bileaflet mechanical valves Hypertension (eg repaired coarctation) Previous thromboembolism Atrial arrhythmia Dilated left atrium Potential reversal of left to right shunt (eg unoperated ASD) ORAL PROGESTERONE ONLY METHODS Can be used in any heart defect. Can induce menstrual irregularities, particularly in the first few months of taking. Various preparations; Standard Progesterone only pill Contraceptive failure rate 5-10% / year Cerazette (new anovulatory POP) Contraceptive failure rate 0.4% / year INJECTABLE PROGESTERONE ONLY METHODS Can be used in any heart defect. Can induce menstrual irregularities initially. With prolonged use many women become amenorrhoeic. Caution with depo Provera IM injection in those taking warfarin. Depo Provera (3 monthly IM injection) Contraceptive failure rate 3% / year Implanon (3 yearly sub dermal implant) Contraceptive failure rate 0.05% / year MIRENA COIL Contraceptive failure rate 0.1% / year If a woman with a congenital heart defect opts to have an intra-uterine device, a Mirena coil has certain advantages over the traditional copper IUD. More effective contraception than sterilisation. Usually induces amenorrhoea. Needs antibiotic prophylaxis at the time of insertion. Insertion induces vasovagal response in about 5% of women. Therefore avoid in patients with pulmonary vascular disease, Eisenmengers syndrome or Fontan circulation, unless other forms of contraception are unacceptable. FEMALE STERILISATION Contraceptive failure rate 0.5% / year Given the efficacy of Implanon, Cerazette and Mirena coil, female sterilisation is rarely indicated. Late failures are more common in younger women and increase the risk of ectopic pregnancy. The surgical procedure can carry risks for women with congenital heart defects. MALE STERILISATION Contraceptive failure rate 0.15% / year Rarely appropriate. Assuming the sterilisation is performed to protect the health of his partner - the male partner may well outlive his female partner with congenital heart disease and may wish to start a family later on. PREGNANCY IN WOMEN WITH CONGENITAL HEART DEFECTS It is perfectly possible for many women with congenital cardiac defects to have normal pregnancies and deliveries. It is important that Pre-conception counselling and assessment be available. Patients can be divided into mild, moderate and severe risk groups. Attention should be paid not only to maternal risk but also to fetal risk. LOW RISK The risk of maternal morbidity and mortality is not detectable higher than that of the general population Uncomplicated, small or mild Pulmonary stenosis Ventricular septal defect Patent ductus arteriosus Mitral valve prolapse with trivial mitral regurgitation Successfully repaired Ostium secundum ASD VSD PDA TAPVD MILD RISK Small increased risk of maternal morbidity and mortality Repaired coarctation with no hypertension, no significant obstruction and no aneurysm formation (as assessed by MRI) Mild aortic stenosis or regurgitation Repaired tetralogy of Fallot (good surgical result and no arrhythmias) Unoperated atrial septal defect Mild to moderate mitral regurgitation Ebsteins anomaly (depends on degree of cyanosis) Moderate pulmonary stenosis MODERATE RISK Maternal morbidity expected in up to 25 %. Mortality expected in up to 10% Unrepaired coarctation Repaired coarctation with residual obstruction and hypertension Repaired tetralogy of fallot with poor haemodynamic result, severe PR and RV dysfunction Very severe PS Moderate to severe aortic stenosis Transposition of the great arteries (Mustard or senning operations) ccTGA Well balanced single ventricle (depends on degree of cyanosis, and presence or absence of pulmonary hypertension) Fontan circulation Mechanical heart valves SEVERE RISK Maternal mortality expected in up to 50% Pulmonary hypertension Severe left heart obstruction >moderate systemic ventricular impairment (Ej # < 30%) Marfans syndrome with dilated aortic root >40mm Women with congenital heart defects in class 1 or class 2 should attend the ACHD specialist centre or the local ACHD centre for pre-pregnancy assessment and counselling. This will sometimes involve extensive investigations including cardiac catheterisation, exercise testing, and imaging. 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