Risks of contraception and pregnancy in heart disease

Thorne, Sara; MacGregor, Anne; Nelson‐Piercy, Catherine

doi:10.1136/hrt.2006.095240

Cited by 399 publications

(281 citation statements)

References 15 publications

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“…Seamless transition from paediatric to adult congenital heart disease services is an important step in the management of future pregnancy enabling timely prepregnancy counselling and appropriate contraception advice. 24 The latest confidential enquiry 1 reported the first two deaths in the UK due to rheumatic heart disease since the 1991-1993 enquiry. Both deaths were in recent immigrants, underlining the fact that rheumatic heart disease remains prevalent in many developing countries.…”

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confidence: 99%

Heart disease – why is maternal mortality increasing?

Gelson

Gatzoulis

Steer

et al. 2009

BJOG

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Please cite this paper as: Gelson E, Gatzoulis M, Steer P, Johnson M. Heart disease -why is maternal mortality increasing ? BJOG 2009;116:609-611. The most recent triennial confidential enquiry confirmed that heart disease is the most common cause of maternal death in the UK. The maternal mortality rate associated with heart disease is 2.27 per 100,000 maternities double that reported in 1990. 1 The incidence of heart disease during pregnancy in the UK has remained constant at 0.9% over several decades. 2 However, the severity of heart disease and the risk it poses during pregnancy appear to be increasing in a wide range of healthcare settings. This commentary examines why mortality rates have risen and makes recommendations as to how this trend can be reversed.Ischaemic heart disease is now the most common cause of cardiac death in the pregnant population in the developed world. This is likely due to increased maternal age; smoking; the adoption of a sedentary lifestyle and poor diet leading to greater rates of obesity, diabetes and hypertension. 3-6 Acute myocardial infarction accounts for the majority of deaths and is most commonly due to coronary atherosclerosis, but coronary artery dissection and consequent occlusion are also relatively frequent. There is a high incidence of recognised risk factors for atherosclerosis in pregnant women suffering an acute myocardial infarction during pregnancy and the postpartum period, which should be targeted both for intervention and for identification. 6 Hyperlipidaemia, hypertension and diabetes should be optimally controlled preconception and smoking cessation and weight loss strongly encouraged. Women with multiple risk factors should be identified, alerting obstetricians to the possibility of ischaemic heart disease and lowering thresholds for the investigation of symptoms. When myocardial infarction is suspected or diagnosed, cardiac catheterisation with acute phase intervention (thrombolysis and/or coronary angioplasty) should not be withheld; these procedures are relatively safe in the pregnancy, 7 although larger studies are required to determine their specific risk to benefit ratios. Following the acute phase, secondary prevention (such as optimal blood pressure control, aspirin and statins [see below]) should be instituted. Many cardiac medications can be used without undue risk in pregnancy, for example beta blockers, digoxin, aspirin, diuretics and hydralazine. ACE inhibitors are known to have teratogenic effects in the first trimester and should therefore best be avoided during early pregnancy. 8 Exposure in the second and third trimesters can lead to marked fetal hypotension and decreased fetal renal blood flow. Where ACE inhibitors must be continued, the lowest possible dose should be used and amniotic fluid levels and fetal growth should be monitored carefully. Statins have been identified as potential teratogens on the basis of theoretical considerations. However, epidemiological data suggest this to be unfounded. Given the scarcity of available data,...

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confidence: 99%

Heart disease – why is maternal mortality increasing?

Gelson

Gatzoulis

Steer

et al. 2009

BJOG

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“…Os cardiologistas que prestam assistência a cardiopatas durante a gestação devem estar aptos não só para informar sobre os riscos de uma gravidez em relação à cardiopatia, como também orientar com segurança qual o método mais adequado para evitar gestações desaconselhadas. Devem integrar equipes multidisciplinares de planejamento familiar, constituídas por clínicos, obstetras, ginecologistas, anestesistas, urologistas, entre outros especialistas 17 . 1,5,13 Na classificação da OMS, como classe de risco 2 ou 3, estão aquelas cardiopatias associadas a pequeno aumento no risco de morbimortalidade materna (vide Tabela 3).…”

Section: -Cardiopatias De Alto Risco E Com Contraindicação à Gravidezunclassified

20. Planejamento familiar e anticoncepção

Ávila¹,

Tedoldi²

2009

Arq. Bras. Cardiol.

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“…women with pulmonary vascular disease or Fontan circulation). 6 When assessing pregnancy risk, existing risk scores must be implemented but also disease-specific risks must be taken into account (figure 1). Data to assist in providing an adequate risk assessment are available from several publications.…”

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confidence: 99%

“…[6][7][8] Contraindications for pregnancy are pulmonary hypertension, severely depressed systemic ventricular function (EF <30%), severe left heart obstruction, Marfan syndrome with ascending aorta >40 mm and peripartum cardiomyopathy with residual impairment of left ventricular function, because in these conditions maternal mortality is high. 6 Maternal risk is significantly increased in women with cyanotic heart disease, other complex congenital heart disease including Fontan circulation and systemic right ventricle, and mechanical prosthetic valves. When assessing maternal risk, it is important to realise that if several risk factors are present, these sometimes add up to an unacceptably high risk.…”

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confidence: 99%

“…When assessing maternal risk, it is important to realise that if several risk factors are present, these sometimes add up to an unacceptably high risk. 6,7 A recent investigation among 116 women visiting a highly specialised congenital heart disease clinic demonstrated that 50% of women with a contraindication for pregnancy and over 30% of women with intermediate or high pregnancy risk did not recall being informed about the increased risk or contraindications. 9 This illustrates the importance of clear and repeated proactive counselling.…”

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confidence: 99%

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