Contraception in women with I cardiovascular disease

Women of childbearing age with congenital or acquired cardiovascular disease including coronary heart disease, heart failure, stroke, and hypertension is estimated at 11.5%.

This population is increasing because of improved pediatric cardiac care enabling more than 90% of children with congenital heart disease to survive until adulthood and increasing rates of cardiovascular risk factors for young women such as obesity, hypertension, and diabetes.

Women with cardiovascular risk factors or cardiovascular disease may require medical therapies which are potentially teratogenic.

These women may require anticoagulation or antiplatelet therapy increasing the risk of significant menorrhagia and anemia, and these cardiovascular risk factors may also be associated with cardiovascular complications and obstetrical complications during pregnancy, such as preeclampsia, thromboembolism and vascular dissection.

The presence of a cardiomyopathy or pulmonary hypertension during pregnancy poses significant life-threatening risks.

Given the above difficulties contraception reduces the risk of adverse cardiovascular events and can optimize pregnancy planning and fetal outcomes.

In all cases, pregnancy among these individuals is associated with a higher cardiovascular risk than contraceptive methods, even those that appear contraindicated.

Hormonal contraceptives include those that contain both estrogen and progesterone, contraceptive transdermal patches and digital rings.

Estrogens are prothrombotic by increasing hepatic production of coagulation factors and subsequent risk for thromboembolism.

Combined hormonal contraceptives are not optimal contraceptive choices for individuals with cardiovascular disease. 

Estrogen containing methods such as pills, patches, O-rings should generally be avoided in individuals with acquired of congenital cardiovascular conditions, which pose an increase risk with developing thromboembolic disease.

Combined hormonal contraceptives are not recommended for patients with uncontrolled hypertension as they may cause a mild increase in blood pressure.

Progestin only contraceptives do not substantially change blood pressure, cholesterol, or coagulation factor levels and do not increase the risk of thrombosis and are generally safe when compared with the risk of pregnancy.

Patients with a higher risk of cardiovascular complications with pregnancy and who require potentially  teratogenic medications and put the fetus at risk with ACE inhibitors, warfarin, and endothelin receptor blockers, amiodarone: should consider long acting reversible contraceptives such as IUD or subdermal implants or permanent sterilization.

Combined hormonal contraceptives are relative or absolutely contraindicated in a number of cardiovascular conditions because of associated thromboembolic risks and include: some congenital heart conditions, right to left shunt, cyanotic conditions, single ventricles,  acute or severe cardiomyopathy, pulmonary hypertension, atrial fibrillation, DVT, pulmonary embolism, ischemic heart disease and mechanical heart valves.

The use of IUDs may increase bleeding in patients who have anti-platelet or anticoagulant medications as part of their cardiovascular therapy.

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