Discussing contraception with young women at risk of CVD

Evelyn Lewin

8/04/2021 3:49:28 PM

Pregnancy can increase mortality and morbidity in women with heart disease.

GP talking to female patient
Women with heart disease experience increased mortality and morbidity in pregnancy.

The role of contraception in women with heart disease is currently in the spotlight following the publication of a new focus seminar in the Journal of the American College of Cardiology.
It found that despite the risks associated with pregnancy in this cohort, many cardiologists are not talking to their patients about contraception.
According to Women’s Heart Clinic cardiologist and heart failure specialist Dr Monique Watts, this is an issue, as cardiovascular disease is one of the leading causes of pregnancy-related deaths in the US.
‘Our populations are similar in many ways,’ she told newsGP. ‘It’s likely to be the same in Australia given our similar societies and disease patterns.
‘This is something all cardiologists and GPs should have on their radar.’
The paper highlights the need for evidence-based guidance for contraceptive safety and effectiveness, as well as pregnancy planning options for women with heart disease.
Lead author, cardiologist Dr Kathryn J Lindley says contraception should be discussed in all women of reproductive age with heart disease.
‘It is important for cardiovascular clinicians to assess for the need for contraception and appropriateness of contraceptive method both at the time of initial assessment and at subsequent annual encounters in all reproductive age women [15–44] with cardiovascular disease,’ she said.
‘If a patient identified to be at increased risk for pregnancy complications is also noted to be using a contraceptive method with low effectiveness, a discussion of reproductive goals and safe and effective methods of contraception is recommended.’
While Dr Watts agrees contraception needs to be discussed in all women in this patient population, she says choosing the right contraceptive is not straightforward.
‘There are so many factors in determining what’s right for a woman,’ she said.
‘With cardiomyopathy patients we need to be careful about thrombotic risk, so oestrogen- containing agents may not be ideal.
‘If you’ve got patients who need to have ACE-inhibitors or other medications that are unsafe in pregnancy, women need to be educated and informed.’
Dr Watts believes it is also important to consider the effect of various contraceptives in different situations.
‘Even women who are on dual antiplatelet therapy after stents who are still menstruating can have issues with bleeding, and that’s something again that can be modified with the right contraceptive method,’ she said.
‘They need to know that, for instance, you [should not] fall pregnant on this drug. So what are we doing to make sure that doesn’t happen?
‘Similarly, if pregnancy is desired and safe, let’s make a plan to change medications in a controlled and informed way.’
When it comes to selecting a contraceptive for women with heart disease, Dr Watts says long-acting reversible contraception (LARC) such as progesterone intrauterine devices (IUDs) are often a preferred option as they do not increase clotting risk and may reduce bleeding. 
Dr Wendy Burton, Chair of RACGP Specific Interests Antenatal/Postnatal Care, says GPs are accustomed to considering the impact of different diseases and medications in pregnancy.
‘This is part of holistic general care,’ she told newsGP.
When prescribing the pill to a patient, Dr Burton often asks whether they are planning a pregnancy.
‘Some of them just look at me like, “Are you daft? I’m getting a pill script, so that would be a no”,’ she said.
‘But it’s important we take the time to do that because every now and then someone will say, “Actually yes, I’m planning to stop it in a month’s time after the wedding” … and that’s a good catch.’

When prescribing the pill, Dr Wendy Burton asks women about their future desire to have children.

Dr Watts believes contraception is often covered ‘really well’ at congenital clinics for patients as they reach their early teens, but worries it is not always considered in general cardiology or general practice.
Dr Burton agrees, saying it can be difficult to know at what age to initiate these conversations, especially with patients with congenital heart issues.
‘If you raise it at the age that it’s really obvious [that the patient may be sexually active] then you’ll be missing some 14- or 15-year-olds who are experimenting,’ she said.
Dr Burton says initiating such conversations can also be difficult with young patients, but that does not mean it should be avoided.
‘This is a great conversation for pregnancy planning and ideally this is a pre-conception conversation,’ she said.
By helping women understand the implications of pregnancy on heart disease, Dr Burton says they are better equipped to advocate for their own needs.
‘Probably the most important thing – and this is always the case – is to empower the woman to understand her own journey, because then if she knows the information that she needs to provide to her care team, that’s really helpful,’ she said.
While the experts believe this issue should be on the radar for clinicians, Dr Watts does not believe GPs and cardiologists need to necessarily ‘have all the answers’.
‘We can’t all have all the knowledge,’ she said.
‘But we can certainly ask the question [of specialists] and highlight this as an issue.
‘Even just telling a patient that you can have a child with this condition, but it needs to be very carefully planned and we will do that for you when you’re ready.
‘Just the knowledge that there is help that can be accessed I think is important.’

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