Contraception and Pregnancy in PH

Pregnancy

Pregnancy and PH are a dangerous combination. The life of both the mother and the child are put at a great risk. Pregnancy takes quite a toll on any woman’s body: your heart rate speeds up, and the immune system doesn’t work as well. If you already have a serious illness, such as PH, getting pregnant can be extremely dangerous. The risk of pregnancy related death in women with PH is between 25%-50%*. Additionally, some of the medications used to treat PH can be harmful to the baby.

It is for this reason that doctors recommend that women who have PH should avoid becoming pregnant. There are many methods of contraception that can be used safely in PH. You should discuss issues related to pregnancy and contraception with your PH team.

* statistics from Pulmonary Hypertension Association of the United Kingdom

Contraceptive options

By Carolyn Pugliese, RN, MSN, Nurse Coordinator Ottawa Pulmonary Hypertension Clinic

Pregnancy is contraindicated (not advisable) in women with known PAH because of the high mortality rate during the pregnancy itself. Normal changes of pregnancy include a 50% increase in blood volume. Patients with PAH have a limited ability to cope with the sudden increase in blood volume. The highest risk is during the third trimester, with a slightly higher risk the first 10 days postpartum. Some medications used to treat PAH are harmful to the fetus. Therefore, an appropriate method of birth control (preferably 2 methods) is highly recommended in all women with pulmonary hypertension who have childbearing potential. 
Guidelines from the American Heart Association and the American College of Cardiology recommend that pregnancy be avoided in women with cyanotic congenital heart disease, PH, and Eisenmenger syndrome. The expert consensus document of the European Society of Cardiology on the management of cardiovascular diseases during pregnancy outlines that severe pulmonary vascular disease has long been known to carry a maternal mortality of 30–50%, however, there is no agreement yet among experts on the most appropriate method of birth control. 
The World Health Organization (WHO) is “the directing and coordinating authority for health within the United Nations system”.  According to their website, “WHO is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends”.

WHO provides evidence-based family planning guidance and recommendations on whether an individual can safely use a contraceptive method in the third edition of The Medical eligibility criteria for contraceptive.

WHO developed risk classifications (1- low risk - 4- high risk) for contraception andpregnancy for women with various cardiovascular conditions in which pregnancy is contraindicated.  Pulmonary hypertension of any cause is considered a class 4 pregnancyrisk, which is the highest risk for maternal mortality.

The risks for contraceptive methods in specific cardiac conditions are summarized below:

Sterilization may appear the obvious choice for many women who should not get pregnant, however it is rated as a class 2 risk because of the risks associated with the procedure itself, its late failure rate, its psychological impact, and, frankly, the availability of secure and safe alternatives. If this is the method you would prefer, speak to your PH physician about the risks of the procedure for you.

Barrier Methods of birth control are considered the safest method. They include condoms in men and/or a diaphragm with spermacide in women.

Combined oral contraceptives (COC) (Estrogen/progesterone containing) come with a class 4 risk due to the increased risk of a blood clot with estrogens. These include oral forms (the pill), skin patch (EVRA), and vaginal rings (Nuva Ring). The current availability of low-estrogen dose products and simultaneous oral anticoagulant treatment (coumadin or warfarin) may limit the risk of these agents. You will need to talk with your PH physician before consideration of these products.

Progestogen only pills (POP), such as the “mini pill”, come with a class 1 risk; however they must be taken at the same time each day to achieve good contraceptive effects, since unlike the COC’s,  they do not inhibit ovulation. This is due to the low dose of progestogen. Low dose POP’s are also contraindicated for women receiving bosentan since bosentan can reduce further reduce the effects.

The new POP, Cerazette is an intermediate progestogen dose POP, therefore it has similar efficacy to the COC and a 12-hour ‘window’ for missed pills. Cerazette (at increased dose) would be the only appropriate POP for patients taking bosentan.

Depo Provera is a high dose progestogen-only contraceptive and a highly effective POP. It is taken as injections once every 3 months but fertility frequently returns to normal if injections are delayed. There is a possibility of retaining fluid, heavy menstrual bleeding and/or bleeding at the injection sites, so speak to your PH team if these occur.
Mirena is an IUD with progestogen.  The medication is continuously released over a period of 5 years. This method along with the standard copper IUD is most often avoided in patients with pulmonary hypertension since the procedure is invasive. Talk to your PH physician before if this procedure is being considered for yourself.

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