image: Multidisciplinary Model for Shared Decision-Making in Contraception and Pregnancy
Counseling for Women With Cardiovascular Conditions
Pregnancy can increase the risk of morbidity and mortality in women with cardiovascular disease; however, many cardiologists are not having pre-pregnancy contraception discussions with their patients of child-bearing age. There is a need to provide evidence-based guidance for contraceptive safety and effectiveness and pregnancy planning options for this high-risk patient group, according to a paper published in the Journal of the American College of Cardiology (JACC). This paper is one of a five-part JACC focus seminar series addressing a wide range of topics in the emerging cardio-obstetrics field.
Prior research has found that 68% of females have had sex at least once by the time they were 17, and a study of congenital heart disease (CHD) patients identified that 26% of all adolescents (age 15-18 years) and 74% of all young adults (age 19-25 years) with CHD report ever having sex. For reproductive-age women with cardiovascular disease, planning for if they want to become pregnant is vital for the health of both the mother and fetus. Many of these women are prescribed medications to treat cardiovascular disease that could potentially harm the fetus, and pregnancy may cause significant morbidity and mortality among women with pre-existing cardiovascular disease. Despite rising rates of acquired cardiovascular disease in women of this age group, the frequency of reproductive planning discussions between cardiologists and these patients is unknown.
Authors of the paper said they urge women with cardiovascular disease to develop reproductive goals that include deciding whether and when to become pregnant and encourage shared decision-making with their obstetrician, cardiologist and primary care provider to create an action plan. The paper also stresses that cardiovascular clinicians need to educate their patients about how their heart conditions impact contraceptive and medical decision-making for pregnancy.
"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 (age 15-44) with cardiovascular disease," said Kathryn J. Lindley, MD, FACC, chair of the ACC's Cardiovascular Disease in Women Committee and member of the ACC's Cardio-Obstetrics Work Group, and lead author of the paper. "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."
Another barrier to optimal care discussed in the paper are the significant disparities that exist in access to contraception and risk of unintended pregnancy among certain minority populations, including women with high cardiovascular disease burden. According to the paper, over 19 million women in the US, particularly in the South, Midwest and Mountain West live in "contraception deserts" and lack access to a contraceptive care facility in their county.
"Given the significant barriers to and the importance of obtaining safe and effective contraception, ensuring contraceptive access is an important part of providing comprehensive cardiovascular care," Lindley said.
Recommendations for the different types of contraception methods, which are divided into three tiers of effectiveness, are provided in the paper: Tier 1 methods (permanent sterilization and long-acting reversible contraceptives), Tier II methods (combined hormonal contraceptives, progestin-only pills and the depot medroxyprogesterone acetate injection) and Tier III methods (barrier methods, withdrawal and natural family planning).