EXECUTIVE SUMMARY

More young adults are living with cardiovascular disease due to rising numbers of adults with congenital heart disease, obesity, and diabetes.

  • Reproductive health providers should watch for potential problems when patients with cardiovascular disease use contraceptives.
  • Progestin-only contraceptives, such as intrauterine devices and subdermal implants, are safe for people with cardiovascular conditions.
  • When counseling patients with cardiovascular disease on contraceptives, take a thorough history and identify their risk factors.

Cardiovascular disease among women of reproductive age has increased in recent years for a variety of reasons, and reproductive health providers should be aware of particular risk factors and issues involving this population. Clinicians should help this high-risk group prevent unplanned pregnancies, researchers noted.1

“There’s a rapidly growing population of young adults with congenital heart disease, related to advancement in cardiopediatric surgery,” says Kathryn Lindley, MD, associate professor of medicine, associate professor of OB/GYN and director of the Washington University Center for Women’s Heart Disease in St. Louis, MO.

Also, there is a growing population of women with acquired cardiovascular disease related to issues such as obesity. “We have a steadily rising rate of hypertension among women of reproductive age, along with cardiovascular disease, heart failure, and diabetes,” she explains. “This is something people will see more frequently over the next decade.”

Women with cardiovascular issues are at risk for complications during pregnancy, and they can develop problems with certain contraceptives. For example, long-acting reversible contraceptives (LARCs) are a good choice for women with cardiovascular disease because they are highly effective in preventing pregnancy, and they are safe for this population. Progestin-only methods, including the hormonal intrauterine device (IUD), the subdermal implant, and progestin-only pills, have not been shown to be associated with increased risk of thromboembolism.1

“LARCs are safe for all underlying cardiovascular conditions,” Lindley says. “IUDs and subdermal implants are safe for every medical condition, including high-risk conditions like heart failure and pulmonary hypertension.”

Plus, hormonal IUDs have the added benefit of reducing menstrual bleeding, which may be a consideration for women taking blood thinner medication and who have anemia because of heavy periods.

“The main things to keep in mind, in terms of safety, are that combined hormonal methods — the pill, patch, and ring — do carry an increased risk of thrombosis or blood clots,” Lindley says.

Since some cardiovascular conditions increase the risk of blood clots, contraceptives that contribute to this health risk are not recommended for some people with congenital heart conditions, mechanical heart valves, cardiomyopathies, vascular disorders, arrhythmias, and other conditions.1

“I recommend LARC for women with higher-risk conditions,” she adds. “It’s important to have careful risk-benefit discussions with patients and to keep in mind what their risks are with pregnancy.”

Patients with these heart conditions should be reminded that hormonal contraceptives carry a lower risk than does pregnancy, Lindley says.

Cardiovascular disease is the leading cause of maternal death, and many deaths are preventable, research shows.2 Overall, maternal morbidity and mortality have been rising in the United States over the past few decades, even as postpartum infections and hemorrhaging have declined. While severe bleeding and infections are the most common causes of maternal deaths worldwide, they no longer are the chief causes of maternal death in the United States.2-5

“My OB/GYN colleagues have done an amazing job of addressing hemorrhages and infections, which used to be the leading causes of maternal death,” Lindley says. “Those are steadily improving, whereas there’s a rising risk of cardiovascular death that has overtaken those obstetric causes as the leading cause of death.”

It is important for providers to counsel women with cardiovascular disease about the risks of pregnancy, she adds.

Clinicians can take these measures to prevent problems with contraceptives and maternal morbidity:

• Take a thorough history. “Begin with multidisciplinary patient care from the preconception period,” Lindley suggests. “Many times, women had heart surgery as an infant or child. Sometimes, they may not even have a good understanding of what their underlying condition is. Or, they think they were completely cured, whereas many of those [cardiac] conditions have long-term sequelae that put women at risk in pregnancy.”

If the patient is at high risk of pregnancy complications because of heart disease, then clinicians could refer the patient to a physician who specializes in this population.

• Identify risk factors. “Sometimes, we can identify risk factors that can be modified and lower the risk of having complications with pregnancy,” Lindley says. “Once she becomes pregnant, it’s recommended for moderate- to high-risk women with cardiovascular disease to be managed in a collaborative fashion with maternal fetal medicine and a cardiovascular specialist. They can develop a multidisciplinary plan for monitoring women during pregnancy.”

Depending on a patient’s risk factors, providers might want to help the patient select an appropriate time of delivery and mode of delivery. “We need to reduce risks and quickly recognize and treat those complications should they occur,” she adds.

• Be aware of disparities. “There are a lot of reasons for disparities. For Black women, it’s quite striking and not solely related to income and education level,” Lindley says. “Almost certainly, some disparities are related to underlying, systemic bias and racism.”

The problem is a failure to recognize the disease in women of color, and failure to promptly treat them and educate them on the risk, she explains. Reproductive health providers need to talk with all patients with cardiac disease and risk factors about how to recognize their symptoms.

“Educate all patients, but particularly women who have risk factors of maternal morbidity, including obesity, Black race, advanced maternal age, and hypertension,” Lindley says. “Educate them on what the risks and symptoms are so they can recognize the symptoms.”

Another step is for reproductive health providers to be part of the solution in working on the larger systemic issues that contribute to racial and other disparities among women seeking contraceptive and pregnancy care. “Pregnant women of color often have a higher burden of underlying cardio risk factors,” Lindley says. “We should continue to address racial bias and improve access to care.”

This means providers should be part of community-based solutions to barriers such as lack of transportation or child care.

• Discuss emergency contraception. Emergency contraception is not a long-term solution, but it is important for women with high risk factors for morbidity and mortality in pregnancy to know there is an option should they have intercourse without optimal contraceptive protection.

“Women are more likely to use emergency contraception if their physician has talked to them about it and prescribed it for them,” Lindley says. “It can be their back-up contraception, which is safe, but shouldn’t be used as their primary contraception.”

REFERENCES

  1. Lindley KJ, Bairey Merz CN, Davis MB, et al. Contraception and reproductive planning for women with cardiovascular disease: JACC Focus Seminar 5/5. J Am Coll Cardiol 2021;77:1823-1834.
  2. Davis MB, Arendt K, Bello NA, et al. Team-based care of women with cardiovascular disease from pre-conception through pregnancy and postpartum: JACC Focus Seminar 1/5. J Am Coll Cardiol 2021;77: 1763-1777.
  3. Hoyert DL. Maternal mortality rates in the United States, 2019. National Center for Health Statistics Health E-Stats. April 2021.
  4. Macrotrends. U.S. maternal mortality rate, 2000-2021. April 27, 2021.
  5. Jones E. Cardiovascular disease is the leading cause of U.S. maternal death. Preventive Cardiovascular Nurses Association. Jan. 16, 2020.