ART in women with cardiac condition

Women with heartdisease are known to have an increased risk of suffering medical complicationscompared to healthy women and it has been seen that this risk increases whenwomen with heart problems undergo IVF.A retrospective study done by NatalieDayan et al. evaluated this risk for the first time and published the resultsin JACC in 2014, confirming that it exists. Twenty women with mean age 37 ± 4years, with 22 pregnancies. Out of these 15 pregnancies (68%) occurred in womenwith congenital heart problems and 7 (32%) in women with acquired heartdisease. One complication was detected in 73% of the pregnancies. 18% of theheart patients suffered ovarian hyperstimulation syndrome (OHSS), compared to1% of the healthy women. Adverse cardiac maternal outcomes were detected in 27%of the cardiac patients, compared to 13% in pregnant women with heart diseasenot conceiving with assisted reproductive technologies (ART). Fetal or neonatalproblems were detected 45% of the cardiac patients compared to 20% of pregnantwomen with heart disease not conceiving with ART. Fetal prematurity was alsohigher in the heart patients (32%) than in a reference ART population (13%).Ovarian hormonal hyperstimulation is a serious complication of ART, which ismore dangerous in heart patients, in such situations even moderate forms ofovarian hyperstimulation can be poorly tolerated.

Multiple pregnancies are common in assisted reproductive technologies (ART) pregnancies and are associated with a higher cardiac output compared with single pregnancies. Multiple pregnancies also increased the hemodynamic burden can cause left-sided obstructive valve lesions or left ventricular systolic dysfunction. Multiple pregnancies have higher rates of pre-eclampsia and other morbidities that are poorly tolerated in the setting of pre-existing heart disease. Pregnancies in women with heart disease are associated with adverse fetal and neonatal outcomes; the frequency of these complications may be even higher in the presence of ART. Putative mechanisms include sub optimal endometrial function at the time of implantation and compromised uteroplacental perfusion.

ART in women with cardiac condition

Current guidelines do address pregnancy risks in women with heart disease. However, more information is urgently needed on women with heart disease undergoing ART. The additional potential risks due to ART along with cardiac-specific maternal and fetal risks must be weighed against the desire for pregnancy. Modified ART protocols and close antenatal surveillance at a center with expertise in pregnancy and heart disease are recommended because of high complication rates.

Contraception

Circulatory changes in pregnancy can cause unmasking and decompensation of pre-existing cardiac disease. Appropriate contraception is essential to ensure that pregnancy is either avoided or planned for a time when the woman’s cardiac disease has been optimized, especially in those at greatest risk of cardiac decompensation. Planning also allows for any necessary adjustments to drug therapy to be instituted prior to pregnancy. It is important to prevent the genetic transmission to the fetus in some hereditary conditions such as Marfan syndrome, dilated cardiomyopathy and familial hypertrophic cardiomyopathy. No method of contraception is 100% effective, so it is essential that all women of childbearing age with heart disease receive thorough pre-pregnancy counselling and advice regarding the most appropriate methods of contraception. Counselling should be offered by clinicians with expertise in heart disease in pregnancy or sexual and reproductive health specialists who have received advanced contraception training. When considering which contraceptive method to offer to a woman with cardiac disease, both the safety of the method and its efficacy must be considered. Contraceptive efficacy can either be perfect if used in the right way all the time or typical use when human error is taken as a factor. Thus, an unplanned pregnancy should be avoided in the scenario.

C section versus Vaginal deliver for pregnant women with cardiac diseases

Reported use of caesarean section in patients with heartdisease varies from 21% to 55% in different registries and studies.Guidelinesare largely based on expert opinion, which broadly states that vaginal deliveryis preferred in women with an adequate cardiac output, but caesarean sectionmay be a better option in selected high-risk patients.European guidelines onpregnancy and heart disease recommend caesarean section in women on oralanticoagulants in pretermlabor, patients with Marfan syndrome and an aorticdiameter >45 mm, patients with acute or chronic aortic dissection and inthose with acute intractable heart failure. Caesarean delivery may also beconsidered in patients with Marfan syndrome and with an aortic diameter largerthan 40 mm. For all other patients, vaginal delivery with an effective epiduralis the preferred method, as it is held to cause fewer and less dramatic changesin hemodynamic parameters and is known to be associated with lower risks ofmaternal complications such as hemorrhage, infection and thrombosis.Despitethis, caesarean section rates are much higher in women with heart disease thanin the normal population,probably because clinicians are worried about thegreater risks of an emergency caesarean section. These decisions however varyin different parts of the world and decision solely lies with the clinician.Across various studies maternal outcomes were similar whether delivery wasachieved after planned caesarean section or planned vaginal delivery and fetaloutcomes were better after a planned vaginal delivery. Therefore, there is noobstetric or cardiac contraindication, a planned vaginal delivery is a better optionfor women with heart disease. Obstetricians and cardiologists should probablyconsider a planned vaginal delivery in women with heart disease.

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