AbortioninwomenwithcardiacdiseaseOskariHeikinheimoDept Ob&GynUniversityofHelsinki

OHeikinheimo conflictsofinterest

• Employedby– HospitaldistrictofHelsinkiand

Uusimaa– UniversityofHelsinki– FinnishmedicalsocietyDuodecim

• Lectures,Ad-boardmembershipsat– BayerAG– Exelgyn– Gedeon Richter– MSD

• Boardmemberat– Suomen Lääketieteen säätiö– Oheikinheimo consulting– Femeda clinic

Contents• Background– Cardiacdiseaseinfertileagedwomen– Contraception inwomenwithcardiacdisease

• EuropeanSocietyofCardiologyguidelines– Whenthepregnancyiscontraindicated?

• Whataretherisks?• Awomanwithcardiacdiseaseseekingabortion– Whattoremember?– Proposedmanagementscheme

• Summary

Background

• Thenumberoffertileagedwomenlivingwithcardiacdiseaseisincreasing– 0.2-0.4%ofallpregnanciescomplicatedbycardiovasculardiseaseinWesternworld (Arif &Thorne,Medicine2014)• Improvedcorrectionofcongenitalheartdisease,bettertreatment, increasingmaternalage,immigration

• Meanageoffirstintercourseamongwomenwithcardiacdiseasesimilartothatofhealthwomen(Vigl etal.,AmJCardiol 2010)

– Arethecontraceptive needcovered?

ContraceptioninwomenwithcardiacdiseaseVigl etal.,AmJCardiol,2010

• Asurveyof536women(medianage29y)withcongenitalheartdiseasefromGermany– Highrateofunplannedpregnancies(1/10)– 20%ofthewomenusedcontraceptivemethodcontraindicated intheircondition

– 28%ofwomenwenotusingcontraceptiondespitebeingsexuallyactive

– Nocounseling• In43%concerningcontraception• In48%concerningpregnancy-relatedrisks

– Timelyandcompetentcounselingoncontraceptionneededforwomenlivingwithcardiacdisease

ContraceptioninwomenwithcardiacdiseaseRoos-Hesselink etal.,Contraceptionandcardiovasculardisease

Eur JHeart2015

• Cardiovasculardiseasemightincreasetherisk– Thrombosis– Endocarditis

• Contraceptivecounseling– Thepossiblerisksofpregnancytomotherandchild– Risksofcontraception– Failurerates– Non-contraceptivebenefits– Availability– Individualpreferences– Protectionagainstinfection– Costs

Whatkindofheartdiseasedopregnantwomenhave?Hink &Bolte,PregnancyHypertension2015

• Allpregnantwomenwithheartdiseasefollowed-up in2000-2011atUniversityMedicalCenterAmsterdam– 122womenwith160pregnancies– Typeofheartdisease

• Congenitalheartdisease in 53%• Arrhythmiain 16%

– NYHA-classification• NYHAI-II 93%• NYHAIII-IV 7%

– Heartfailurein• NYHAI-II 7%• NYHAIII-IV 38%• Maternaldeath 2%

https://www.escardio.org/static_file/Escardio/Guidelines/publications/PREGN%20Guidelines-Pregnancy-FT.pdf

ModifiedWHOclassificationofcardiovascular risks- principles

ModifiedWHOclassificationofcardiovascular risks– WHOI

ModifiedWHOclassificationofcardiovascular risks– WHOII-III

ModifiedWHOclassificationofcardiovascular risks– WHOIII

Managementofthehigh-risk(i.e.WHOIV)cardiacconditions

• Ifpregnancyoccurs,terminationshouldbeofferedinatertiarycenterwithexperiencedunit!

• Alsoterminationcarriesarisk!

Whataretheriskstothewoman?

Condition Maternal risks

Pulmonaryhypertension High maternalmortality• 30-50%inolderseries,17-33%innewer• DuringIIItrimester/post-partumperiod• Cardiovascularcollapsefollowingevenminor

hemodynamic/volumechangesINPATIENTSWITHNOORLITTLEDISABILITYBEFORE

History ofperipartumcardiomyopathy

Mortality rateupto15%• Deteriorationupto50%despiteoptimaltherapyRecurrenceriskinsubsequent pregnancy30-50%especially ifEFnotnormalized

Whichcardiacpatientsshouldbereferredtohospital foranabortion?

Soc Fam Plan,Contraception2012• Congenital

– Cyanoticdisease,right/leftventriculardilatation,uncontrolledtachyarytmia

• Coronarydisease– HistoryofAMI,treatmentangina

• Cardiomyopathy– Dilated,hypertrophic,historyofperipartum CMP

• Valvular disease– Significantaortic/mitralstenosis– Aortic/mitralregurgitationwithLVdilatation

Abortioninwomenwithsignificantcardiacdisease

• Identifythewomenwithcardiovasculardisease• Consultacardiologist– Notallcardiacdiseasesarealike

• EuropeanSocietyofCardiologyguidelines

• Consultananesthesiologistexperiencedincardiacanesthesia– Followselectedpatients(pulmonaryhypertension!)longenough(atleastovernight)!

• Medicalvs.surgicalabortion– Individualdecision

Medicalvs. surgicalabortioninwomenwithsignificantcardiacdisease

• Nopublishedliterature!• Medicalabortion– CAVEinwomenwithanticoagulation• MIFEand/orMISO

– Noknowneffectsonhemostasis– Nointeractionswithcommonlyusedanticoagulants

• Useinhospitalsetting• Surgicalabortion–Mightbehemodynamically morecontrollableinsomesituations

Additionalantibiotics?

• Routineprophylacticantibioticsrecommended beforesurgicalabortionbyseveralguidelinesinallcases– UK,WHO,Finnish

• Morevariablerecommendationsconcerningconcerningmedicalabortion…

• Cardiologicindicationsforprophylacticantibiotics– Ifartifical materialinheart– giveantibiotics

Womanwithuncertainhistoryofcardiacdiseaseseekingabortion

• Cardiologistsadvice– Absenceofseriousdiagnosis,nosymptoms,normalperformance• Noneedforinvestigations!

– Patientwithregularcardiacfollow-up-consultacardiologists• Referselectedcasestounitexperiencedintreatingpregnantwomenwithcardiacdisease

Summary - abortioninwomenwithcardiacdisease

• Recognizethewomenwithahistoryof/currentcardiacdisease– Iscardiologyconsultationneeded?– Isreferral toaspecialunitneeded?

• Makenecessarypreparations,suchas– Anticoagulantmedication,antibioticprophylaxisetc.

• Chooseabortionmethodconsideringamong(amongmanythings)themedicalfactorsabove

• Starteffectiveandsuitablecontraceptionaftertheabortion

Thankyou!Specialthanksto• HeidiEriksson• Jouni Ahonen• Janne Rapola