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.................................................................................................................................................................. and tetracyclines, and they should therefore only be used for vital indications.115

Given the inherent foetal risk, decision-making for valve surgery during pregnancy is particularly difficult.112 Urgent surgery is mandatory in cardiogenic shock or refractory HF due to acute regurgitation. When surgery is indicated for uncontrolled infection or prevention of embolism, an individual approach should weigh the foetal risk of surgery and the risk of maternal complications under medical therapy alone. A viable foetus should be delivered prior to surgery where possible. These patients should be managed in tertiary centres, and the endocarditis and pregnancy teams should interact closely.

3.10 Methods of contraception and

termination of pregnancy, and in vitro fertilization 3.10.1 Methods of contraception The risk of using a particular type of contraception needs to be balanced against the risk of pregnancy, estimated using the modified WHO classification (see above),116 which assesses the risk with each method for a given medical condition.117 Advice is best provided by cardiologists with appropriate training or obstetricians, and should be given from the time of menarche since an unplanned pregnancy has to be avoided. The average age of first intercourse in the UK is 17 years, with <_30% before 15 years,118 regardless of the presence of heart disease.119 The key issues are reliability and the potential for complications, with thrombosis and infection being the most important. Hormonal contraception can have important non-contraceptive benefits, including the control of menstruation, prevention of anaemia, reduction of dysmenorrhoea, and of hyperandrogenism.120 Ethinyloestradiol-containing contraceptives have the greatest risk of thrombosis121,122 and are not advised in women with high-risk of thrombo-embolic disease; they also increase BP and are contraindicated in pre-existing hypertension.117 Progestin-only contraceptives are an alternative, since they have little (implant or depot injection) or no (levonorgestrel-loaded intrauterine device or oral desogestrel) effect on coagulation factors, BP, and lipid levels.123 Oral desogestrel inhibits ovulation, which could be an advantage for patients with polycystic ovary syndrome, endometriosis, or dysfunctional uterine bleeding. Levonorgestrel-based long-acting reversible contraception implants or intrauterine devices are the safest and most effective contraceptives. However, intrauterine device insertion may cause a vasovagal response; consequently, this should be performed in a hospital setting, particularly for Fontan and Eisenmenger’s syndrome patients. The levonorgestrel-releasing intrauterine device reduces periods, causing amenorrhoea in <_60% of women, in contrast to copper intrauterine devices, which cause heavier periods. The newer, smaller levonorgestrel-based intrauterine devices are easier to insert, reducing the risk of pain and therefore vasovagal response. Barrier methods are unreliable but reduce the risk of pelvic inflammatory disease. A good approach is the combination of barrier methods and long-acting reversible contraception (levonorgestrel-based long-acting reversible contraception, progestin-releasing implant, or progestin-releasing intrauterine devices).

For emergency contraception, a copper intrauterine device is most effective and additionally provides ongoing contraception. Alternatively, a single dose of 1.5 mg levonorgestrel is effective if taken within 72 h after unprotected sex (1.1% failure rate),124 with no evidence of increased rates of thrombosis.125 The progesterone receptor modulator ulipristal acetate (UPA) has been shown to be more effective than levonorgestrel. UPA is not associated with an increased risk of thrombosis.126,127

3.10.2 Sterilization Sterilization by tubal ligation is not unreasonable if pregnancy is contraindicated or the family is complete. Laparoscopy is not without risks in patients with PAH, cyanosis, and a Fontan circulation, and the risks are probably lower with the hysteroscopic method performed under regional anaesthesia.128 Vasectomy is an effective option.

3.10.3 Methods of termination of pregnancy Pregnancy termination should be discussed if there is a high-risk of maternal morbidity or mortality, and/or of foetal abnormality. Both medical and surgical methods are effective with similar rates of major complications, but the greater need for unanticipated operative evacuation (2.1 vs. 0.6%) favours the surgical approach in this group of women.129 High-risk patients should be managed in an experienced centre with on-site cardiac surgery. Antibiotics are given to reduce the risk of endometritis and these should be modified to provide endocarditis prophylaxis. Medical terminations can be considered up to 9 weeks of gestation using a reduced misoprostol dose of 100 mg.

3.10.4 In vitro fertilization The rates of subfertility in most women with heart disease are likely to those of the general population,130 but their management is more complex. Hysteroscopy and laparoscopy can be life-threatening procedures in women with some forms of heart disease (PH and Fontan), and should be undertaken in an experienced centre with appropriate support. Assisted reproduction has added risks above those of pregnancy alone; superovulation is pro-thrombotic and can be complicated by ovarian hyperstimulation syndrome (OHSS), with marked fluid shifts and an even greater risk of thrombosis. The risk of OHSS can be reduced by careful cycle monitoring, using low-dose follicle-stimulating hormone in combination with a gonadotropinreleasing hormone antagonist, freezing all embryos, or only transferring a single embryo.131 The last option is strongly advised in women with heart disease, since conceiving a multiple pregnancy is associated with greater cardiovascular changes132 and more maternal and foetal complications.133 Pregnancy, and consequently fertility treatment, is contraindicated in women with mWHO class IV. In women with mWHO class III or those who are anticoagulated, the risk of superovulation is very high and the alternative of natural cycle in vitro fertilization should be considered. Downloaded from academic.oup.com/eurheartj/article/39/34/3165/5078465 by guest on 07 October 2026