What are the recommended contraceptive methods for women with a history of peripartum cardiomyopathy (PPCM)?

Contraception Options for Women with Peripartum Cardiomyopathy

Intrauterine devices (both copper and progestogen-releasing IUDs) are the recommended first-line contraceptive method for women with peripartum cardiomyopathy due to their high effectiveness and safety profile without increasing thromboembolic risk. 1

Recommended Contraceptive Methods

• Intrauterine devices (IUDs):

  • Both copper and progestogen-releasing IUDs provide very effective, long-lasting contraception 1
  • Do not increase the risk of thromboembolism, which is particularly important in PPCM patients 1
  • No reported cases of cardiovascular complications or infective endocarditis among women with cardiac disease using IUDs 2

• Progestogen-only contraceptives:

  • Intramuscular, subcutaneous, and subdermal forms of progesterone-only contraception appear to be safe alternatives 1
  • Examples include progestin-only pills, implants, and depot medroxyprogesterone acetate 2
  • Should be considered as second-line options after IUDs 1

Contraceptive Methods to Avoid

• Combined hormonal contraceptives:

  • Estrogen-containing contraceptives should be strictly avoided 1
  • Estrogens significantly increase the risk of thromboembolism, which is already elevated in PPCM 1, 2
  • Cases of hypertension, transient ischemic attack, thromboembolism, and heart failure have been reported in women with cardiac disease using hormonal methods 2

• Barrier methods:

  • Not recommended as primary contraception due to high failure rates 1
  • The high risk of relapse in subsequent pregnancies makes reliable contraception essential 1

Permanent Contraception Options

• Sterilization options to consider:
  • Vasectomy for male partners 1
  • Tubal ligation or insertion of intratubal stents for women 1
  • Requires careful counseling due to psychological impact 1
  • For women with persisting severe LV dysfunction, anesthetic risk must be considered when planning surgical sterilization procedures 1

Importance of Effective Contraception in PPCM

• Women with PPCM have a high risk of relapse in subsequent pregnancies 1, 3
• Mortality risk is particularly high in women with persistently low LVEF who become pregnant again 1
• Studies show that three women with persistently low LVEF who entered subsequent pregnancies died, while none with normalized LVEF died 1
• Even termination of pregnancy may not prevent the onset of PPCM, making reliable contraception crucial 1

Risk Stratification for Future Pregnancies

• Women with LVEF <25% at diagnosis or whose LVEF has not normalized should be strongly advised against subsequent pregnancies 1, 3
• All PPCM patients should be informed that pregnancy can negatively affect cardiac function with risk of heart failure and death 1, 4
• About 30-50% of PPCM patients recover with normal baseline LV systolic function 5
• For those with normalized LV function, the risk in subsequent pregnancies is lower but still present 6, 4

Pitfalls and Caveats

• Do not rely solely on barrier methods due to high failure rates 1
• Never prescribe combined hormonal contraceptives containing estrogen to PPCM patients 1, 2
• Consider anesthetic risks when planning surgical sterilization for women with persistent LV dysfunction 1
• Comprehensive contraceptive counseling should be provided early in the management of PPCM 3, 4