Pregnancy and PH

The consensus of medical opinion is that PH and pregnancy is very dangerous. The life of the mum and baby are put at great risk. Women with any serious illnesses must face several questions before they decide to have children, including whether the pregnancy and delivery could be life-threatening. Pregnancy can really take its toll on a woman’s body.  For example, the heart rate speeds up and the immune system doesn’t work quite as well. For a woman whose body already has to deal with a severe illness, pregnancy can actually have catastrophic consequences.

It seems really unfair that PH is a disease that often is seen in women of child-bearing age as unfortunately this makes pregnancy a quite common issue. The risk of pregnancy-related death in women with PH is substantial (reported to be as high as 30 to 50%). For this reason alone therefore, pregnancy does not offer very good prospects for women with PH. In addition some of the drugs commonly used to treat PH (e.g. warfarin) can be harmful to the developing foetus. Because of this twofold risk to both the patient and the foetus, use of some form of birth control to avoid pregnancy is strongly advised in women of childbearing age with PH.

Which form of contraception to use?
There are no published guidelines for birth control use in PH, and there is no consensus regarding the best form of birth control. Birth control must be discussed with you PH team, don’t be embarrassed or avoid the issue, it is too important.

Below is a brief résumé of some of the important factors to consider:

Why do I need to use contraception?

• PH specialists strongly advise you against becoming pregnant when you have pulmonary hypertension as pregnancy can make the disease worse. Sadly you run a high risk of dying if you become pregnant.
• If your pulmonary hypertension is secondary to another medical problem, such as systemic lupus, it is possible that the other problem may also reduce your chances of having a healthy baby.
• Some of the medication you may take can also affect a developing baby.
• If you do become pregnant it is important for you to be seen by your specialist team as soon as possible, so they can discuss the options for treatment with you.
• Many doctors would advise a permanent method of contraception because of concerns about your health if you became pregnant. This is one of the few conditions when sterilisation is offered to a woman who has not had any children.

Can I take the oral contraceptive pill?

• The combined pill (which is usually taken for 3 weeks out of every 4) should be avoided as it contains oestrogen which is thought to actually make PH worse.
• The progesterone only pill (also known as the minipill) is probably not advised because it may make the risk of developing blood clots a little higher. It is also a method with a medium risk of failure.

What about other hormonal methods?

• Progesterone can also be given by injection (e.g. Depo-Provera) given every 12 weeks. This is a very reliable method of contraception: for every 1,000 women using it, less than 3 pregnancies occur a year. It can cause irregular bleeding but after a year of use most women actually stop having periods, which many see as an advantage. There is still a very small risk of developing blood clots using this method, but it is probably less than with any other hormonal method.
• Some women may also wish to opt for a longer lasting implant of progesterone (known as Implanon) that lasts for up to 3 years.

Can I have an intrauterine device (coil) fitted?

• It is often difficult to fit a coil if someone has never been pregnant and sometimes an anaesthetic is necessary. You would probably also need antibiotics during the fitting to reduce the risk of infection. Many women with a copper-containing coil find their periods are heavier after it is fitted. This may already be a problem for you if you are taking warfarin. There is also a slightly increased risk of developing pelvic infection.  All in all, this method is probably not ideal.
• There is also a progesterone-coated coil, called Mirena. Many women using it find after 6 months that their periods may last only 1 - 2 days. Mirena is a very reliable method of contraception, which lasts for up to 5 years.

What about permanent methods?

• The most reliable method of contraception is male sterilisation or vasectomy. This has a very low failure rate once it has been checked as effective by a negative sperm count.
• Female sterilisation involves an operation under general anaesthetic.  This carries risks because of your medical condition, particularly if you are on blood thinning medications. Clips block the tubes leading from the womb to the ovaries. There are no long-term side effects or risks, but there is a small failure rate.
• It is very difficult to reverse these procedures and a great deal of thought and advice needs be sought before going down this path.

Are there any alternatives?

• Barrier methods such as condoms, caps and diaphragms are less reliable. They should always be used with a spermicidal gel to reduce the chance of failure.