LARCs appear safe in adolescents with CVD



SAN DIEGO – Long-acting reversible contraceptive devices appear safe and effective for adolescents with congenital heart defects and cardiovascular disease, results from a retrospective case series demonstrated.

"Pregnancies can be complicated for patients with congenital cardiac defects," Dr. Anne-Marie Amies Oelschlager said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. "Physiologic changes of pregnancy pose an increased risk of complications in women with congenital cardiac anomalies. We know that the levonorgestrel-releasing intrauterine system [LNG-IUS] is effective for heavy menstrual bleeding, endometriosis, and dysmenorrhea. Long-acting reversible contraceptive [LARC] methods also have minimal interaction with other medications, they’re not known to exacerbate hypertension, and they are not known to be thrombogenic."

Dr. Anne-Marie Amies Oelschlager

In one published prospective study of 40 patients aged 20 and older with heart disease who used the copper intrauterine device, no cases of endocarditis occurred (Contraception 2008; 78:315-8). One patient had pelvic inflammatory disease, and there were no expulsions, pregnancies, or early removals other than those due to a desire for pregnancy.

"However, there is limited data regarding the safety and efficacy of LARCs in adolescents with congenital cardiac defects and cardiovascular disease," said Dr. Amies Oelschlager, director of pediatric and adolescent gynecology in the department of obstetrics and gynecology at the University of Washington, Seattle.

In an effort to evaluate the safety and efficacy of LARC methods in adolescents with cardiovascular conditions, she and her associates conducted a retrospective chart study of 30 patients with congenital cardiac anomalies or other cardiovascular disease who were aged 22 or younger and who had a LARC device placed at Seattle Children’s Hospital or at the University of Washington Medical Center between Jan. 1, 2007, and March 1, 2012. The average age on device insertion was 18 years, and 12 patients (40%) reported a previous pregnancy. Contraception was the most commonly cited reason for placement (73%), followed by heavy menstrual bleeding and menstrual suppression (20% each).

All but one of the patients had structural lesions. The most common was ventricular septal defect, which affected six patients (20%). There were also five patients with cardiomyopathy (17%). One patient had rheumatic heart disease, and one had familial tachyarrhythmia.

In the 30 patients studied, 31 devices were placed: 27 LNG IUS in 26 patients (1 patient experienced expulsion of the device and subsequently had another one placed), 1 copper IUD in 1 patient, and 3 etonogestrel implants in 3 patients.

Ten patients (33%) had their IUDs placed immediately after delivery or at their postpartum visit. For the remainder of the patients who did not have their IUDs placed post partum, nine of the IUDs were placed in the clinic (31%), and eight were placed in the operating room (28%).

There were no cases of endocarditis, but two patients experienced subsequent pregnancies. "One occurred 3 months post expulsion, in a patient who was not using a contraceptive," Dr. Amies Oelschlager noted. "The other [patient] had postpartum placement. However, the date of removal was not noted and was reported as a desired pregnancy. Our assumption from our review is that this was a case of a desired removal for a desired pregnancy."

The researchers observed no cases of pelvic inflammatory disease or pregnancies while the implants and IUDs were in place. Twenty-seven of the patients (90%) were continuing LARC use at last follow-up.

Dr. Amies Oelschlager acknowledged certain limitations of the study, including its retrospective design and the potential for selection bias. Also, the duration of IUD use was less than 5 years, and the duration of etonogestrel implant use was less than 3 years. "So we don’t know what the expulsion rates would be farther out, and we don’t know if there will be a higher rate of contraceptive failure in the later years using these devices," she said. For now, "we recommend close monitoring and follow-up with these patients to confirm that their rate of expulsion is low and that they’re receiving adequate contraception."

Dr. Amies Oelschlager said she had no relevant financial conflicts to disclose.

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