Women with hypertension, angina pectoris, or mitral valve prolapse require special considerations when selecting an appropriate method of contraception. All three effective, reversible options (oral contraceptives, intrauterine devices, or progestin implants) carry some degree of added risk for these patient populations. However, pregnancy itself presents certain risks and, in the event of contraceptive failure, certain women with these disorders are at increased risk of developing serious cardiovascular sequelae that affect both mother and fetus. These negative effects can carry far into the neonatal period. This article describes the risk/benefit profiles of the currently available contraceptive options relative to their potential impact in these compromised women.
PIP: Physicians should be concerned about contraception for women with mitral valve prolapse (MVP), hypertension, and angina pectoris, because pregnancy places an extra burden on the cardiovascular system (e.g., about 50% rise in blood volume and cardiac output and a large increase in extravascular fluid) and the chosen contraceptive method could cause adverse circulatory effects. Nonpregnant hypertensive should be treated with hygienic measures (e.g., weight reduction and restriction of sale) before physicians prescribe drugs (e.g., diuretics and beta blockers). Oral contraceptives (OCs) tend to induce only small increases in blood pressure. Further, hypertension in women causes less target organ damage than it does in men in the same age group. Therefore, OC use in nonsmoking, hypertensive women has little clinical effect, although physicians should monitor their blood pressure of these patients. Safe alternative contraceptives are progestin-only OCs and the IUD. MVP usually has benign clinical symptoms, so it generally does not pose a risk during pregnancy. Coagulation problems do occur, however, in a small number of MVP patients, thereby making those who use Ocs more vulnerable to thromboembolism. As long as an MVP patient does not have clinical symptoms (e.g., mitral regurgitation) or does not smoke, she can use OCs. MVP patients can use the IUD, but those with mitral regurgitation should take antibiotics during insertion to avoid systemic infection. Pregnant women with true angina are at increased risk of myocardial infarction (MI). Women who experience MI during pregnancy face an infant mortality rate of 34%. Women with angina and no other risk factors can use OCs, especially because of their potential antiatherosclerotic effect. The IUD and progestin implants are safe and effective contraceptive choices for women with angina caused by coronary atherosclerosis. In many women with cardiovascular conditions, the risk of pregnancy is frequently greater than the risks linked to contraceptive use.