P3C020: Barrier or Boundaries: Accessing Contraception for Women with Congenital Heart Disease in a Politically Challenging Landscape

Introduction: Women with congenital heart disease (CHD) have unique challenges with contraception and their reproductive health. These women face even greater barriers to care with the current political landscape, where the overturning of Roe vs. Wade in June, 2022 has made access to contraception increasingly restricted. In this case report, we evaluate the contraceptive options available to a woman with CHD.

Case Description: A 22-year-old female with a history of complex congenital heart disease consisting of dextro-transposition of the great arteries, valvular heart disease, status post Fontan procedure and heterotaxy syndrome presented for contraceptive counseling. She reported irregular periods with recent increased stressors, no current sexual activity, and a desire for children in the future. Options discussed were progestin only oral contraceptive pills, a progestin implant, intrauterine devices, and natural family planning methods. Ultimately, she decided to start progestin only contraceptive pills and the use of condoms if she becomes sexually active for both the prevention of sexually transmitted infections and contraception. She was scheduled for a follow up visit in 3 months to assess response to oral contraceptives and coordination was done between her primary care and cardiology services.

Discussion: Contraceptive and fertility options are difficult yet crucial topics to discuss with patients with CHD. Combined hormonal contraception has an increased risk of arterial and venous thrombosis, which is already elevated in CHD patients. Intrauterine devices (IUDs) have increased risk of arrhythmia, infection which could potentially result in endocarditis and can induce a vagal response with insertion which could lead to severe complications in patients with Fontan circulation or pulmonary vascular disease. Non-medical options have lower cardiac risks but have lower efficacy. Pregnancy in patients with CHD is complex and is associated with increased maternal morbidity and mortality, which may ultimately lead to the choice to pursue an abortion. Most patients with CHD have not been adequately counseled on their contraceptive options and associated risks. Contraceptive options and discussions are now even more limited with new and developing legislation. Total abortion bans are present in 13 states, gestational age limits are in effect in 5 states and 6 states currently have abortion bans blocked by state courts, as of April 2023.

Conclusion: Ultimately, the best contraceptive option for women with CHD will depend on their individual medical history, reproductive goals and severity of CHD. Guidelines should be developed to guide physicians in these discussions. Pediatricians and Internal Medicine-Pediatrics physicians need to be better aware of the contraceptive options for patients with CHD and advocate for their rights in the face of the new challenges with access of contraception.