Contraception Practices and Pregnancy Outcome in Patients After Fontan Operation

Abstract

Objective. The feasibility and safety of pregnancy after the Fontan operation is not well understood. We sought to determine contraception practices and early and late outcomes of pregnancy after the Fontan operation. Design. We performed a retrospective review of medical records to identify women of childbearing age from the Mayo Clinic Fontan database. A follow-up questionnaire was mailed to all patients not known to be deceased at the time of study. Patients with available contraception and pregnancy data were included in the study. Results. Of the 138 women with available contraception data, 44% used no contraception, 12% each used barrier methods, combination hormone therapy or sterilization, 8% used Depo-Provera, 7% had intrauterine devices, 4% had a partner with a vasectomy and 1% used progestin pills. Six women had thrombotic complications (only one using oral contraceptives). Thirty-five women had pregnancy data available. Prior to the Fontan operation there were 10 pregnancies (8 miscarriages, 2 therapeutic abortions, and no live births). After the Fontan operation there were 70 pregnancies resulting in 35 miscarriages (50%), 29 live births (41%), and 6 therapeutic abortions (9%). There were no maternal deaths during pregnancy. During long-term follow up (26 ± 6 years since the Fontan), 1 death, and 1 cardiac transplant occurred. Mean gestational age of the newborns (n = 22/29) was 33.1 ± 4.0 weeks; mean birth weight (n = 20/29) was 2086 ± 770 g. There was 1 neonatal death because of prematurity and two children were born with congenital heart disease (one patent ductus arteriosus and one membranous ventricular septal defect). Conclusions. Pregnancy after the Fontan operation is associated with a high rate of miscarriages, preterm delivery, and low birth weight. Further studies are needed to identify specific variables influencing risk stratification of pregnancy in this patient population.

Pregnancy outcomes in patients with a fontan circulation and proposal for a risk-scoring system: single centre experience

“…In contrast to published series, we observed a high rate of pre-term delivery (92%) and a higher rate of CS delivery [7,8,10]. The latter may be attributed to a higher rate of maternal and fetal morbidity seen in our cohort necessitating delivery rather than allowing spontaneous labour to take place.…”

“…In both studies, women received therapeutic or prophylactic low molecular weight heparin that was paused at delivery [13]. In contrast, in the series from the Mayo clinic [8], the majority of women received no anticoagulation or aspirin during pregnancy and suffered no significant haemorrhagic or thromboembolic complications. These important differences suggest that approaches to anticoagulation in pregnant women with a Fontan circulation require further study and may need to be reconsidered.…”

“…Published data regarding pregnancy in Fontan patients consists largely of small case series, as described in Table 1 [6][7][8][9][10][11][12][13]. Maternal cardiovascular morbidity, primarily due to atrial arrhythmias and deterioration of functional status has been observed.…”

“…Moreover, a significant proportion of pregnancies (69-81%) resulted in premature births in the contemporary series [7,8,10]. Drenthen et al and Cannobio et al advised against pregnancy in these women, whereas more contemporary literature suggests that despite the comorbidities associated with the Fontan circulation, women can undergo pregnancy, albeit at the risk of encountering significant maternal morbidity [6][7][8][9].…”

A cohort study of women with a Fontan circulation undergoing preconception counselling

“…Higher rates of infertility and miscarriage in women with a Fontan circulation have been reported before 7 10. However, the overall rate of miscarriage (excluding failed attempts at assisted conception) was 66%, which is much higher than described previously 11.…”