Pregnancy after cardiac transplantation
- Michael R Foley, MD
Michael R Foley, MD
- University of Arizona College of Medicine - Phoenix
- Section Editors
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Sharon A Hunt, MD
Sharon A Hunt, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Heart Transplantation
- Professor of Medicine
- Stanford University School of Medicine
Experience with pregnancy after cardiac transplantation has grown since the first report in 1988 [1,2]. The number of women of childbearing age who have received heart transplants has risen due partly to some overall increase in heart transplantation in adults and to survival of pediatric heart transplant recipients to childbearing age. Pregnancy after cardiac transplantation is associated with risks to the prospective mother and fetus and with concerns regarding maternal longevity [2-7].
The maternal and fetal risks associated with pregnancy after cardiac transplantation and recommendations for management of these patients during pregnancy will be reviewed here. The indications and complications of cardiac transplantation are discussed separately. (See "Indications and contraindications for cardiac transplantation in adults" and "Acute cardiac allograft rejection: Diagnosis".)
Preconception counseling — Family planning and pregnancy including individualized maternal and fetal risks , alternatives, and timing should be discussed with all women of childbearing age undergoing cardiac transplantation as many transplant recipients are fertile. As recommended by the American Society of Transplantation (AST) consensus conference on reproductive issues, preconception counseling should be introduced during the pretransplant evaluation (or earlier) and should be followed up throughout the post-transplant process . Transplant recipients need to know what to expect in terms of their own outcome and that for their potential children .
The reason for the mother's cardiac transplant should be investigated and discussed in terms of risk of recurrence of the underlying cardiac disease in mother or offspring. As an example, women who have received cardiac allografts because of severe peripartum cardiomyopathy are theoretically at risk for recurrent problems in future pregnancies (see "Peripartum cardiomyopathy: Etiology, clinical manifestations, and diagnosis"). Another example is the risk of cardiac defects (concordant or discordant with the mother) in offspring of women with congenital or familial/genetic types of heart disease (eg, 20 to 50 percent of idiopathic dilated cardiomyopathy cases may be familial). (See "Genetics of dilated cardiomyopathy" and "Pregnancy in women with congenital heart disease: General principles", section on 'Inheritance'.)
Timing of pregnancy — Most experts recommend that cardiac transplant recipients avoid pregnancy during the first year post-transplantation when the risk of rejection is greatest and immunosuppressive therapy most aggressive . (See "Prognosis after cardiac transplantation".)
- Löwenstein BR, Vain NW, Perrone SV, et al. Successful pregnancy and vaginal delivery after heart transplantation. Am J Obstet Gynecol 1988; 158:589.
- Coscia LA, Constantinescu S, Moritz MJ, et al. Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation. Clin Transpl 2010; :65.
- Branch KR, Wagoner LE, McGrory CH, et al. Risks of subsequent pregnancies on mother and newborn in female heart transplant recipients. J Heart Lung Transplant 1998; 17:698.
- Cupples SA. Cardiac transplantation in women. Crit Care Nurs Clin North Am 1997; 9:521.
- Kim KM, Sukhani R, Slogoff S, Tomich PG. Central hemodynamic changes associated with pregnancy in a long-term cardiac transplant recipient. Am J Obstet Gynecol 1996; 174:1651.
- Radomski JS, Ahlswede BA, Jarrell BE, et al. Outcomes of 500 pregnancies in 335 female kidney, liver, and heart transplant recipients. Transplant Proc 1995; 27:1089.
- Troché V, Ville Y, Fernandez H. Pregnancy after heart or heart-lung transplantation: a series of 10 pregnancies. Br J Obstet Gynaecol 1998; 105:454.
- Costanzo MR, Dipchand A, Starling R, et al. The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. J Heart Lung Transplant 2010; 29:914.
- McKay DB, Josephson MA, Armenti VT, et al. Reproduction and transplantation: report on the AST Consensus Conference on Reproductive Issues and Transplantation. Am J Transplant 2005; 5:1592.
- Ross LF. Ethical considerations related to pregnancy in transplant recipients. N Engl J Med 2006; 354:1313.
- Krajewski CM, Geetha D, Gomez-Lobo V. Contraceptive options for women with a history of solid-organ transplantation. Transplantation 2013; 95:1183.
- Armenti VT, Stefanosky EV, Cater JR, et al. Pregnancy in transplant recipients. J Transplant Coordination 1995; 5:130.
- Wagoner LE, Taylor DO, Olsen SL, et al. Immunosuppressive therapy, management, and outcome of heart transplant recipients during pregnancy. J Heart Lung Transplant 1993; 12:993.
- Wu DW, Wilt J, Restaino S. Pregnancy after thoracic organ transplantation. Semin Perinatol 2007; 31:354.
- Scott JR, Wagoner LE, Olsen SL, et al. Pregnancy in heart transplant recipients: management and outcome. Obstet Gynecol 1993; 82:324.
- Sibanda N, Briggs JD, Davison JM, et al. Pregnancy after organ transplantation: a report from the UK Transplant pregnancy registry. Transplantation 2007; 83:1301.
- Armenti VT, Radomski JS, Moritz MJ, et al. Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation. Clin Transpl 2004; :103.
- Hoeltzenbein M, Elefant E, Vial T, et al. Teratogenicity of mycophenolate confirmed in a prospective study of the European Network of Teratology Information Services. Am J Med Genet A 2012; 158A:588.
- Klieger-Grossmann C, Chitayat D, Lavign S, et al. Prenatal exposure to mycophenolate mofetil: an updated estimate. J Obstet Gynaecol Can 2010; 32:794.
- http://www.fda.gov/drugs/drugsafety/postmarketdrugsafetyinformationforpatientsandproviders/ucm124776.htm (Accessed on May 02, 2014).
- Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007; 116:1736.
- Mendelson MA. Pregnancy after cardiac transplantation. In: Principles and practice of medical therapy in pregnancy, Gleicher N (Ed), Norwalk, Appleton & Lange, 1992. p.841.
- Akin SJ. Pregnancy after heart transplantation. Prog Cardiovasc Nurs 1992; 7:2.
- PRECONCEPTION CARE
- Preconception counseling
- Timing of pregnancy
- Baseline assessment
- MATERNAL PHYSIOLOGY AND MONITORING
- Physiologic changes
- Maternal monitoring
- MATERNAL RISKS IN PREGNANCY
- Abnormal liver function
- Hypertension and preeclampsia
- FETAL RISKS
- Maternal medications
- INTRAPARTUM RISKS AND MANAGEMENT
- Mode of delivery
- Antibiotic prophylaxis
- Stress dose steroids
- Maternal monitoring
- POSTPARTUM RISKS AND MANAGEMENT
- SUMMARY AND RECOMMENDATIONS