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Management Strategies
Preconception counseling/Contraceptive methods
Most women with a repaired or unrepaired ASD can have a successful pregnancy. In the absence of ventricular dysfunction or pulmonary hypertension, heart related complications are rare.
Ideally, a comprehensive cardiovascular examination should be undertaken before embarking on pregnancy. This includes a careful history and physical examination, an echocardiogram and an electrocardiogram. The additional prognostic benefit of cardiopulmonary exercise testing has not been defined.
Indications for ASD closure prior to pregnancy are based on current guidelines. (5) In the absence of standard indications for ASD closure, women should not undergo surgery or intervention for the sole purpose of reducing the maternal cardiac risk during pregnancy.
Transmission of congenital heart disease to offspring should be discussed. The risk of transmission of congenital heart disease is approximately 5-10%, compared to a background risk of approximately 1% of having a baby with congenital heart disease. However, rarely, ASD may be associated with genetic syndromes such as the Holt-Oram syndrome. Genetic counseling is recommended for women with other congenital defects including non-cardiac defects or those with a family history of ASD or congenital heart disease.
A discussion regarding contraceptive methods is appropriate in all women with ASD. In the presence of an unrepaired or residual ASD, estrogen-containing formulations of contraception are relatively contraindicated due to the risk of paradoxical emboli. In the setting of an ASD with concomitant pulmonary hypertension, estrogen-containing birth control formulations are contraindicated.
Medication use should be reviewed if a woman is contemplating pregnancy or is pregnant. The MOTHERISK website is an excellent resource.
