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Schirm N, Böhm L, Zimmermann T, Meyer N, von Versen-Höynck F. Family planning after transplantation: sex- and organ-related differences in the perception of medical counseling and social challenges. Arch Gynecol Obstet 2025; 311:275-322. [PMID: 39470769 PMCID: PMC11890408 DOI: 10.1007/s00404-024-07703-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2024] [Accepted: 08/17/2024] [Indexed: 11/01/2024]
Abstract
PURPOSE Transplant patients are increasingly of childbearing age. Organ-related health as well as pregnancy-related risks require a standardized approach to family planning counseling. The aim of this study was to explore sex- and organ-related counseling differences and expectations in family planning to improve counseling services and reduce risks after transplantation. METHODS The study was designed as a cross-sectional, multi-center cohort study. A total of 251 participants aged between 18 and 45 years with a visceral or thoracic transplant completed a questionnaire on their attitude toward family planning and experience with medical consultation. RESULTS More female than male participants had a desire to have children. Males believed their transplantation-related medication had an influence on their fertility, while women worried it could harm their child. Contraceptive counseling was negated by 43.6% of the women and 73.4% of the men. Medical advice regarding family planning was highly requested by both sexes. Women felt more influenced in their family planning than men. Female thoracic organ recipients worried about a pregnancy more than visceral organ recipients. Women showed great awareness for pregnancy-related risks with the majority wanting to plan a pregnancy beforehand. CONCLUSION The findings revealed a lack of contraceptive counseling and a lack of family planning advice by physicians.
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Affiliation(s)
- Nina Schirm
- Department of Obstetrics and Gynecology, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Lea Böhm
- Department of Obstetrics and Gynecology, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Tanja Zimmermann
- Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Nadia Meyer
- Department of Obstetrics and Gynecology, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Frauke von Versen-Höynck
- Department of Obstetrics and Gynecology, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany.
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Hussien M, Lorente-Ros M, Lam PH, Frishman WH, Aronow WS, Gupta R. Preparing the Heart for a New Baby: Management of Pregnancy in Heart Transplant Recipients. Cardiol Rev 2024:00045415-990000000-00305. [PMID: 39078143 DOI: 10.1097/crd.0000000000000758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
Heart transplant (HT) recipients are more frequently reaching childbearing age given improvement in median survival and outcomes after HT. Although most pregnancies in HT recipients have favorable outcomes, poor fetal outcomes and maternal complications such as hypertensive disorders of pregnancy are more common in HT recipients than in the general population. In this review, we summarize the current evidence to guide the management of pregnancy in HT recipients. Preconception counseling, focused on risk stratification and optimal timing of conception, is the first important step to optimize pregnancy outcomes. During pregnancy and in the postpartum period, frequent monitoring of graft function and immunosuppressive levels is recommended. Calcineurin inhibitors and corticosteroids should be the mainstay of treatment for both prevention and treatment of graft rejection. Delivery planning should follow usual obstetric indications, preferably with vaginal delivery at term using regional anesthesia. A multidisciplinary care team should be involved in management through all stages of pregnancy to ensure success.
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Affiliation(s)
- Merna Hussien
- From the Department of Cardiology, MedStar Washington Hospital Center, Georgetown University Medical Center, Washington, DC
| | - Marta Lorente-Ros
- From the Department of Cardiology, MedStar Washington Hospital Center, Georgetown University Medical Center, Washington, DC
| | - Phillip H Lam
- From the Department of Cardiology, MedStar Washington Hospital Center, Georgetown University Medical Center, Washington, DC
| | - William H Frishman
- Department of Medicine, New York Medical College, Westchester Medical Center, Valhalla, NY
| | - Wilbert S Aronow
- Departments of Cardiology and Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Richa Gupta
- From the Department of Cardiology, MedStar Washington Hospital Center, Georgetown University Medical Center, Washington, DC
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3
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Bhagra CJ, Cherikh WS, Ross H, Kittleson MM, Stehlik J, Lewis A, DeFilippis EM, Macera F. Informing preconception counseling: Outcomes among female heart transplant recipients in the ISHLT registry. J Heart Lung Transplant 2024; 43:727-736. [PMID: 38101760 DOI: 10.1016/j.healun.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 11/02/2023] [Accepted: 12/04/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND The numbers of women of child-bearing age undergoing heart transplantation (HT) and female pediatric HT recipients surviving to child-bearing age have increased, along with improvements in post-transplant survival. Data regarding life expectancy and comorbidities in reproductive-aged female HT recipients are needed to inform shared decision-making at the time of preconception counseling. METHODS The International Society for Heart and Lung Transplantation (ISHLT) Thoracic Organ Transplant Registry was investigated for HT recipients between January 1, 2000 and June 30, 2017. Women of childbearing age were defined as those aged 15-45 years, either at transplant, or at the respective post-transplant follow-up. Characteristics and outcomes of female recipients of childbearing age at transplant, 5-, 10-, and 15-year follow-up were compared to females > 45 years of age, males 15-45 years and males > 45 years of age at the corresponding time intervals. Outcomes included survival, development of diabetes (DM), severe renal dysfunction (CKD), and cardiac allograft vasculopathy (CAV). RESULTS During the study period, 71,585 HT recipients were included: 24% (n = 17,194) were female and 9.2% (n = 6602) were of childbearing age at HT. A pre-transplant diagnosis of peripartum cardiomyopathy was associated with significantly worse post-transplant survival, a finding that remained independent of panel reactive antibody levels. The presence of pre-transplant DM and/or severe CKD was significantly associated with lower survival as were the presence of CAV, DM, and CKD post-HT. CONCLUSION Knowledge of the impact of pre-existing comorbidities and complications post-HT on survival are important for risk stratification for preconception counseling post-HT.
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Affiliation(s)
- Catriona J Bhagra
- Department of Cardiology, Royal Papworth NHS Foundation Trust, Cambridge, United Kingdom
| | | | - Heather Ross
- Division of Cardiology, Ted Rogers Centre for Heart Research, Toronto General Hospital, Toronto, Ontario, Canada
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Josef Stehlik
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
| | | | - Ersilia M DeFilippis
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia University Irving Medical Center, New York, New York.
| | - Francesca Macera
- Heart Failure and Heart Transplant Unit, Department of Cardiovascular Medicine, Great Metropolitan "Niguarda" Hospital, Milan, Italy; Division of Cardiology, Erasme Hospital, Cliniques Hospitalières Universitaires de Bruxelles, Brussels, Belgium
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4
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Herrick N, Urey M, Alshawabkeh L. Adults with Congenital Heart Disease and Transplant: Challenges, Opportunities, and Policy. Heart Fail Clin 2024; 20:167-174. [PMID: 38462321 DOI: 10.1016/j.hfc.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
The rate of heart transplantation in adults with congenital heart disease (ACHD) is rising, but the 1-year mortality posttransplantation remains higher than non-ACHD patients. A robust pretransplant assessment and operative and postoperative planning can mitigate much of the perioperative risk. Importantly, ACHD patients who survive the first year have significantly better 10-year survival compared with non-ACHD patients. The current allocation system gives ACHD patients a relatively high priority, but providers must use the prespecified exception requests for higher status, especially for patients with the Fontan circulation. It is vital that ACHD patients with end-stage heart failure are cared for at centers with ACHD subspecialty care.
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Affiliation(s)
- Nicole Herrick
- Division of Cardiovascular Medicine, Department of Medicine, University of Calilfornia San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Marcus Urey
- Division of Cardiovascular Medicine, Department of Medicine, University of Calilfornia San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Laith Alshawabkeh
- Adult Congenital Heart Disease Program, Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, 9452 Med Center Drive, ACTRI-3E, Mail 7411, La Jolla, CA 92037, USA.
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5
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Jha N, Jha AK, Mishra SK, Parida S. Thoracic organ transplantation and pregnancy outcomes: systematic review and meta-analysis. Arch Gynecol Obstet 2024; 309:385-396. [PMID: 37147484 DOI: 10.1007/s00404-023-07065-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 05/01/2023] [Indexed: 05/07/2023]
Abstract
PURPOSE Pre-conceptual comorbidities, an inherent risk of graft loss, rejection during pregnancy, and the postpartum period in women with thoracic lung transplant may predispose them to increased risk of adverse feto-maternal outcomes. The study aimed to systematically analyze and assess the risk of adverse pregnancy outcomes in women with thoracic organ transplant. METHODS MEDLINE, EMBASE, and Cochrane library were searched for publication between January 1990 and June 2020. Risk of bias was assessed using Joanna Briggs critical appraisal tool for case series. The primary outcomes included maternal mortality and pregnancy loss. The secondary outcomes were maternal complications, neonatal complications, and adverse birth outcomes. The analysis was performed using the DerSimonian-Laird random effects model. RESULTS Eleven studies captured data from 275 parturient with thoracic organ transplant describing 400 pregnancies. The primary outcomes included maternal mortality {pooled incidence (95% confidence interval) 4.2 (2.5-7.1) at 1 year and 19.5 (15.3-24.5) during follow-up}. Pooled estimates yielded 10.1% (5.6-17.5) and 21.8% (10.9-38.8) risk of rejection and graft dysfunction during and after pregnancy, respectively. Although 67% (60.2-73.2) of pregnancies resulted in live birth, total pregnancy loss and neonatal death occurred in 33.5% (26.7-40.9) and 2.8% (1.4-5.6), respectively. Prematurity and low birth weight were reported in 45.1% (38.5-51.9) and 42.7% (32.8-53.2), respectively. CONCLUSIONS Despite pregnancies resulting in nearly 2/3rd of live births, high incidence of pregnancy loss, prematurity and low birth weight remain a cause of concern. Focused pre-conceptual counseling to avoid unplanned pregnancy, especially in women with transplant-related organ dysfunctions and complications, is vital to improve pregnancy outcomes. PROSPERO NUMBER CRD42020164020.
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Affiliation(s)
- Nivedita Jha
- Department of Obstetrics and Gynecology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Ajay Kumar Jha
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India.
| | - Sandeep Kumar Mishra
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Satyen Parida
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
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DeFilippis EM, Kittleson MM. Pregnancy as a Sentinel Event: Preventing Severe Maternal Morbidity in Heart Transplant Recipients. JACC. HEART FAILURE 2023; 11:1675-1677. [PMID: 37855755 DOI: 10.1016/j.jchf.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/05/2023] [Indexed: 10/20/2023]
Affiliation(s)
- Ersilia M DeFilippis
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Michelle M Kittleson
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA.
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7
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Management of pregnancy in left ventricular assist device and heart transplant recipients: a concise review. Curr Opin Cardiol 2023; 38:257-265. [PMID: 36927986 DOI: 10.1097/hco.0000000000001036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
PURPOSE OF REVIEW Women of reproductive age are increasingly undergoing heart transplantation (HT) or left ventricular assist device (LVAD) implantation for advanced heart failure. This review is intended to give an overview of the current state of the art management of pregnancy in patients with LVAD or HT recipients. RECENT FINDINGS Heart transplant recipients are at increased risk for graft rejection, renal dysfunction, preeclampsia and worsening of comorbidities (hypertension and diabetes). Patients with LVAD are at higher risk of thromboembolic events, infections, right ventricular failure and require close surveillance during pregnancy. Preconception counseling must be offered to all women of reproductive age group with HT or LVAD to avoid unplanned pregnancies. SUMMARY A multidisciplinary approach with close antepartum and postpartum surveillance is recommended.
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8
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Kittleson MM, DeFilippis EM, Bhagra CJ, Casale JP, Cauldwell M, Coscia LA, D'Souza R, Gaffney N, Gerovasili V, Ging P, Horsley K, Macera F, Mastrobattista JM, Paraskeva MA, Punnoose LR, Rasmusson KD, Reynaud Q, Ross HJ, Thakrar MV, Walsh MN. Reproductive health after thoracic transplantation: An ISHLT expert consensus statement. J Heart Lung Transplant 2023; 42:e1-e42. [PMID: 36528467 DOI: 10.1016/j.healun.2022.10.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 10/10/2022] [Indexed: 11/16/2022] Open
Abstract
Pregnancy after thoracic organ transplantation is feasible for select individuals but requires multidisciplinary subspecialty care. Key components for a successful pregnancy after lung or heart transplantation include preconception and contraceptive planning, thorough risk stratification, optimization of maternal comorbidities and fetal health through careful monitoring, and open communication with shared decision-making. The goal of this consensus statement is to summarize the current evidence and provide guidance surrounding preconception counseling, patient risk assessment, medical management, maternal and fetal outcomes, obstetric management, and pharmacologic considerations.
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Affiliation(s)
- Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Ersilia M DeFilippis
- Division of Cardiology, New York Presbyterian-Columbia University Irving Medical Center, New York, New York
| | - Catriona J Bhagra
- Department of Cardiology, Cambridge University and Royal Papworth NHS Foundation Trusts, Cambridge, UK
| | - Jillian P Casale
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland
| | - Matthew Cauldwell
- Department of Obstetrics, Maternal Medicine Service, St George's Hospital, London, UK
| | - Lisa A Coscia
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, Pennsylvania
| | - Rohan D'Souza
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Nicole Gaffney
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | | | - Patricia Ging
- Department of Pharmacy, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Kristin Horsley
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Francesca Macera
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy; Dept of Cardiology, Cliniques Universitaires de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Joan M Mastrobattista
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine Houston, Texas
| | - Miranda A Paraskeva
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Lynn R Punnoose
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Quitterie Reynaud
- Cystic Fibrosis Adult Referral Care Centre, Department of Internal Medicine, Hospices civils de Lyon, Pierre Bénite, France
| | - Heather J Ross
- Peter Munk Cardiac Centre of the University Health Network, Toronto, Ontario, Canada; Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Mitesh V Thakrar
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta, Canada
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022; 42:e1-e141. [PMID: 37080658 DOI: 10.1016/j.healun.2022.10.015] [Citation(s) in RCA: 238] [Impact Index Per Article: 79.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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10
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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11
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(Outcomes of pregnancy in pre-existing cardiomyopathy and after heart transplantation). COR ET VASA 2022. [DOI: 10.33678/cor.2021.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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12
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In-Hospital Outcomes in Pregnancy After Heart Transplantation. Am J Cardiol 2022; 172:68-72. [PMID: 35331474 DOI: 10.1016/j.amjcard.2022.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 02/08/2022] [Accepted: 02/15/2022] [Indexed: 11/20/2022]
Abstract
Although the number of successful pregnancies in heart transplantation (HT) recipients is increasing, data regarding outcomes after delivery are limited. The 2010 to 2015 Nationwide Inpatient Sample was queried to identify index hospitalizations for delivery in HT recipients. Adverse delivery events of HT patients were compared with those of women without history of HT or systolic heart failure (HF) undergoing delivery. Of 21,922,631 delivery hospitalizations, 94 hospitalizations were of HT recipients. Compared with women without a history of HF or HT, post-HT women had greater comorbidity burden, as evidenced by the Elixhauser Comorbidity Index (1.16 vs 0.24, p <0.001), lower household incomes (p = 0.03), and were more likely to deliver at large hospitals (90% vs 58%, p = 0.02) and hospitals categorized as teaching institutions (100% vs 59%, p <0.001). After adjustment for clinical variables, history of HT was significantly associated with increased incidence of hypertensive disorders of pregnancy (odds ratio 6.97, p = 0.001) primarily driven by increased rates of preeclampsia, and induction of labor (odds ratio 3.18, p = 0.01). There were no differences in gestational diabetes, cesarean section, fetal growth restriction, fetal malformations, or preterm delivery (all p >0.3). In conclusion, post-HT women have greater comorbidity burden and experience increased maternal risks compared with women without history of HT or systolic HF, including increased risk of hypertensive disorders of pregnancy and need for induction. More studies are needed to improve obstetric care and maternal-fetal outcomes for the HT population.
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13
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Usage of Tacrolimus and Mycophenolic Acid During Conception, Pregnancy, and Lactation, and Its Implications for Therapeutic Drug Monitoring: A Systematic Critical Review. Ther Drug Monit 2021; 42:518-531. [PMID: 32398419 DOI: 10.1097/ftd.0000000000000769] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Conception, pregnancy, and lactation following solid organ transplantation require appropriate management. The most frequently used immunosuppressive drug combination after solid organ transplantation consists of tacrolimus (Tac) plus mycophenolic acid (MPA). Here, the effects of Tac and MPA on fertility, pregnancy, and lactation are systematically reviewed, and their implications for therapeutic drug monitoring (TDM) are discussed. METHODS A systematic literature search was performed (August 19, 2019) using Ovid MEDLINE, EMBASE, the Cochrane Central Register of controlled trials, Google Scholar, and Web of Science, and 102 studies were included. Another 60 were included from the reference list of the published articles. RESULTS As MPA is teratogenic, women who are trying to conceive are strongly recommended to switch from MPA to azathioprine. MPA treatment in men during conception seems to have no adverse effect on pregnancy outcomes. Nevertheless, in 2015, the drug label was updated with additional risk minimization measures in a pregnancy prevention program. Data on MPA pharmacokinetics during pregnancy and lactation are limited. Tac treatment during conception, pregnancy, and lactation seems to be safe in terms of the health of the mother, (unborn) child, and allograft. However, Tac may increase the risk of hypertension, preeclampsia, preterm birth, and low birth weight. Infants will ingest very small amounts of Tac via breast milk from mothers treated with Tac. However, no adverse outcomes have been reported in children exposed to Tac during lactation. During pregnancy, changes in Tac pharmacokinetics result in increased unbound to whole-blood Tac concentration ratio. To maintain Tac concentrations within the target range, increased Tac dose and intensified TDM may be required. However, it is unclear if dose adjustments during pregnancy are necessary, considering the higher concentration of (active) unbound Tac. CONCLUSIONS Tac treatment during conception, pregnancy and lactation seems to be relatively safe. Due to pharmacokinetic changes during pregnancy, a higher Tac dose might be indicated to maintain target concentrations. However, more evidence is needed to make recommendations on both Tac dose adjustments and alternative matrices than whole-blood for TDM of Tac during pregnancy. MPA treatment in men during conception seems to have no adverse effect on pregnancy outcomes, whereas MPA use in women during conception and pregnancy is strongly discouraged.
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Abstract
Uterine transplantation (UTx) is a fertility restoring treatment for women with absolute uterine factor infertility. At a time when there is no question of the procedure's feasibility, and as the number of livebirths begins to increase exponentially, various important reproductive, fetal, and maternal medicine implications have emerged. Detailed outcomes from 17 livebirths following UTx are now available, which are reviewed herein, along with contextualized extrapolation from pregnancy outcomes in other solid organ transplants. Differences in recipient demographics and reproductive aspirations between UTx and other transplant recipients make extrapolating management strategies and outcomes in other solid organ transplants inappropriate. Whereas preterm delivery remains prominent, small for gestational age or hypertensive disorders do not appear to be as prevalent following UTx when compared to other solid organ transplants. Given the primary objective of undertaking UTx is to achieve a livebirth, publication of reproductive outcomes is essential at this early stage, to reflect on and optimize the management of future cases.
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DeFilippis EM, Haythe JH, Walsh MN, Kittleson MM. Intersection of Heart Failure and Pregnancy: Beyond Peripartum Cardiomyopathy. Circ Heart Fail 2021; 14:e008223. [PMID: 33980039 DOI: 10.1161/circheartfailure.120.008223] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Heart failure (HF) is a leading cause of morbidity and mortality in pregnant women in the United States. Although peripartum cardiomyopathy is the most common diagnosis for pregnant women with HF, women with preexisting cardiomyopathies and systolic dysfunction are also at risk as the hemodynamic demands of pregnancy can lead to decompensation, arrhythmia, and rarely death. The differential diagnosis of HF in pregnancy is broad and includes Takotsubo or stress cardiomyopathy, exacerbation of a preexisting cardiomyopathy, such as familial cardiomyopathy, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, or left ventricular noncompaction. This review will explore the implications of pregnancy in women with preexisting cardiomyopathies and de novo HF, risk assessment and preconception planning, decisions about contraception, the safety of HF medications and implantable cardioverter-defibrillators during pregnancy, pregnancy in women with left ventricular assist devices and following heart transplantation.
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Affiliation(s)
- Ersilia M DeFilippis
- Division of Cardiology, New York Presbyterian-Columbia University Irving Medical Center (E.M.D., J.H.H.)
| | - Jennifer H Haythe
- Division of Cardiology, New York Presbyterian-Columbia University Irving Medical Center (E.M.D., J.H.H.)
| | | | - Michelle M Kittleson
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.K.)
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16
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Boyle S, Sung-Him Mew T, Lust K, McKenzie S, Javorsky G, Parsonage W. Pregnancy Following Heart Transplantation: A Single Centre Case Series and Review of the Literature. Heart Lung Circ 2020; 30:144-153. [PMID: 33162367 DOI: 10.1016/j.hlc.2020.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 10/03/2020] [Accepted: 10/13/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Maternal and fetal outcomes of pregnancy amongst cardiac transplant recipients are limited in the current literature. METHODS We describe five pregnancies in three cardiac transplant recipients managed between a tertiary centre for obstetric medicine and an associated state-wide transplant centre between 2014-2018, and provide a narrative review of the literature. RESULTS Pre-conception counselling was undertaken. There were no recent rejection episodes and all women demonstrated good baseline cardiac function. Median maternal age was 27 years (range 23-38 yrs.). Median time from transplantation to pregnancy was 5 years (range 2-14 yrs.). All women were managed with modified immunosuppressant regimens and multidisciplinary care. Cardiac function, tacrolimus levels and renal function were closely monitored with frequent monitoring for common complications of pregnancy. There were no maternal or fetal deaths. There was no evidence of graft rejection and no deterioration in cardiac function. Tacrolimus doses were increased to maintain therapeutic targets. Gestational diabetes occurred in three women and cholestasis of pregnancy occurred in one. Each infant was delivered by vaginal delivery. One mother had postpartum haemorrhage in both pregnancies. Pre-eclampsia did not occur. Median gestation at delivery was 37 weeks (range 35+4-40+5 days) with two preterm deliveries. One (1) infant was born with low birth weight. One (1) infant had jaundice requiring phototherapy. All infants were breastfed. CONCLUSION Pregnancy in transplant recipients confers risk to the mother and fetus. Pre-conception counselling, immunosuppressant tailoring and regular monitoring are paramount to avoid rejection and possible teratogenic complications. Favourable pregnancy outcomes are achievable with specialist multidisciplinary care.
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Affiliation(s)
- Siobhan Boyle
- Department of Cardiology, Princess Alexandra Hospital, Brisbane, Qld, Australia; Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia
| | - Thomas Sung-Him Mew
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Qld, Australia; Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia
| | - Karin Lust
- Women's and Newborn's Service, Royal Brisbane and Women's Hospital, Herston, Qld, Australia; Department of Medicine, University of Queensland, Qld, Australia
| | - Scott McKenzie
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Qld, Australia
| | - George Javorsky
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Qld, Australia
| | - William Parsonage
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia; Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Qld, Australia.
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17
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Tzatzaki E, Spartalis E, Spartalis M. Pregnancy after heart transplantation: A second-generation transmission of the gift of life. J Heart Lung Transplant 2020; 39:1321-1322. [PMID: 32576420 DOI: 10.1016/j.healun.2020.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 05/26/2020] [Accepted: 05/31/2020] [Indexed: 12/27/2022] Open
Affiliation(s)
- Eleni Tzatzaki
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Eleftherios Spartalis
- Laboratory of Experimental Surgery and Surgical Research, Medical School, University of Athens, Athens, Greece
| | - Michael Spartalis
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
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18
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Defilippis EM, Kittleson MM. Pregnancy after Heart Transplantation. J Card Fail 2020; 27:176-184. [PMID: 32771397 DOI: 10.1016/j.cardfail.2020.07.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 06/04/2020] [Accepted: 07/20/2020] [Indexed: 10/23/2022]
Abstract
As post-transplant survival improves, many heart transplant (HT) recipients are of, or are surviving to, childbearing age. Solid-organ transplant recipients who become pregnant should be managed by a multidisciplinary cardio-obstetrics team, including specialists in maternal and fetal medicine, cardiology and transplant medicine, as well as anesthesia, neonatology, psychology, genetics, and social services. With careful patient selection, pregnancy after HT can been managed safely. The purpose of this comprehensive review was to summarize the current evidence and recommendations surrounding preconception counseling, medical management and surveillance, maternal outcomes, breastfeeding, and remaining gaps in knowledge.
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Affiliation(s)
- Ersilia M Defilippis
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Michelle M Kittleson
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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19
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DeFilippis EM, Haythe J, Farr MA, Kobashigawa J, Kittleson MM. Practice Patterns Surrounding Pregnancy After Heart Transplantation. Circ Heart Fail 2020; 13:e006811. [DOI: 10.1161/circheartfailure.119.006811] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Pregnancy after heart transplantation (HT) is a concern for many female recipients. The International Society for Heart and Lung Transplantation has guidelines regarding reproductive health, but limited data exist regarding providers’ attitudes and practices surrounding pregnancy post-HT.
Methods:
We conducted an independent, confidential, voluntary, web-based survey sent electronically to 1643 United States heart transplant providers between June and August 2019.
Results:
There were 122 responses, the majority from cardiologists (n=85, 70%) and nurse or transplant coordinators (n=22, 18%). Thirty-one percent (n=37) of respondents indicated that pregnancy should be avoided in all HT recipients, and only 43% (n=52) reported that their center had a formal policy regarding pregnancy following HT. The most commonly reported contraindications included nonadherence (n=109, 89%), reduced left ventricular ejection fraction (n=104, 85%), coronary allograft vasculopathy (n=86, 70%), prior rejection (n=76, 62%), presence of donor-specific antibodies (n=69, 57%), and prior peripartum cardiomyopathy pretransplant (n=57, 47%). Respondent sex, specialty, transplant volume, or prior experience with pregnancy after HT were not associated with recommendations to avoid posttransplant pregnancy.
Conclusions:
Transplant providers’ attitudes regarding posttransplant pregnancy vary widely. Despite International Society for Heart and Lung Transplantation guidelines, a significant proportion indicates that pregnancy is contraindicated in all recipients and the majority of programs have no center-specific policy to manage such pregnancies. While the low response rate limits the generalizability of the findings, they do suggest that education on the feasibility of pregnancy post-HT is indicated as many recipients are of, or survive to, childbearing age.
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Affiliation(s)
- Ersilia M. DeFilippis
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York (E.M.D., J.H., M.F.)
| | - Jennifer Haythe
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York (E.M.D., J.H., M.F.)
| | - Maryjane A. Farr
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York (E.M.D., J.H., M.F.)
| | - Jon Kobashigawa
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (J.K., M.M.K.)
| | - Michelle M. Kittleson
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (J.K., M.M.K.)
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20
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Acuna S, Zaffar N, Dong S, Ross H, D'Souza R. Pregnancy outcomes in women with cardiothoracic transplants: A Systematic review and meta-analysis. J Heart Lung Transplant 2019; 39:93-102. [PMID: 31839511 DOI: 10.1016/j.healun.2019.11.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/07/2019] [Accepted: 11/25/2019] [Indexed: 12/23/2022] Open
Abstract
Increasing numbers of women with thoracic transplants are planning and continuing pregnancies. However, pregnancy outcomes and risks to the mother and baby have not been systematically assessed. MEDLINE, EMBASE, and Cochrane Central were searched from their inception to January 2018, to identify studies reporting outcomes on 3 or more pregnancies following thoracic transplants. Pooled incidences were calculated using a random-effect meta-analysis. Risk-of-bias was assessed using the Joanna Briggs Checklist for case series. Subgroup analysis was conducted based on the organ transplanted. Of the 3,658 records identified, 12 studies were included that reported on 385 pregnancies in 272 thoracic transplant recipients. Maternal complications included mortality (pooled incidence 0.5% [95% confidence intervals 0, 1.1%] during pregnancy and 15.4% [10.4, 20.3%] during follow-up, which ranged between 3 and 7 years), graft rejection (7.4% [4.2, 10.5%]), hypertensive disorders of pregnancy [26.6% [13.7, 39.6%]), and cesarean deliveries (41.4% [33.4, 48.7%]). Maternal mortality was more common in recipients of lung vs heart transplants (41.4% [23.4, 59.3] vs 10.8% [5.9, 15.8]), respectively. Although 78.4% (69.8, 86.9%) of the pregnancies resulted in live births, 51.2% (31, 71.3%) were born preterm and neonatal deaths occurred in 3.4% (1.3, 5.6%). Congenital anomalies affected 4.3% (1.8, 6.8%) of the newborns. Although few maternal deaths occurred during pregnancy, in keeping with median survival data, delayed mortality for thoracic transplant recipients remains high. Despite the high numbers of live births, these pregnancies continue to be at risk for hypertensive disorders, graft rejection, preterm birth, and neonatal mortality. Prospectively gathered data from international registries should supplement these findings to better inform clinical counseling and practice.
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Affiliation(s)
- Sergio Acuna
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Nusrat Zaffar
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Susan Dong
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Heather Ross
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rohan D'Souza
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada.
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21
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Yuksel Y, Yuksel D, Yucetin L, Erbis H, Sarier M, Karatas O, Emek M, Erdogan M, Yavuz A, Demirbas A. Use of Tacrolimus During Pregnancy After Kidney Transplantaion. Transplant Proc 2019; 51:2361-2366. [DOI: 10.1016/j.transproceed.2019.01.150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 01/31/2019] [Indexed: 11/24/2022]
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22
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Rajapreyar IN, Sinkey RG, Joly JM, Pamboukian SV, Lenneman A, Hoopes CW, Kopf S, Hayes A, Moussa H, Acharya D, Aryal S, Weeks P, Cribbs M, Wetta L, Tallaj J. Management of reproductive health after cardiac transplantation. J Matern Fetal Neonatal Med 2019; 34:1469-1478. [PMID: 31238747 DOI: 10.1080/14767058.2019.1636962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Pregnancy after cardiac transplantation poses immense challenges. Maternal risks include hypertensive disorders of pregnancy, rejection, and failure of the cardiac allograft that may lead to death. Fetal risks include potential teratogenic effects of immunosuppression and prematurity. Because of the high-risk nature of pregnancy in a heart transplant patient, management of reproductive health after cardiac transplantation should include preconception counseling to all women in the reproductive age group before and after cardiac transplantation. Reliable contraception is vital as nearly half of the pregnancies in this population are unintended. Despite the associated risks, successful pregnancies after cardiac transplantation have been reported. A multidisciplinary approach proposed in this review is essential for successful outcomes. A checklist for providers to guide management is provided.
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Affiliation(s)
- Indranee N Rajapreyar
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rachel G Sinkey
- Department of Obstetrics and Gynecology, Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Joanna M Joly
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA.,Birmingham VA Medical Center, Birmingham, AL, USA
| | - Salpy V Pamboukian
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrew Lenneman
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Charles W Hoopes
- Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sabrina Kopf
- Department of Transplant Operations, Cardiothoracic Transplant Program, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Allison Hayes
- Department of Transplant Operations, Cardiothoracic Transplant Program, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hind Moussa
- Department of Obstetrics and Gynecology and Maternal Fetal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Deepak Acharya
- Department of Medicine, Division of Cardiology, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Sudeep Aryal
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Phillip Weeks
- Department of Pharmacy, Memorial Hermann Texas Medical Center, Houston, TX, USA
| | - Marc Cribbs
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Luisa Wetta
- Department of Obstetrics and Gynecology, Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jose Tallaj
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA.,Birmingham VA Medical Center, Birmingham, AL, USA
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23
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Abstract
Solid organ transplantation has evolved significantly in the last 50 years. When heart transplantation began, patient survival was scarcely past a year[1], and the question of pregnancy for female heart transplant patients was not a significant consideration. Now, since the era of cyclosporine and conventional triple drug therapy, is important to anticipate that women of childbearing age may desire to become pregnant. Since the survival post-transplant for heart patients is an average of 10-12 years (with some surviving 20 years), this is not an unreasonable notion. This article is protected by copyright. All rights reserved.
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