Pregnancy After Heart Transplant

Overview

The first reported pregnancy in a cardiac transplant patient was in 1988, and since then several hundred cases have been reported. Successful pregnancies also have been reported in patients with other organ transplants, including heart–lung transplants. It is expected that in years to come, more women who have had heart transplants will wish to conceive. About 25% of female heart transplant recipients are of childbearing age, and adult survival rate is greater than 90% with a survival half-life of 13 years.

The International Society for Heart and Lung Transplantation (ISHLT) and the American Society of Transplantation recommend the following: pregnancy should not be attempted before 1 year after heart transplant. Heart transplant recipients considering pregnancy should have had no rejection in the past year, adequate and stable graft function, and stably dosed immunosuppression. The ISHLT recommends baseline assessment of graft function before conception with an electrocardiography, echocardiography, and coronary angiography if not performed within the previous 6 months; right heart catheterization and biopsy may also be considered. Relative contraindications include rejection within the first posttransplant year, history of peripartum cardiomyopathy, advanced maternal age, comorbid factors, and nonadherence to medical care. The ISHLT guidelines also recommend that preconception counseling be offered to both the patient and her partner. The impact on the child of the mother’s expected longevity and potential for prolonged hospitalization should be considered as well.

Prepregnancy Counseling

Prepregnancy counseling is vital and should include an assessment of both maternal and fetal risks. The risks to the mother include the possibility of acute graft rejection, graft dysfunction, and infection. In some centers, potential fathers are asked to undergo human leukocyte antigen typing to see if he shares antigens with the donor heart, in which case the risk of rejection is higher.

The cause of the heart condition leading to the woman’s need for a heart transplant also should be considered. A woman with congenital heart disease has an approximately 10% risk of having a baby with congenital heart disease. It is unknown if women with a pretransplant diagnosis of peripartum cardiomyopathy are at increased risk of recurrence with subsequent pregnancies. However, most factors likely to contribute to peripartum cardiomyopathy are thought to be extrinsic to the heart, and it is feared that the transplanted heart is in jeopardy if a woman becomes pregnant again. Women with unrecovered peripartum cardiomyopathy have a 50% recurrence rate and 20% mortality rate with subsequent pregnancies. The outlook may be the same in women with a transplanted heart.

Pregnancy Risks

A meta-analysis of 385 pregnancies in 272 cardiothoracic transplant recipients included 220 pregnancies in 140 heart transplant patients. The average maternal age of these 140 patients was 28 years, and the average transplant-to-pregnancy interval was 81.4 months. There were no maternal deaths during pregnancy. Two women died in the first postpartum year. Graft rejection occurred during pregnancy in 9.4% of patients. Data from the National Transplant Registry indicate a higher rejection rate of 21%, with 40% of those cases being mild and requiring no treatment. When pregnancy has occurred, the risk of spontaneous abortion is 15% to 20%.