Abstract
Adequate contraception is an essential component of managing pulmonary hypertension in women of childbearing age. Intrauterine devices are a popular contraceptive choice for many women but are associated with a risk of vagal response upon placement in certain patients with pulmonary hypertension, which may not be well tolerated. More recently, newer permanent contraception devices have emerged in the market, such as the Essure. We describe the first case, to our knowledge, of vagal-associated response due to an Essure device placement.
CASE DESCRIPTION
We recently encountered a 34-year-old woman who had received a diagnosis of pulmonary arterial hypertension (PAH) secondary to a moderately large secundum atrial septal defect 2 years earlier. The patient was initially prescribed two oral PAH therapies, ambristentan (10 mg daily) and tadalafil (40 mg daily). Later, therapy with nebulized treprostinil, titrated to a goal dosage of nine puffs four times daily, was initiated in addition to the other oral medications. The following pressures were observed on the most recent right heart catheterization: right atrium pressure, 4 mmHg; right ventricle pressure, 107/4 mmHg; pulmonary artery pressure, 106/44 mmHg; mean pulmonary artery pressure, 69 mmHg; and pulmonary artery occlusion pressure, 14 mmHg. The patient's cardiac output, obtained via thermodilution, was 7.9 L/min, and the pulmonary vascular resistance was 6.9 Wood units. Vasodilatory testing revealed no response to inhaled nitric oxide, and there was no step-up in the patient's oxygen saturation during a saturation run.
On presentation to our clinic, the patient was gravida 2, para 2, and was receiving medroxypregesterone for oral contraception. The patient and her husband expressed a desire for a more permanent method of contraception, given her understanding of the high risk associated with pregnancy. After discussing all options with her gynecologist, she opted to have a device placed for permanent sterilization (Essure; Conceptus, San Carlos, CA). Given her underlying cardiopulmonary disease and complicated pharmacotherapy for PAH, we recommended that the procedure be performed at the hospital in the event of a vagal response.
After placement of the device, the patient experienced an episode of palpitations and a sustained run of ventricular bigeminy immediately after the procedure. She was treated with lidocaine and magnesium, which abated the arrhythmia. The patient was admitted to the hospital for monitoring without further arrhythmias or complications.
DISCUSSION
PAH carries a high maternal risk; with the advent of emerging pharmacotherapy options, the associated mortality has decreased but remains significant at 16%. 1 Therefore, physicians and patients must take extreme precaution to prevent pregnancy. In this setting, temporary contraception with oral contraceptives and intrauterine devices (IUDs) is used most frequently, along with permanent sterilization via laparoscopic surgery or placement of sterilization devices, such as Essure. Sterilization of the male partner via vasectomy is an additional option.
IUD placement has been associated with vagal responses. Certain patients with PAH are not able to tolerate such a complication; this includes those with significant cardiopulmonary comorbidities, World Health Organization functional class III or IV, or those receiving two or more treatment modalities for PAH. Specific to this population, it is advised to place IUDs or perform laparotomies in a controlled environment secondary to the risk of inducing a vagal response that may lead to arrhythmias and acute right-sided heart failure.
The Essure device is a new, irreversible, transcervical method that works by occluding the fallopian tubes. Overall, the device has been observed to have great results as a permanent, well-tolerated contraception device with low rates of complication, and placement of the device does not require general anesthesia. Initial trials revealed a low rate of complication, with vagal response occurring in 1% of patients. 2 To our knowledge, there have been no reported cases to date of patients with PAH experiencing a vagal response after device insertion. 3
The recommendations regarding these new permanent contraception devices should be the same as for IUDs intended for temporary contraception. Certain patients with PAH who may not tolerate a vagal response will need to have the device placed in a controlled hospital environment, and physicians should be cognizant of the potential complications if the patient experiences a vagal event.
To our knowledge, this is the first reported case of a vagal response with the placement of the Essure permanent contraceptive device in a patient with PAH. We recommend that patients have the device placed in a hospital setting in anticipation of a possible vagal event.