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Introduction
Recently, the Organization for Economic Cooperation and Development reported that, among its 35 permanent members, Mexico is ranked first in adolescent pregnancy, with about half a million of pregnancies every year1. Of this group, 60% corresponds to low-income population that is unable to optimally have access to health services, education, healthy nutrition and better development opportunities for both the mother and the child. According to the 2015 Inter-census Survey of the National Institute of Statistics and Geography (INEGI Instituto Nacional de Estadística y Geografía), in Mexico there are 48.7 million of females aged 12 years and older, out of which 67.3% have had at least one live birth. It is important pointing out that 7.8% of those aged between 12 and 19 years have already procreated, exercising their motherhood without having a couple in 27.8% of cases2.
Thus, adolescent girls have become one of the most vulnerable groups in our country and this represents a serious public health problem, since pregnant adolescents have twice higher probabilities of dying due to complications during pregnancy or delivery in comparison with adult women3, so much so, that it is the second cause of death between 15 and 19 years of age. In the INEGI inter-census survey in Mexico, the analysis of the global fertility rate by level of education shows that, the higher the level of education, the lower the fertility (Table 1), and in developing countries, adolescent girls usually have a low level of education and, in many cases, their pregnancy may be related to sexual abuse or violence, which adds high rates of sexually-transmitted diseases to the obstetric problem, including human immunodeficiency virus infection, whose burden is higher in females than in males4.
Table 1 Overall fertility rate (total number of children that on average a woman will have at the end of her reproductive life) by level of education
| Level of education | 1997* | 2000** | 2014† |
|---|---|---|---|
| No instruction | 5.18 | 3.34 | 3.30 |
| Incomplete primary education | 4.06 | 3.26 | 3.21 |
| Complete primary education | 3.31 | 2.93 | 2.99 |
| Secondary education | 2.75 | 2.70 | 2.70 |
| Middle and higher education | 2.09 | 1.70 | 1.79 |
Total fertility rate refers to the total number of children that on average woman will have at the end of her reproductive life.
*Corresponds to the 1992-1996 five-year period.
**Corresponds to the 2006-2008 triennium.
†Corresponds to the 2011-2013 triennium.
Source: National Institute of Statistics and Geography, 20162.
Currently, advances in diagnostic testing methods, surgical techniques, cardiopulmonary bypass circuits miniaturization and postoperative care have allowed to maintain a survival higher than 85% in patients with heart disease, especially with congenital conditions3. In the latter case, the surviving child population will reach reproductive age, whereby new health risks are created. In the National Institute of Cardiology Ignacio Chávez, between 2003 and 2016, 4,000 pediatric patients were operated and, by 2016, 640 of them had already become adults, out of which more than 50% were of the female gender, who represent a variable risk in case of combining pregnancy with a congenital heart disease5. For the cardiologist involved in the management of pregnant women with congenital or acquired heart disease, the primary goal should be the prevention of cardiovascular complications. Nevertheless, complication rates are extremely high, especially when there are heart diseases that significantly increase the risk of dying during gestation, such as primary pulmonary arterial hypertension and Eisenmenger syndrome, which have a mortality risk of between 30 and 50% during pregnancy6,7 (Table 2). Another example of high risk of morbidity and mortality in this group is the need for anticoagulation for arrhythmias and/or use of mechanical prostheses, which implies higher maternal and fetal risk. In addition to the risk that cardiovascular disease generates for the mother, cardiovascular drugs can pose a high risk to both the mother and the fetus during pregnancy8,9.
Table 2 Conditions that put pregnant women with congenital heart disease at high risk
| Conditions that put pregnant women with congenital heart disease at high risk |
|---|
| − Eisenmenger syndrome |
| − Severe left ventricular outflow tract obstruction |
| − Severe right ventricular outflow tract obstruction |
| − Severe pulmonary artery hypertension |
| − Operated with Fontan surgical procedure |
| − Tricuspid atresia |
| − Corrected transposition |
| − Marfan syndrome |
Source: Cossio-Aranda, 20028.
In the cases of mothers with congenital or acquired heart disease, fetal risk is 18%, in comparison with that of the general population, which is 7%, and it is reflected by delayed intrauterine growth, prematurity and intracranial hemorrhage, among other consequences10. Some heart defects have a dominant autosomal inheritance pattern, i.e., a mother with these types of defects can have a 50% probability for the child to be born with the same genetic defect.
Emotional impact on women with heart disease and pregnancy
Since the first years of this century, the topic adolescent pregnancy has occupied an important space in global public health because it affects physical and emotional health, and constitutes a social and economic problem, especially in a vulnerable group of countries with low economic income.
There are investigations that show that a high percentage of adolescents lack education and information on sexuality and reproductive health. In Mexico, the Ministries of Health and Public Education have created policies with physical spaces and human resources to facilitate adolescent education, and to help them understand their sexuality and protect them against unwanted pregnancies, sexually-transmitted infections and the subsequent risk of sterility. However, these programs deserve more diffusion and actions of society in general.
The pregnant adolescent experiences mood alterations, with feelings of frustration, anger, irritability, hostility, guilt and shame. As pregnancy advances, she develops fear, concerns about dying, increased stress, symptoms of anxiety and depression, which impact on emotional health of the mother and the fetus. Therefore, psychological care aimed at the prevention of pregnancies in adolescents with heart disease is of the utmost importance, by making education on sexuality effective, focusing on the following aspects:
Transmission of the concept of comprehensive sexuality with responsibility.
Development of skills and attitudes that allow the training of autonomous people, able to make decisions to prevent and/or face the risks involved in the practice of sexuality.
Generation of self-awareness on sexuality.
Development or strengthening of social and assertive communication skills.
Development of competences, abilities and attitudes that influence self-esteem.
Motivation of adolescents to complete their education.
Information of parents about adolescent girls needs on sexuality issues and how to help them.
Reproductive health and adolescent pregnancy prevention
In view of the serious problem of maternal death, especially in adolescent females with heart diseases, the National Health Institutes and High Specialty Hospitals Coordinating Commission, within a multidisciplinary approach in collaboration with the National Institute of Perinatology and the National Institute of Cardiology Ignacio Chávez, has developed a program of high-risk pregnancy prevention.
For the accomplishment of this program, and with the support of medical and nursing authorities, a place for the care of patients of childbearing age and cardiovascular conditions, called high reproductive risk module (MARR Módulo de Alto Riesgo Reproductivo), which involves the prevention of pregnancy in cardiac disease, especially in adolescents11, was implemented in the Outpatient Department of the National Institute of Cardiology Ignacio Chávez (Fig. 1).
The medical and nursing staff at MARR received training through theoretical and practical courses on pregnancy and contraceptive methods in heart disease patients, as well as the legal framework that should rule in this context.
This module has a prevention system based on truthful and timely information. It includes education and diffusion of pregnancy prevention mechanisms, genetic counseling and gynecological help for pregnancy prevention. In a legal framework, adolescent patients with heart disease are informed on the risk that pregnancy would entail for the mother and the fetus, and on the way to prevent it. To promote knowledge about reproductive risk and contraceptive methods, Ministry of Health official information material is distributed to patients with cardiac disease, and counseling and psychological support activities are also carried out in order to encourage the users to establish a reproductive life plan.
The use of the institutional electronic agenda allows keeping a record of patients cared for and thereby it is possible to generate a database that facilitates the report to be generated to the Ministry of Health on the advances, achievements and needs of the module, and it will also allow measuring the impact of the program on this group of patients.
Legal framework, consequences and patient and doctor rights
The Political Constitution of the Mexican United States establishes the human rights every person is entitled to with regard to being informed on pregnancy prevention in women with congenital heart disease and on the risk for her life and/or for the life of the fetus in gestation, which requires from us to safeguard these rights. Article 4 of said ordinance states that everyone has the right to freely, responsibly and duly informedly decide about the number and spacing of their children; in addition, it contemplates the protection of the right to health, and in the same train of thought, the Declaration of Human Rights, the Declaration of Rights and Duties of Man and the International Covenant on Civil and Political Rights converge in having contemplated the human right by excellence that is life, which must be guarded and/or protected above other rights.
The alternatives for pregnancy prevention a woman with congenital heart disease has are adoption and surrogate motherhood. Adoption is the legal act whereby a person with legal capacity takes anothers child as his own, with the purpose to establish a parental-filial relationship with him/her, thus contracting the same rights and obligations that are born from a consanguineous bond. The law provides that, in order to be able to adopt, the person who wants to do it must comply with a series of requirements, among which a minimum age of 25 years is cited. Surrogate motherhood involves using a medical practice known as assisted reproductive technology, whose purpose is to perform extracorporeal fertilization, i.e., outside the maternal body. This requires the intervention of the three following agents: the mother, the gestating woman and the treating physician, who in addition to informing those involved in the procedure, will apply said assisted reproduction technology under proper medical care and supervision in order to effectively bring that pregnancy to term. Article 3 of the Law for Surrogate Motherhood initiative defines surrogacy as The medical practice consisting of human morulae implantation in a woman, which result from the binding of an ovule and a sperm fertilized by a couple bound by marriage or who cohabitate, and that contribute their genetic load or material that concludes with the delivery of a child. Thus, the legal relationship arises with the recognition of the woman of her child as her own, i.e., at the moment after the delivery, and by virtue of the above, once the purpose has been accomplished, the surrogate will hand the conceived child over to the biological mother, subrogating all acquired rights and obligations with regard to the newborn; to surrogate or to substitute is legally defined as the act of replacing a person in terms of rights and obligations; this is going to give rise to a legal bond called filiation. In short, there are two benefits that are obtained under this option: conceiving the fetus in a viable way exercising the right to reproductive health while preserving the ultimate legal good protected by the law: life.
Considering that the woman would decide not to opt for adoption or surrogate motherhood and her posture is still to continue with the gestation period, the alternate way to protect life is legal termination of pregnancy, a procedure that the Federal District Statute of Health and its regulations stipulate as being free and that can be carried until before of the twelfth week of gestation.
Legal termination of pregnancy can be practiced after the twelfth week, without falling into the criminal figure of abortion (termination of pregnancy after the twelfth week of gestation) provided that the Federal District Criminal Code regulatory hypotheses, which indicate the situations where there is criminal liability exemption, are updated. These hypotheses establish situations such as when according to the judgement of the doctor who assists the procedure, with the support of the opinion of another doctor, both determine that not performing the abortion would put the life of the pregnant woman in serious danger, or when in the opinion of two medical specialists there is reason enough to diagnose that the fetus has genetic or congenital alterations that may result in severe physical or mental damage that can put its survival at risk.
Conclusions
In the face of a serious social and health problem in a vulnerable population group such as adolescent females, preconception counselling should be offered to all women with heart disease, maintaining a multidisciplinary care approach constantly emphasizing the importance of preventing pregnancy in adolescence and at all levels.
Despite the evident diversity between medical specialties, with the creation of a module of pregnancy prevention in adolescent and adult females at high risk of morbidity and mortality due to their heart disease, we hope to gather, integrate and complement the necessary elements for a multidisciplinary approach, as todays medicine demands, in order to achieve the ultimate desideratum: prevention, this time in defense of womens childbearing age.
