Postpartum Contraception - Nagercoil Obstetric and ...

Postpartum Contraception - Nagercoil Obstetric and ...

Postpartum Contraception Prof N Palaniappan Chennai No women is completely free unless she has control over her own reproductive destiny Margaret Sanger USA

Breast Feeding Abstinence PROGESTERONE ONLY PILLS Cerazette Femulen

Micronor Norgeston Noriday Desogestrel 75 Etynodiol diacetate 500 Norethisterone 350 Levonorgestrel 30 Norethisterone 350

4 A POP with a difference: oral desogestrel Estrogen-free contraception 75 g desogestrel per g desogestrel per day Continuous oral regimen

5 POPs: Mechanisms of Action Suppress ovulation Reduce sperm transport in upper genital tract (fallopian tubes) Change endometrium making

implantation less likely Thicken cervical mucus (preventing sperm penetration) 6 POPs: Contraceptive Benefits

Effective when taken at the same time every day (0.055 pregnancies per 100 women during the first year of use) Immediately effective (< 24 hours) Pelvic examination not required prior to use Do not interfere with intercourse Do not affect breastfeeding Immediate return of fertility when stopped

POPs: Contraceptive Benefits Few side effects Convenient and easy-to-use

No bone loss as with depot provera Can be provided by trained nonmedical staff Contain no estrogen POPs: Noncontraceptive Benefits May decrease menstrual cramps May decrease menstrual bleeding May improve anemia

Protect against endometrial cancer Decrease benign breast disease Decrease ectopic pregnancy Protect against some causes of PID POPs: Limitations

Cause changes in menstrual bleeding pattern Some weight gain or loss may occur

User-dependent (require continued motivation and daily use) Must be taken at the same time every day Forgetfulness increases method failure Effectiveness may be lowered when certain drugs for epilepsy (phenytoin and barbiturates) or tuberculosis (rifampin) are taken Do not protect against STDs (e.g., HBV, HIV/AIDS) POPs: Conditions Requiring Precaution (WHO

Class 3) POPs are not recommended unless other methods are not available or acceptable if woman:

Is breastfeeding (< 6 weeks postpartum) Has unexplained vaginal bleeding (only if serious problem suspected) Has breast cancer (current or history) Is jaundiced (active, symptomatic) Is taking drugs for epilepsy (phenytoin and barbiturates) or tuberculosis (rifampin)

Has severe cirrhosis Has liver tumors (adenoma and hepatoma) Has had a stroke Has ischemic heart disease (current and history of) POPs: Conditions for Which There Are No Restrictions

Blood pressure (< 180/110) Diabetes (uncomplicated or < 20 years duration) Pre-eclampsia (history of)

Smoking (any age, any amount) Surgery (with or without prolonged bed rest) Thromboembolic disorders Valvular heart disease (symptomatic or asymptomatic) 12 POPs: When to Start

Day 1 of the menstrual cycle Anytime you can be reasonably sure the woman is not pregnant Postpartum: after 6 months if using lactational amenorrhea method (LAM) after 6 weeks if breastfeeding but not using LAM immediately or within 6 weeks if not breastfeeding

Postabortion (immediately) 13 Oral desogestrel - negligible effects

Metabolic parameters Hemostasis Lipid metabolism Carbohydrate metabolism 14 POP There is no evidence that the efficacy of progestogen-only pills

(traditional or desogestrel-only) is reduced in women weighing >70 kg and therefore the licensed use of one pill per day is recommended. (Grade B) Women may be advised that if a traditional progestogen-only pill is more than 3 hours late or a desogestrel-only pill is more than 12 hours late they should: take the late or missed pill now continue pill taking as usual (this may mean taking two pills at the same time)

use condoms or abstain from sex for 48 hours after the pill is taken. (Grade C) 15 If a woman vomits within 2 hours of pill taking another pill should be taken as soon as possible (Grade C) Women using liver enzyme-inducing medications short term should be advised to use condoms in addition to progestogenonly pills and for at least 4 weeks after the liver enzymeinducer is stopped. (Grade C) Women using liver enzyme-inducing medications long term

should be advised that the efficacy of progestogen-only pills is reduced and an alternative contraceptive method should be considered. (Grade C) 16 Women may be advised that there is no evidence of a causal association between progestogen only pill use and weight change

Women should be advised that mood change can occur with progestogen-only pill use but there is no evidence of a causal association for depression. (Grade C) Women should be advised that there is no evidence of a causal association between the use of a progestogen-only pill and headache. (Good Practice Point) 17

There is no causal association between progestogen-only pill use and cardiovascular disease (MI, VTE and stroke) or breast cancer. (Grade B) Women may be advised that a progestogen-only pill can be continued until the age of 55 years when natural loss of fertility can be assumed. Alternatively they can continue using a POP and have FSH concentrations checked on two occasions 12 months apart

18 Injectable Contraceptives Types DMPA - Mechanism of Action DMPA Widely used Injectable

Best known as Depo Provera Used by more than 14 million women worldwide Administered by deep intramuscular injection 150 mg every 3 months Injection site : upper arm or buttocks When to Initate Anytime during menstrual cycle if provider is

reasonably sure woman is not pregnant Backup recommended if given after day 7 Postpartum Not breastfeeding immediately Breastfeeding delay 6 weeks Post abortion immediately

Advantages

Safe Highly effective Easy to use Long acting Reversible

Can be discontinued without providers help Can be provided outside of clinics Requires no action at the time of intercourse Use can be private Has no effect on lactation Has no contraceptive health benefits Non Contraceptive Heath Benefits DMPA use may reduce

Risk of endometrial cancer Risk of ectopic pregnancy Risk of symptomatic pelvic inflammatory disease Uterine fibroids Frequency and severity of sickle cell crises Symptoms of endometriosis Disadvantages Causes side effects, particularly menstrual

changes Action cannot be stopped immediately Causes delay in return to fertility Provides no protection in STIs/HIV DMPA Common side effects Menstrual changes Prolonged or heavy bleeding Irregular bleeding or spotting

Amenorrhea (absence of menses) Weight gain Headache, dizziness, changes in mood and sex drive One third of users discontinued during the first year because of side effects DMPA Return to Fertility

Does not permanently reduce fertility Length of time DMPA was used makes no difference Return to fertility depends on how fast woman fully metabolizes DMPA On average, it takes 9 to 10 months for women to become pregnant after their last injection Infant exposures to DMPA through

Breastfeeding DMPA has no effect on Onset or duration of lactation Quantity or quality of breast milk Health and development of infant When to initiate After child is 6 weeks old (preferred) Who can use DMPA

Source: WHO, 2004 DMPA use by women with HIV Women with HIV or AIDS can use without restrictions Nevirapine reduces blood progestin level by ~ 20% DMPA dose provides wides

margin of effectiveness On time injections encouraged Dual method use should be encourages Post partum IUCD Types of Insertion

Post Placental Insertion : Insertion of IUD within 10 min of the delivery of the placenta. Types of Insertion Intra cesarean Insertion : o Done manually / instrumental o Insertion before uterine closure o No need to pass the string through the Cx os

(infection , displace IUD) o No need to fix with ligature Types of Insertion Immediate Post partum : o With in 48 hrs following delivery o Can use regular ring forceps Extended Post partum/ Interval insertion : o After 6 wks of delivery

o Similar to regular IUD insertion. Immediate post abortal IUD insertion Safe and practical. Expulsion rates were higher after secondtrimester abortions than after earlier abortions, So delaying insertion may be advisable after later abortions.. Post abortion insertion - major reduction in pregnancy -cost effective

Cochrane Database review 2004 Timing of Insertion UNITED NATIONS POPULATION INFORMATION NETWORK (POPIN) with support from the UN Population Fund (UNFPA) Because of expulsion risks, insertion ideally should take place soon after delivery, or delayed for weeks.

US agency Cu T - as early as 4 wks others -6wks Immediate vs Delayed Insertion A t 6 months the two groups were similar in o Pregnancy prevention (same) oContinuation [84% vs 77%,) OR - 1.65 oExpulsion more in the immediate than in the delayed group (OR 6.77)

RHL WHO 2010 IUD insertion during post partum period A systematic Review Search till Dec 2008 297 articles , 15 included for review All included Cu T, no studies with LNG identified Contraception 2009

Results Immediate PP insertion - safe than late PP Immediate - low expulsion risk than late But more than interval insertion Post LSCS - low expulsion than Immediate insertion No Increase in risk of complications

Techniques 2 techniques o Instrumental Insertion - using Placental forceps o Manual insertion- IUD held in hand Types of Insertion Instrumental Insertion Manual Insertion

A comparative study of two techniques used in immediate postplacental insertion (IPPI) of the Copper T-380A IUD in Shanghai, People's Republic of China. Two different insertion techniques do not significantly affect discontinuation rates IPPI using the TCu 380A, Cu T380A appears to be suitable for postpartum insertion in Chinese women

Xu Rivera et al Contraception Cochrane Review 2007 Modifications of existing device with absorbable sutures or additional appendages - NOT BENEFICIAL No difference with hand or Instrumental Insertion

Lippes loop & Progestesert - not better than CU containing device Anatomy of Post Partum Uterus Insertion Technique Confirm

Proper Instruments Visualise R/o Active bleed Cervix held with ring forceps Grasp the IUD with Forceps

Insertion Straighten the Angle Traction Straighten the Angle Process of Insertion

Removal of Ring Forceps Inspect Post procedure Counseling Advantages - women

Convenience - saves time & additional visit Safe, sure she is not pregnant

High motivation Decreased - risk of perforation ( post placental) Decreased perception of initial side effects No effect on breast feeding. Patient has effective method of contraception before discharge. Post Insertion - problems o Changes in menstrual bleeding pattern

o Cramps o Infection o IUD string problems o Expulsion - partial / Complete o Pregnancy Complications Expulsion rate : 7-15/HW at 6m , Risk of Infection: 0.1-1.1/HW

Perforation rate : 1 in 1150 Removal for bleeding : 13.7 vs 23.6/HW No increase in risk of Infection, bleeding, perforation, endometritis Does not affect Involution Chi et al 4th Int conf on IUD Expulsion rates Depends on Clinician experience - special training

Skilled clinicians have been associated with lower expulsion rates than unskilled clinicians. Contraception 1985; Tips to reduce spontaneous expulsion Right technique : Elevate the uterus Place IUD at fundus

Sweep the instrument to the side of uterine cavity Keep placental forceps closed while going in & open while out Tips to reduce spontaneous expulsion Right Instrument : Long to reach the fundus Fenestrated.

Right time : Post placental & Intra cesarean - to reduce expulsion rate. Post-partum bleeding and infection after post-placental IUD insertion Post-placental insertion appears to be a convenient approach to IUD initiation, No observed increase in the incidence of excessive bleeding or

endometritis. Contraception 2001 Special situations PPH : Priorities to achieve hemodynamic stability Insert once hrage is controlled / next day Insert prior to suturing episiotomy

AMTSL: Need not be modified Doesnt increase risk of expulsion. Breast feeding Not affected With Cu T380A, breast feeding women have less pain at insertion & lower removal rates than non breast feeding women

Farr et al Am J Obstet Gynecol 1996 Conclusions Postpartum is a right time for counselling

Choice of contraception is wide It should suit the couple 3 accepted methods are POP, IUCD and INJECTABLES All have their own pros & cons It is essential to save the fragile ecosystem of planet earth and prevent mankind from becoming his own executioner . With the population of the world currently increasing a

quarter of a billion each day , we have not a moment to lose. SHORT 1994 WOMEN They are our mothers & daughters Our sisters & wives They are our friends, our partners Our strength & conscience

They guide us , nurture us And protect us TO AWAKEN PEOPLE IT IS THE WOMEN WHO MUST BE AWAKENED ONCE SHE IS ON THE MOVE THE FAMILY MOVES THE VILLAGE MOVES THE NATION MOVES

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