contraception dr. susheela rani postgraduates

91
Contraception Dr. Susheela Rani Postgraduates Postgraduates

Upload: randall-ambrose-shields

Post on 21-Jan-2016

224 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Contraception   Dr. Susheela Rani  Postgraduates

Contraception

Dr. Susheela Rani

PostgraduatesPostgraduates

Page 2: Contraception   Dr. Susheela Rani  Postgraduates

WHO Recommendation criteria for safe contraceptive use (2009)

Category1Category1 = no restriction on use = no restriction on useCategory2 Category2 = the advantages of using the = the advantages of using the

method generally outweigh the theoretical method generally outweigh the theoretical or proven risksor proven risks

Category3Category3 = the theoretical or proven risks = the theoretical or proven risks usually outweigh the advantages of using usually outweigh the advantages of using the methodthe method

Category4Category4 = an unacceptable health risk = an unacceptable health risk

Page 3: Contraception   Dr. Susheela Rani  Postgraduates

Outpatient yesterday

G3P1A1(MTP) with 7weeks amenorrhoea G3P1A1(MTP) with 7weeks amenorrhoea wants termination of pregnancy. wants termination of pregnancy.

Condom contraception all these days.Condom contraception all these days. Condom failure previous pregnancy, Condom failure previous pregnancy,

hence MTP hence MTP Present pregnancy resulted despite the Present pregnancy resulted despite the

use of double condoms!!!use of double condoms!!!

Page 4: Contraception   Dr. Susheela Rani  Postgraduates

Have condoms failed?Have condoms failed?

Page 5: Contraception   Dr. Susheela Rani  Postgraduates

Double bagging

It increases the friction It increases the friction

between the condoms duringbetween the condoms during

intercourse, making them intercourse, making them

more likely to tear – this is the same for the more likely to tear – this is the same for the both simultaneous use of male and female both simultaneous use of male and female condoms. When condoms do fail, it is most condoms. When condoms do fail, it is most often a result of human error, rather than often a result of human error, rather than defects in the condom themselvesdefects in the condom themselves

Page 6: Contraception   Dr. Susheela Rani  Postgraduates

Case 1

Mrs G 28yr, P2 L2 A3 (all MTPs) wants Mrs G 28yr, P2 L2 A3 (all MTPs) wants contraceptioncontraception

Regular periods with moderate flowRegular periods with moderate flow Clinical Examination – Uterus normal size Clinical Examination – Uterus normal size

mobile, fornices freemobile, fornices free

Page 7: Contraception   Dr. Susheela Rani  Postgraduates

Among contraceptives, which one of these is the Among contraceptives, which one of these is the most most cost - effective cost - effective

CondomsCondoms IUDIUD OCsOCs DMPADMPA Vaginal RingVaginal Ring

Page 8: Contraception   Dr. Susheela Rani  Postgraduates
Page 9: Contraception   Dr. Susheela Rani  Postgraduates

You are talking to her about effectiveness of You are talking to her about effectiveness of each method. She is worried that the IUD each method. She is worried that the IUD “will go into the abdomen”. “will go into the abdomen”. How would you How would you explain failure rate, perforation rate and explain failure rate, perforation rate and expulsion rate of IUD?expulsion rate of IUD?

Page 10: Contraception   Dr. Susheela Rani  Postgraduates

Failure rateFailure rate<2 in 100 WY for CuT<2 in 100 WY for CuT<1 in 100WY for LNG IUS<1 in 100WY for LNG IUS

Perforation rate Perforation rate <2 in 1000 women getting inserted<2 in 1000 women getting inserted

Expulsion rateExpulsion rate1 in 20 and usually happens within first 1 in 20 and usually happens within first year particularly within 3 monthsyear particularly within 3 months

Page 11: Contraception   Dr. Susheela Rani  Postgraduates

She says she is OK with the insertion of Cu She says she is OK with the insertion of Cu T and you get ready by wearing gloves for T and you get ready by wearing gloves for insertion. insertion.

Did we miss something here?Did we miss something here?

Page 12: Contraception   Dr. Susheela Rani  Postgraduates

Informed (written)consentInformed (written)consent

Page 13: Contraception   Dr. Susheela Rani  Postgraduates

Pt requests for a Cu IUCDPt requests for a Cu IUCD

However, examination reveals vulvo vaginitis suggestive of monilial However, examination reveals vulvo vaginitis suggestive of monilial infectioninfection

Would you still go ahead with with the insertion?Would you still go ahead with with the insertion?

Page 14: Contraception   Dr. Susheela Rani  Postgraduates

You are ready for insertion. While the patient is You are ready for insertion. While the patient is

lying on the couch she gives history of lying on the couch she gives history of

gestational diabetes. Her FBS done a week back gestational diabetes. Her FBS done a week back

was 215mg/dLwas 215mg/dL

Would you still insert the IUD? Would you still insert the IUD?

Page 15: Contraception   Dr. Susheela Rani  Postgraduates

Would you give prophylactic antibiotic? If Would you give prophylactic antibiotic? If so, what drug and what dosage?so, what drug and what dosage?

Page 16: Contraception   Dr. Susheela Rani  Postgraduates

IUD & prophylactic antibiotics

Low risk women – no benefitLow risk women – no benefit

High risk women – single dose ofHigh risk women – single dose of

Doxycycline 200mg PO Doxycycline 200mg PO

Azithromycin 500mg POAzithromycin 500mg PO

Women with previous endocarditis or with a prosthetic

heart valve require intravenous antibiotic prophylaxis to

protect against bacterial endocarditis during intrauterine

contraception insertion or removal (Grade C).

Page 17: Contraception   Dr. Susheela Rani  Postgraduates

If this patient had a cardiac disease instead If this patient had a cardiac disease instead of Diabetes, what caution would you of Diabetes, what caution would you exercise?exercise?

Page 18: Contraception   Dr. Susheela Rani  Postgraduates

Vasovagal reaction may occur as a result Vasovagal reaction may occur as a result of cervical stimulation during insertion or of cervical stimulation during insertion or removal of IUD. removal of IUD.

Inj Atropine IM 10mins before the Inj Atropine IM 10mins before the procedure or use a short GA procedure or use a short GA

Page 19: Contraception   Dr. Susheela Rani  Postgraduates

Is it true?

IUD use IUD use Cleaning the vagina with Povidone Iodine before Cleaning the vagina with Povidone Iodine before

insertion decreases the risk of infectioninsertion decreases the risk of infection Increased risk of infection is related only to the Increased risk of infection is related only to the

insertion process and not to IUDinsertion process and not to IUD Doubles the incidence of tubal infertilityDoubles the incidence of tubal infertility Increases the risk of ectopic pregnancy Increases the risk of ectopic pregnancy

Page 20: Contraception   Dr. Susheela Rani  Postgraduates

Is it true?IUD use Cleaning the vagina with Povidone Iodine before

insertion decreases the risk of infection. Iodine preparation is of little benefit. No touch technique is more important

Increased risk of infection is related only to the insertion process and not to IUD True

Doubles the incidence of tubal infertility – No increased incidence

Increases the risk of ectopic pregnancy - No increased incidence

Page 21: Contraception   Dr. Susheela Rani  Postgraduates

Patient comes back within 3 days saying that Patient comes back within 3 days saying that

she cannot feel the threads. Ultrasound reveals she cannot feel the threads. Ultrasound reveals

an empty uterus. IUCD on the antero superior an empty uterus. IUCD on the antero superior

surface of uterussurface of uterus

Page 22: Contraception   Dr. Susheela Rani  Postgraduates

Patient is asymptomatic & not keen on surgeryPatient is asymptomatic & not keen on surgery

Page 23: Contraception   Dr. Susheela Rani  Postgraduates

Perforated IUD

Is it best left alone if the woman is Is it best left alone if the woman is asymptomatic?asymptomatic?

Is it best removed soon after it is located? Is it best removed soon after it is located?

Page 24: Contraception   Dr. Susheela Rani  Postgraduates

Perforated IUD

Copper can lead to adhesion formation. Copper can lead to adhesion formation. It is best removed soon after it is located – It is best removed soon after it is located –

before adhesion formation can occurbefore adhesion formation can occur It is left alone ONLY if the risk of surgery is high It is left alone ONLY if the risk of surgery is high

AND if the woman is asymptomaticAND if the woman is asymptomatic

Page 25: Contraception   Dr. Susheela Rani  Postgraduates

Say this woman had an uneventful period after Say this woman had an uneventful period after insertion of Cu380A and comes for removal and insertion of Cu380A and comes for removal and reinsertion of a new one after 10years. She has a reinsertion of a new one after 10years. She has a Multi loadCu 375 inserted this time. When does Multi loadCu 375 inserted this time. When does she need to come for removal and insertion of she need to come for removal and insertion of another one?another one?

Page 26: Contraception   Dr. Susheela Rani  Postgraduates

Women who have a Cu-IUD inserted at the age of 40 years or over can retain the device for 1 year after the last menstrual period if aged over 50 years (or 2 years if under 50 years) or until contraception is no longer required

Page 27: Contraception   Dr. Susheela Rani  Postgraduates

Mr & Mrs P visit your clinic because Mrs P has Mr & Mrs P visit your clinic because Mrs P has

missed her period and is worried she could be missed her period and is worried she could be

pregnant. They have not used contraception so pregnant. They have not used contraception so

far. She has a regular 30days cycle far. She has a regular 30days cycle

Case 2

Page 28: Contraception   Dr. Susheela Rani  Postgraduates

She is found to be not pregnant. She is found to be not pregnant.

They have 2 children, 3 and 2 yrs old and are They have 2 children, 3 and 2 yrs old and are

keen to postpone the third. However, they are a keen to postpone the third. However, they are a

religious couple and are not keen on using any religious couple and are not keen on using any

barriers / IUD or any medications. They have barriers / IUD or any medications. They have

heard of the (safe) Standard method and want to heard of the (safe) Standard method and want to

know what days are safe to have UPSIknow what days are safe to have UPSI

Page 29: Contraception   Dr. Susheela Rani  Postgraduates

Safe period

Works best for women with cycles Works best for women with cycles

between 26 and 32 daysbetween 26 and 32 days

It identifies days 8-19 as fertile days It identifies days 8-19 as fertile days

Avoid UPSI from days 8 through 19Avoid UPSI from days 8 through 19

Failure rate 20%Failure rate 20%

Page 30: Contraception   Dr. Susheela Rani  Postgraduates

Case 3

Mrs D 28yrs, software professional, often travels overseas on work

Married for 1 year Irregular periods cycle 45- 90days with

flow for 15-30days BMI 26, BP 120/70mmHg, pallor + Ut normal size, mobile, fx free

Page 31: Contraception   Dr. Susheela Rani  Postgraduates

What would you advice?What would you advice?

OC pillsOC pills

Progesterone only pillsProgesterone only pills

LNG IUSLNG IUS

IUCDIUCD

Page 32: Contraception   Dr. Susheela Rani  Postgraduates

Mrs D opts to use OC pills, the low dose variety. In Mrs D opts to use OC pills, the low dose variety. In

fact, OC pills have been advised to her even fact, OC pills have been advised to her even

before her marriage for regularization of periods. before her marriage for regularization of periods.

Can you add value to your prescription of OC pills? Can you add value to your prescription of OC pills?

Page 33: Contraception   Dr. Susheela Rani  Postgraduates

Extended OC pills for 3or more months Extended OC pills for 3or more months

6 RCTs show similar efficacy and safety for

continuous dosing and 28 day combination

contraceptive pills

Adv - convenience, reduction of menorrhagia, Adv - convenience, reduction of menorrhagia,

dysmenorrhoea and premenstrual syndrome, dysmenorrhoea and premenstrual syndrome,

improvement in Hb, general wellbeing. improvement in Hb, general wellbeing.

Disadv – Breakthrough bleeding in first few cyclesDisadv – Breakthrough bleeding in first few cycles

Page 34: Contraception   Dr. Susheela Rani  Postgraduates

What is LARC?What is LARC?

Page 35: Contraception   Dr. Susheela Rani  Postgraduates

LARC is defined as

Methods that require administering less than Methods that require administering less than once per cycle or monthonce per cycle or month

Page 36: Contraception   Dr. Susheela Rani  Postgraduates

Miss K,18yrs, student, has irregular periods, Miss K,18yrs, student, has irregular periods, 4days /2-3 months. She has undergone medical 4days /2-3 months. She has undergone medical TOP 6months back. TOP 6months back.

She seeks consultation for irregular bleeding since She seeks consultation for irregular bleeding since 18days18days

She gives history of having used She gives history of having used ‘‘II’’ pills twice pills twice since her LMP since her LMP

You find her 6weeks pregnant and have provided You find her 6weeks pregnant and have provided medical TOPmedical TOP

What contraceptive advice would you now give her?What contraceptive advice would you now give her?

Case 4

Page 37: Contraception   Dr. Susheela Rani  Postgraduates

AbstinenceAbstinence COCsCOCs POPsPOPs IUDIUD Injectable contraceptionInjectable contraception

You educate her about the correct method of You educate her about the correct method of use of Emergency Contraception. You advice…use of Emergency Contraception. You advice…

Page 38: Contraception   Dr. Susheela Rani  Postgraduates

She does not want to take OCs because she She does not want to take OCs because she fears she may forget taking during her exams & fears she may forget taking during her exams & also fears that her parents will find out. also fears that her parents will find out. She is not sure if she can abstain from SI She is not sure if she can abstain from SI

What would you advice? What would you advice?

Page 39: Contraception   Dr. Susheela Rani  Postgraduates

This girl needs regular contraception. This girl needs regular contraception.

LARC – user friendly, convenient, discreetLARC – user friendly, convenient, discreet

Long acting Injectable Progesterones need to be Long acting Injectable Progesterones need to be

used with caution in adolescents because of used with caution in adolescents because of

possible effect on Bone mineral densitypossible effect on Bone mineral density

Both Cu IUD and LNG IUD are Category 1 for Both Cu IUD and LNG IUD are Category 1 for

women >20yrs and Category 2 for women <20yrswomen >20yrs and Category 2 for women <20yrs

Page 40: Contraception   Dr. Susheela Rani  Postgraduates

Why would you think twice before offering Cu IUD to Why would you think twice before offering Cu IUD to

a nulliparous woman?a nulliparous woman?

Page 41: Contraception   Dr. Susheela Rani  Postgraduates

Why would you think twice before offering Cu IUD to Why would you think twice before offering Cu IUD to

a nulliparous woman?a nulliparous woman?

Because the risk of expulsion is higherBecause the risk of expulsion is higher

Page 42: Contraception   Dr. Susheela Rani  Postgraduates

Mrs KS, 34yr, presented with migraine without

aura associated with COC use. Migraine occurs

during the pill-free week. Her BP is 120/70

mmHg and BMI 26 kg/m2. There has been no

weight gain or any other side effect. There is no

family or personal history of diabetes, hepatic

disease, migraine, cardiovascular disease or

cancer.

Case 5

Page 43: Contraception   Dr. Susheela Rani  Postgraduates

Would you recommend a change of Would you recommend a change of contraceptive?contraceptive?

Page 44: Contraception   Dr. Susheela Rani  Postgraduates

There is a 2–4-fold increased risk of stroke in women who experience migraine (with or without aura) while using COCs compared with those who experience migraine but do not use COCs

Mrs KS is < 35 years old and did not have the migraines until she started the new COC, the risk of stroke outweigh the advantages

Alternatives include CuT, POPs, Inj DMPA, LNG IUS, Barrier methods

Page 45: Contraception   Dr. Susheela Rani  Postgraduates

Case 6

Keerthi, 22yr, delivered normally a healthy female baby today. She has a 1 year old daughter and is demanding Tubectomy. Her husband has decided to go with her wishes.

Is she an eligible candidate for Tubectomy?

Page 46: Contraception   Dr. Susheela Rani  Postgraduates

Eligibility for female sterilization

Should be married (including ever-married) Should be below 49yr and above 22yr Should have at least one child >1year unless the

sterilization is medically indicated Clients or their spouses/partners must not have

undergone sterilization in the past (not applicable in cases of failure of previous sterilization)

Must be in a sound state of mind

Page 47: Contraception   Dr. Susheela Rani  Postgraduates

Sterilization Regret

Nationally, 5% of sterilized women aged 15–49 reported sterilization regret.

Women sterilized before age 25 were more likely to express regret

Compared with women having only sons, those who had only daughters were more likely to express regret

Page 48: Contraception   Dr. Susheela Rani  Postgraduates

Encouraging couples to delay sterilization and increasing the availability of highly effective reversible contraceptives are options that India may consider to avert sterilization regret.

International Perspectives on Sexual and Reproductive Health, 2012, 38(4): 187–195

Sterilization Regret

Page 49: Contraception   Dr. Susheela Rani  Postgraduates

Despite counselling, Keerthi undergoes Despite counselling, Keerthi undergoes Tubectomy.Tubectomy.

15months later she returns with missed 15months later she returns with missed periodperiod

Examination reveals a live Intrauterine Examination reveals a live Intrauterine pregnancy of 6weekspregnancy of 6weeks

What was the reason for failure of Tubectomy? What was the reason for failure of Tubectomy?

Page 50: Contraception   Dr. Susheela Rani  Postgraduates

Factors Contributing to Failure

Page 51: Contraception   Dr. Susheela Rani  Postgraduates

Operator Error Ligating the wrong Ligating the wrong

structurestructure Failure to Failure to

systematically systematically check the processcheck the process

Not ligating due to Not ligating due to technical technical problems and not problems and not informing the informing the womanwoman

Page 52: Contraception   Dr. Susheela Rani  Postgraduates

Failures Independent of Operator

Tuboperitoneal fistulaTuboperitoneal fistulaRecanalaisationRecanalaisation

Page 53: Contraception   Dr. Susheela Rani  Postgraduates

Tuboperitoneal fistula

Spontaneous Ectopic Pregnancy after tubal ligationSpontaneous Ectopic Pregnancy after tubal ligation

Progress 2015Progress 2015

Page 54: Contraception   Dr. Susheela Rani  Postgraduates

Spontaneous Tubal Recanalisation

Progress 2015Progress 2015

Page 55: Contraception   Dr. Susheela Rani  Postgraduates

Case 6

Mrs G 32yrs, P2 L2 Mrs G 32yrs, P2 L2 Irregular heavy periodsIrregular heavy periods Clinical Examination – 10wks size uterusClinical Examination – 10wks size uterus Ultrasound examination – Bulky uterus with Ultrasound examination – Bulky uterus with

multiple intramural fibroids, largest measuring multiple intramural fibroids, largest measuring 3cmX2cm. The endometrial cavity is not 3cmX2cm. The endometrial cavity is not distorted distorted

Endometrial thickness 11mm, contour - normal Endometrial thickness 11mm, contour - normal

Page 56: Contraception   Dr. Susheela Rani  Postgraduates

Which one of these would be appropriate? Which one of these would be appropriate?

IUDIUD

OCsOCs

DMPADMPA

LNG IUD LNG IUD

Page 57: Contraception   Dr. Susheela Rani  Postgraduates

OC pills & Fibroids

The administration of low dose OC pills to The administration of low dose OC pills to women with leiomyomas does not stimulate women with leiomyomas does not stimulate fibroid growth and is associated with decreased fibroid growth and is associated with decreased bleedingbleeding

Friedman AJ Thomas PP, Does low dose OC pill use affect uterine size or menstrual Friedman AJ Thomas PP, Does low dose OC pill use affect uterine size or menstrual flow in premenopausal women with leiomyomas Obstet Gynecol85: 631, 1995flow in premenopausal women with leiomyomas Obstet Gynecol85: 631, 1995

Page 58: Contraception   Dr. Susheela Rani  Postgraduates

LNG IUS & Fibroids

In studies of the levonorgestrel device in women In studies of the levonorgestrel device in women with troublesome bleeding associated with with troublesome bleeding associated with fibroids, the size of the uterus and the largest fibroids, the size of the uterus and the largest individual tumors diminished slightly. individual tumors diminished slightly.

Friedman AJ Thomas PP, Does low dose OC pill use affect uterine size or menstrual Friedman AJ Thomas PP, Does low dose OC pill use affect uterine size or menstrual flow in premenopausal women with leiomyomas Obstet Gynecol85: 631, 1995flow in premenopausal women with leiomyomas Obstet Gynecol85: 631, 1995

Page 59: Contraception   Dr. Susheela Rani  Postgraduates

Mrs G chooses to get an LNG IUS inserted. She Mrs G chooses to get an LNG IUS inserted. She

comes back to you after 3yrs for a check up. comes back to you after 3yrs for a check up.

She reveals that she was recently hospitalized She reveals that she was recently hospitalized

for a bad lung infection. She is presently for a bad lung infection. She is presently

undergoing treatment for tuberculosis and is on undergoing treatment for tuberculosis and is on

a 4 drug regime. a 4 drug regime.

Page 60: Contraception   Dr. Susheela Rani  Postgraduates

Would you like to suggest a change in her Would you like to suggest a change in her contraceptive method?contraceptive method?

Page 61: Contraception   Dr. Susheela Rani  Postgraduates

Data shows no reduction in the efficacy of LNG-Data shows no reduction in the efficacy of LNG-IUS with liver enzyme-inducing drugsIUS with liver enzyme-inducing drugs

Current WHO-MEC recommendations Current WHO-MEC recommendations LNG-IUS - Category ‘1’ for women who are LNG-IUS - Category ‘1’ for women who are prescribed drugs which affect liver enzymes, prescribed drugs which affect liver enzymes, such as rifampicin and anti-epileptic drugssuch as rifampicin and anti-epileptic drugs

Page 62: Contraception   Dr. Susheela Rani  Postgraduates

Case 7

Mrs D 38yrs, P3 L3 TOP 3, is planning to undergo Mrs D 38yrs, P3 L3 TOP 3, is planning to undergo

Incisional hernia repair and Tubectomy. She is Incisional hernia repair and Tubectomy. She is

on low dose OC pills for contraception. on low dose OC pills for contraception.

Page 63: Contraception   Dr. Susheela Rani  Postgraduates

When would you ask her to stop the OC pill?When would you ask her to stop the OC pill? 4weeks before the planned surgery 4weeks before the planned surgery 2weeks before the planned surgery2weeks before the planned surgery The day before the planned surgeryThe day before the planned surgery

Page 64: Contraception   Dr. Susheela Rani  Postgraduates

Data shows that high dose OC pills carry a risk Data shows that high dose OC pills carry a risk

of postoperative thrombosis of postoperative thrombosis

Low dose OC pills have not shown similar riskLow dose OC pills have not shown similar risk

Stopping OC pills well before the procedure is Stopping OC pills well before the procedure is

recommended only when prolonged recommended only when prolonged

immobilization is required following surgeryimmobilization is required following surgery

Page 65: Contraception   Dr. Susheela Rani  Postgraduates

Mrs C is being discharged today after a FTND of Mrs C is being discharged today after a FTND of

a healthy boy baby 3 days back. Both the a healthy boy baby 3 days back. Both the

mother and the baby are in good health and she mother and the baby are in good health and she

is breast feeding the baby.is breast feeding the baby.

When would you schedule her postpartum visit When would you schedule her postpartum visit

to provide contraception?to provide contraception?

Case 8

Page 66: Contraception   Dr. Susheela Rani  Postgraduates

6 weeks after delivery6 weeks after delivery 4 months after delivery4 months after delivery 3 months after delivery3 months after delivery 3 weeks after delivery3 weeks after delivery

ii

Page 67: Contraception   Dr. Susheela Rani  Postgraduates

Most studies have shown that half the women Most studies have shown that half the women

ovulate before the 6ovulate before the 6thth week week (before the (before the

traditional postpartum visit) . traditional postpartum visit) . A 3 week visit A 3 week visit

would be idealwould be ideal

Page 68: Contraception   Dr. Susheela Rani  Postgraduates

Rule of 3’s

Beginning of postpartum contraceptive useBeginning of postpartum contraceptive use

Full breast feeding – 3Full breast feeding – 3rdrd month month

Partial or No breast feeding – 3Partial or No breast feeding – 3rdrd week week

Page 69: Contraception   Dr. Susheela Rani  Postgraduates

Mrs C and her husband visit after 3weeks. She Mrs C and her husband visit after 3weeks. She is partially breast feeding her baby.is partially breast feeding her baby.

What are her contraceptive options?What are her contraceptive options? COCsCOCs POPsPOPs LNG IUDLNG IUD Cu IUD Cu IUD Injectable progesteronesInjectable progesterones

Page 70: Contraception   Dr. Susheela Rani  Postgraduates

Mr CMr C considers Cu IUD and asks considers Cu IUD and asks

““What would be the ideal time to insert CuIUD?What would be the ideal time to insert CuIUD?

””

ImmediatelyImmediately

At 4weeksAt 4weeks

At 6weeksAt 6weeks

Postpartum visit at 3 weeks

Page 71: Contraception   Dr. Susheela Rani  Postgraduates

At 4weeksAt 4weeks

Is it true about IUD in breast feeding Is it true about IUD in breast feeding

women…..women…..

Insertion is easierInsertion is easier

Rate of expulsion is higherRate of expulsion is higher

Rate of perforation is higherRate of perforation is higher

Postpartum visit at 3 weeks

Page 72: Contraception   Dr. Susheela Rani  Postgraduates

Postpartum insertion of either a Cu IUD or LNG Postpartum insertion of either a Cu IUD or LNG

IUD is best done within 48hours or AT or IUD is best done within 48hours or AT or

AFTER 4weeks . It is not inserted between AFTER 4weeks . It is not inserted between

48hrs to 4weeks. 48hrs to 4weeks.

WHO eligibility criteria 2008WHO eligibility criteria 2008

Postpartum visit at 3 weeks

Page 73: Contraception   Dr. Susheela Rani  Postgraduates

Despite allaying her fears of IUD, Mrs C is Despite allaying her fears of IUD, Mrs C is

unwilling to consider it. She is doubtful of taking unwilling to consider it. She is doubtful of taking

pills regularly. What are her options now?pills regularly. What are her options now?

Page 74: Contraception   Dr. Susheela Rani  Postgraduates

She chooses to use Inj DMPA. When would you She chooses to use Inj DMPA. When would you

start her on the injection?start her on the injection?

ImmediatelyImmediately

Later….if so when?Later….if so when?

Page 75: Contraception   Dr. Susheela Rani  Postgraduates

She takes Inj DMPA. Her periods are irregular with She takes Inj DMPA. Her periods are irregular with

spotting on & off despite the non steroidal anti- spotting on & off despite the non steroidal anti-

inflammatory drugs prescribed. She is disturbed inflammatory drugs prescribed. She is disturbed

by it because she cannot say her prayers when by it because she cannot say her prayers when

she has bleeding. What would you do now? she has bleeding. What would you do now?

Page 76: Contraception   Dr. Susheela Rani  Postgraduates

Discontinue injectable straight awayDiscontinue injectable straight away

If no gynaec problems are found treat with If no gynaec problems are found treat with

ethinyl estradiol, short termethinyl estradiol, short term

Page 77: Contraception   Dr. Susheela Rani  Postgraduates

She takes Inj DMPA and is quite happy with it. Her She takes Inj DMPA and is quite happy with it. Her

periods are irregular with spotting on & off but periods are irregular with spotting on & off but

since she has been counselled, she is not since she has been counselled, she is not

unduly disturbed by it and the bleeding settles. unduly disturbed by it and the bleeding settles.

Following the second injection, she returns to the Following the second injection, she returns to the

clinic only after 4months clinic only after 4months

Page 78: Contraception   Dr. Susheela Rani  Postgraduates

What would you do now?What would you do now?

Check for pregnancy. If negative give the injection and Check for pregnancy. If negative give the injection and

ask her to use additional method for the next 7days ask her to use additional method for the next 7days

Check for pregnancy and if negative give the injection Check for pregnancy and if negative give the injection

without any additional advice about contraceptionwithout any additional advice about contraception

Give the injection without any additional advice about Give the injection without any additional advice about

contraceptioncontraception

Page 79: Contraception   Dr. Susheela Rani  Postgraduates

Late for an injection?? grace period extended!

The repeat injection of The repeat injection of

DMPA can be given up to 4 weeks lateDMPA can be given up to 4 weeks late

NET-EN can be given up to 2 weeks late NET-EN can be given up to 2 weeks late

without requiring additional contraceptive without requiring additional contraceptive

protectionprotection

Selected Practice Recommendations for Contraceptive Use 2008 updateSelected Practice Recommendations for Contraceptive Use 2008 update

Page 80: Contraception   Dr. Susheela Rani  Postgraduates

Thanks

Page 81: Contraception   Dr. Susheela Rani  Postgraduates

Mrs A, 25yrs, married for 4 yrsMrs A, 25yrs, married for 4 yrsDetected HT soon after marriageDetected HT soon after marriageP2 L2, I – IUD at 28wks, II – LSCS for P2 L2, I – IUD at 28wks, II – LSCS for

twins, super added GDM twins, super added GDM Investigations after the I pregnancyInvestigations after the I pregnancyAPLA negativeAPLA negativeLipid profile – within normal limitsLipid profile – within normal limitsSugars – within normal limits Sugars – within normal limits

Case 4

Page 82: Contraception   Dr. Susheela Rani  Postgraduates

Menorrhagia since 2yrs. Underwent D&C – Cystic glandular Hyperplasia

Amen 2months , UPT – Negative Ht 5’, Wt 102kg, BP- 190/100 No withdrawal bleeding with

medroxyprogesterone acetate 20mg for 7days Scan – Ovaries bulky, Uterus NS, End – 10mm,

Cholelithiasis + Needs regularization of periods and

contraception

Page 83: Contraception   Dr. Susheela Rani  Postgraduates

Would you like to investigate her or Would you like to investigate her or prescribe contraception right away?prescribe contraception right away?

Page 84: Contraception   Dr. Susheela Rani  Postgraduates

What investigations would you ask for?What investigations would you ask for?

Page 85: Contraception   Dr. Susheela Rani  Postgraduates

Routine examinations / tests before contraception

WHO eligibility criteria 2004WHO eligibility criteria 2004

Page 86: Contraception   Dr. Susheela Rani  Postgraduates

Lipid profile shows raised cholesterol. However Lipid profile shows raised cholesterol. However

HDL/VLDL ratio is within normal limitsHDL/VLDL ratio is within normal limits

SGOT, SGPT, Renal function tests are normalSGOT, SGPT, Renal function tests are normal

Ultrasound scan of the abdomen shows normal Ultrasound scan of the abdomen shows normal

uterus with polycystic ovariesuterus with polycystic ovaries

Page 87: Contraception   Dr. Susheela Rani  Postgraduates

What would you advice? What would you advice?

OC pills?OC pills?

Progesterone only pills?Progesterone only pills?

LNG IUS?LNG IUS?

IUCD?IUCD?

Page 88: Contraception   Dr. Susheela Rani  Postgraduates

Hypertension and OC pills

Low dose OC pills can be used in women less Low dose OC pills can be used in women less than 35yrs with HT.than 35yrs with HT.

Progesterone only pills are betterProgesterone only pills are better Low dose OC pills have negligible impact on the Low dose OC pills have negligible impact on the

lipoprotein levellipoprotein level However, BP & lipid levels need to be closely However, BP & lipid levels need to be closely

monitoredmonitored

Page 89: Contraception   Dr. Susheela Rani  Postgraduates

What can a woman do if she vomits and / or has What can a woman do if she vomits and / or has

severe diarrhoea while using COCs or severe diarrhoea while using COCs or

progestogen-only pills (POPs)?progestogen-only pills (POPs)?

Page 90: Contraception   Dr. Susheela Rani  Postgraduates

Continue taking it orally despite her discomfort Continue taking it orally despite her discomfort (consider like missing pills)(consider like missing pills)

Use the vaginal route at the same dosage as oral

Coutinho EM et al, Comparitive study on the efficacy and acceptability of contraceptive Coutinho EM et al, Comparitive study on the efficacy and acceptability of contraceptive pills administered vaginally, an international multicentrer clinical trial. Clinical pills administered vaginally, an international multicentrer clinical trial. Clinical PharamacolPharamacol

Ziaei et al, Compartive study and evaluation of side effects of low dose OC pills Ziaei et al, Compartive study and evaluation of side effects of low dose OC pills adminsrtered by the oral and vaginal route, Contraception 2002adminsrtered by the oral and vaginal route, Contraception 2002

Page 91: Contraception   Dr. Susheela Rani  Postgraduates

THANK YOUTHANK YOU