post partum kontrasepsi

8/13/2019 Post Partum Kontrasepsi

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Contraceptive methods available to women postpartum

Unrestricted methods Methods not usually recommended, or used with restriction

Non breast-feedingwomen


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breast-feeding womenbetween 6 weeks and 6months postpartum

based methods - if previous user Barrier methodsSterilisation

Progestogen-only injectiblescan generally be used wheretheir advantages generallyoutweigh the risks

Fertility awarenessbasedmethods - a new user shoulddelay learning to use the methoduntil her periods start

Not fully or almost fullybreast-feeding womenbetween 6 weeks and 6months postpartum

POPProgestogen-onlyinjectables andimplantsCopper IUD and IUSFertility awareness-based methods - if previous user or newlearner if periodshave resumedBarrier methodsSterilisation

Can generally be used wherebenefits outweigh risks:

COCPsCombinedcontraceptive patch

Combined contraceptive vaginalring - not recommended until babyis fully weaned

Breast-feeding women>6 months postpartum

COCPsCombinedcontraceptive patchPOPProgestogen-onlyinjectables andimplantsCopper IUDs and theIUSFertility awareness

based methods -new user shoulddelay learning to usethe method untilperiods resumeBarrier methodsSterilisation

Combined contraceptive vaginalring - not recommended until babyis fully weanedLAM - inadequate contraception

from 6 months postpartum

The LAMThis is a method of avoiding pregnancy based upon the natural postpartum infertility associated with fullybreast-feeding: suckling an infant reduces the release of gonadotrophins, which suppress ovulation but, assuckling reduces, ovulation returns. It is over 98% effective in preventing pregnancy if a woman is:[4]

Less than 6 months postpartum Amenorrhoeic (no vaginal bleeding after the first 56 days postpartum)

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Fully breast-feeding day (at least four-hourly feeds) and night (at least six-hourly feeds)[3]

The risk of pregnancy is increased if:

Breast-feeding decreases, particularly stopping night feeds, or with the introduction of formula or solids and where pumping rather than nursing occursMenstruation resumesThe woman is more than 6 months postpartum [3]

However, much of the efficacy data are based upon women living in non-industrialised countries.

POPs and implantsThe World Health Organisation (WHO) recommends that progestogen-only methods should not be used inthe first 6 weeks postpartum.[5] However, in the UK, it is common practice that POPs and implants are usedbefore 6 weeks postpartum because there is no evidence of effect on breast milk volume and infant growthduring this period.[3]

Starting regime for POP:

Commence up to day 21 postpartum without the need for extra contraception.If started after day 21, additional contraception is needed for 2 days and need to excludepregnancy.If regular menstrual cycles have returned, start POP up to and including day 5 of period withoutthe need for extra barrier methods.

Starting regime for etonogestrel implant:

Start 21-28 days after delivery.If later than this, extra barrier methods of contraception are needed for 7 days.

Progestogen-only injectablesThese are licensed for use only after 6 weeks post-partum:

It is recommended that injections start at, or after, 6 weeks if breast-feeding.They can be started within 5 days of delivery, provided the woman is not breast-feeding but thismay risk heavy or prolonged bleeding.If started on or before day 21 postpartum, no extra precautions are needed

COCPs

For breast-feeding women:There are concerns about hormonal effects on the quality and quantity of milk, passage of hormones to the infant and adverse effects on infant growth if COCPs are used in breast-feedingwomen before 6 months postpartum.

A recent systematic review did not show an adverse effect on infant growth or development.[6]However, WHO recommends that COCPs should not be used in the first 6 weeks postpartum andshould only be used between 6 weeks and 6 months if other, more appropriate methods, areunacceptable. [5]Use in breast-feeding women before 6 months postpartum is outside product license.

For non-breast-feeding women:

Pregnancy is a thrombophilic state; by about 2 weeks postpartum, these changes have reversedin most women.

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The earliest start date for the COCP should be 21 days postpartum but later if the woman is atincreased risk of thrombosis; for example, following severe pregnancy-related hypertension orHaemolytic anaemia, E levated L iver enzymes and L ow P latelet count (HELLP) syndrome.[7]If started later than 21 days, additional barrier methods of contraception are needed for 7 days.

IUD and levonorgestrel-releasing IUSFor the IUD:

This has no effect on breastmilk production.[8] [9]There is a 1 in 20 expulsion risk.[9]Review 4-6 weeks after insertion or after the first period, then annually.Teach woman to feel threads after each period.

Timing of insertion:

NICE guidance suggests that both the IUD and IUS may be fitted from 4 weeks postpartum.[10]The Mirena IUS's product licence however specifies fitting from 6 weeks postpartum.[11]

A recent systematic review suggests that there is no increased risk of complications of insertionin the postpartum period compared with outside of it. However, risk of expulsion is greater withdelayed compared with immediate (


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Follow-upRegardless of the contraceptive choice made:

Written information about contraceptive choices should be provided. This has been shown toincrease a woman's ability to make an informed decision about birth control postpartum.[15]Provide detailed advice about what to do if things go wrong, preferably with written information totake away, eg missed pill advice, IUD expulsion advice.

A follow-up appointment should be arranged.

Further reading & references Amy JJ, Tripathi V; Contraception for women: an evidence based overview. BMJ. 2009 Aug 7;339:b2895. doi: 10.1136/bmj.b2895.

1. Postnatal care: Routine postnatal care of women and their babies , NICE Clinical Guideline (2006)2. Guillebaud J; Postpartum contraception. Unnecessary before three weeks. BMJ. 1993 Dec 11;307(6918):1560-1.3. Contraceptive choices for breastfeeding women, Faculty of Family Planning and Reproductive Health Care RCOG (2004)4. Van der Wijden C, Kleijnen J, Van den Berk T; Lactational amenorrhea for family planning. Cochrane Database Syst Rev.

2003;(4):CD001329. [abstract]5. Medical eligibility criteria for contraceptive use. World Health Organization, 20046. Truitt ST, Fraser AB, Grimes DA, et al; Hormonal contraception during lactation. systematic review of randomized controlled

trials. Contraception. 2003 Oct;68(4):233-8. [abstract]7. Guillebaud J, Contraception. 3rd ed, Churchill Livingstone (1999) 124-1278. Diaz S, Zepeda A, Maturana X, et al; Fertility regulation in nursing women. IX. Contraceptive performance, duration of lactation,

infant growth, and bleeding patterns during use of progesterone vaginal rings, progestin-only pills, Norplant implants, and Copper T 380-A intrauterine devices. Contraception. 1997 Oct;56(4):223-32. [abstract]

9. Penney G, Brechin S, de Souza A, et al ; FFPRHC Guidance (January 2004). The copper intrauterine device as long-termcontraception. J Fam Plann Reprod Health Care. 2004 Jan;30(1):29-41; quiz 42. [abstract]

10. Long-acting reversible contraception, NICE Clinical guideline (October 2005); (the effective and appropriate use of long-actingreversible contraception)

11. Summary of Product Characteristics (SPC) - Mirena; Summary of Product Characteristics (SPC) - Mirena (levonorgestrelintrauterine system), Schering Health Care Limited, electronic Medicines Compendium. Updated April 2009

12. Kapp N, Curtis KM; Intrauterine device insertion during the postpartum period: a systematic review. Contraception. 2009Oct;80(4):327-36. Epub 2009 Aug 29. [abstract]

13. Celen S, Moroy P, Sucak A, et al ; Clinical outcomes of early postplacental insertion of intrauterine contraceptive devices.Contraception. 2004 Apr;69(4):279-82. [abstract]

14. Male and female sterilisation, Royal College of Obstetricians and Gynaecologists (2004)15. Johnson LK, Edelman A, Jensen J ; Patient satisfaction and the impact of written material about postpartum contraceptivedecisions.; Am J Obstet Gynecol. 2003 May;188(5):1202-4.

Original Author: Dr Michelle Wright Current Version: Hilary ColeLast Checked: 20/04/2011 Document ID: 2643 Version: 22 EMIS

Disclaimer : This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warrantyas to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medicalconditions. For details see ourconditions.

View this article online atwww.patient.co.uk/doctor/Postpartum-Contraception.htm.Discuss Postpartum Contraception and find more trusted resources at www.patient.co.uk.EMIS is a trading name of Egton Medical Information Systems Limited.

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