Prepregnancy Care & Ensuring Success For Contraception

O&G Update 2014Hospital Sarikei, Sarawakyongsoonleong@yahoo.com

Contraception is a stepping stone for

effective prepregnancy care especially for high

risk women

Failure rates of various contraceptive methods

Method Typical Use Perfect Use

COCP 8 0.3

POP 8 0.3

IM Depo Provera 3 0.3

IUCD- Copper- Mirena

0.80.2

0.60.2

Implanon 0.05 0.05

Tubal Ligation (♀) 0.5 0.5

Vasectomy (♂) 0.15 0.1

Condom 15 2

Coitus Interruptus 18 4

Types of contraception● Hormonal

Oral (COCP, POP) Injectable (Depo Provera, NET) Implant (Implanon) Vaginal (NuvaRing)

● Intrauterine contraceptive devices

● Barrier method

● Permanent sterilisation (BTL, Vasectomy)

Combined Oral Contraceptives Pills (COCP)

● Contains 2 types of hormones

-> estrogen & progesterone

COCP

Examples of COCP available in Malaysia:

•Regulon

•Rigevidon

•Microgynon

•Mercilon

•Marvelon

When to start COCP?

● Day 1 – 5 of menses

● At any other time if patient is sure NOT pregnant, but with additional protection for the first 7 days ie. condom

When to start COCP?

Postpartum

1. Fully breastfeeding-> 6 months postpartum

2. Not breastfeeding

-> 3weeks postpartum

Non-contraceptive benefits

WHO medical eligibility criteria

Categories Classification

1 Use the method in any circumstances

2 Generally use the method

3 Use of the method is not usually recommended unless other more appropriate methods are not available

4 Methods not to be used

Absolute Contraindication WHO Category 4

• Pregnancy• Cerebrovascular accident• Thromboembolism• Liver diseases• Estrogen-dependent tumours (breast cancer)• Undiagnosed genital tract bleeding• Recent trophoblastic disease• Ischaemic heart disease

Relative Contraindication WHO Category 2&3

• Age above 40• Age >35 and smoking• Migraine• Hypertension• Diabetes• Obesity• Sickle cell disease• Varicose vein

Missed pills (COCP)

1st question to ask patient:Which type of COCP than you are taking?Which type of COCP than you are taking?

30 mcg or 20 mcg of ethinyloestradiol

Missed pills (COCP)For COCP containing 30mcg of ethinyloestradiol•If 1 or 2 pills are missed at anytime, take the pill ASAP (NO NEED EXTRA COVER, DO NOT STOP)

•If 3 or more pills are missed in the: 1st week, needs emergency contraception if

unprotected sex and use condoms for 7 days

2nd week, use condom for 7 days

3rd week, use condom for 7 days and continue with next packet without a break

Missed pills (COCP)For COCP containing 20mcg of ethinyloestradiol•If 2 or more pills are missed, apply the rules of missing 3 or more 30mcg pills.

Progestogen only pills (POP)

- Contains synthetic progestogen only, NO ESTROGEN.

When to start POP?

• Day 1 till up to day 5 of menses

• At any time when patient is sure not pregnant, but with additional protection for the next 48 hours i.e. condom

When to start POP?

• Postpartum Up to day 21 postpartum with no additional

contraception After day 21 postpartum, need additional

contraception (ie condom) or avoid sexual intercourse for the next 48 hours.

Side effects of POP

• Amenorrhoea

• Irregular bleeding or spotting

• Weight gain or loss (change in apetite)

• Breast tenderness

• Headaches, acnes

• Increased risk of benign functional ovarian cysts

Missed pills(POP)

Missed pills(POP)Cerazette (desogestrel-only pill)- 12 hours window period (compared

to conventional POP which allow only 3 hours window)

Vomit (POP)

• If vomit within 2 hours of taking a POP, she should be advised to take another pill.

Injectable Progestogen

• Depo Provera (DMPA) 150mg depot medroxyprogesterone acetate every 12 weeks

• Noristerat (NET-EN) 200mg norethisterone enanthate every 8 weeks

When to start Injectable Progestogen?

• Day 1 to 5 of menses no backup contraceptive method is necessary

• Anytime during the menstrual cycle when patient is sure not pregnant

additional contraceptive method should be used for the next 7 days, ie condom

• Postpartum Maybe initiated up to day 21 postpartum with immediate

contraception cover If initiated after day 21, then condom or avoid sexual

intercourse for the next 7 days.

When to start Injectable Progestogen?

Disadvantages• Changes in menstrual cycle

20% amenorrhoeic 40% menses regularly 40% erractic bleeding

• Delay in return of fertility average of 9-10 months from the date of last injection

• Weight gain (evidence is not strong)

• Headache & dizziness

Disadvantages• Nausea

• Mood changes (depression)

• Hirsutism

• Hyperpigmentation over injection site

• Loss of libido

Missed injection??Come early/late for injection??

IM Depo Provera / IM NET-EN

can be given 2 weeks earlier or late

Intrauterine contraceptive devices (IUCD)

• Non-hormonal Multiload Cu-250 : 3 years Multiload Cu-375 : 5 years

• Hormonal Mirena (LNG-IUS)

Multiload Cu250

Mirena

Risk of IUCD• Uterine perforation 1 in 1000

• Pelvic infection 1 in 100

• Expulsion 1 in 20 particularly within 3 months of insertion

• Abnormal bleeding Cu-IUD: first 3-6 months of insertion Mirena (LNG-IUS): Irregular bleeding first 6 months,

amenorrhoea or light bleeding by 1 year

Contraindication

• Current PID or in the last 3 months

• STD

• Distorted uterine cavity

• Pregnancy

• Unexplained abnormal PV bleed

Timing of insertion● Anytime during the menstrual cycle when you can be sure

that the client is not pregnant

● Postpartum Immediately after expulsion of placenta or after 4

weeks postpartum

● Post-miscarriage Within 48 hours or delay until 4 weeks later

IUCD insertion after 40sWhen to remove?

Off License

Use

Implanon(Progestogen-only Implant)

Choice of contraception should be tailored to her health condition & the couple wish.

Counseling to her involving the spouse will ensure success for contraception & prepregnancy care.

Thank you