Family planning

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Prepregnancy Care & Ensuring Success For Contraception O&G Update 2014 Hospital Sarikei, Sarawak [email protected]

Transcript of Family planning

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Prepregnancy Care & Ensuring Success For Contraception

O&G Update 2014Hospital Sarikei, [email protected]

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Contraception is a stepping stone for

effective prepregnancy care especially for high

risk women

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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

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Types of contraception● Hormonal

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

● Intrauterine contraceptive devices

● Barrier method

● Permanent sterilisation (BTL, Vasectomy)

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Combined Oral Contraceptives Pills (COCP)

● Contains 2 types of hormones

-> estrogen & progesterone

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COCP

Examples of COCP available in Malaysia:

•Regulon

•Rigevidon

•Microgynon

•Mercilon

•Marvelon

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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

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When to start COCP?

Postpartum

1. Fully breastfeeding-> 6 months postpartum

2. Not breastfeeding

-> 3weeks postpartum

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Non-contraceptive benefits

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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

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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

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Relative Contraindication WHO Category 2&3

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

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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

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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

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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.

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Progestogen only pills (POP)

- Contains synthetic progestogen only, NO ESTROGEN.

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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

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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.

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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

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Missed pills(POP)

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

to conventional POP which allow only 3 hours window)

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Vomit (POP)

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

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Injectable Progestogen

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

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

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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

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• 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?

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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

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Disadvantages• Nausea

• Mood changes (depression)

• Hirsutism

• Hyperpigmentation over injection site

• Loss of libido

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

IM Depo Provera / IM NET-EN

can be given 2 weeks earlier or late

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Intrauterine contraceptive devices (IUCD)

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

• Hormonal Mirena (LNG-IUS)

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Multiload Cu250

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Mirena

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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

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Contraindication

• Current PID or in the last 3 months

• STD

• Distorted uterine cavity

• Pregnancy

• Unexplained abnormal PV bleed

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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

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IUCD insertion after 40sWhen to remove?

Off License

Use

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Implanon(Progestogen-only Implant)

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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.

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Thank you