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Postpartum Contraception: Ways to avoid VTE

Under conditions of stasis, hypercoagulability and/or endothelial injury, deep vein thrombosis may occur in the veins of the leg, such as the femoral or popliteal veins. This can result in VTE, a risk that may be further exacerbated by the use of certain postpartum contraceptives. (ILLUSTRATION FOR CONTEMPORARY OB/GYN BY 3FX, 3D LIFE SCIENCE ANIMATION AND EFFECTS)
Postpartum contraception is essential for any new mother wishing to space pregnancies or limit family size, but it is often confusing for the provider and patient to navigate the evolving recommendations for the best method of postpartum birth control. The World Health Organization (WHO) and the United States Centers for Disease Control and Prevention (CDC) have published guidelines on contraception in the postpartum period that can assist in choosing the right plan for your patient. The CDC guidelines, which are more recent than the WHO document and more familiar to clinicians, will be referenced in this discussion.

Choosing or planning a method of postpartum contraception ideally should be done during the antenatal period to allow adequate time for discussion about the various options available. Antenatal counseling is also necessary to obtain consent for those options, such as tubal ligation, that require a decision before the admission to labor and delivery.

The definitive contraceptive plan should be determined after delivery and before discharge if it was not decided during antenatal care. Indeed, the majority of women will initiate sexual intercourse before the 6-week postpartum visit, and the earliest reported ovulation occurs at 25 days postpartum in nonbreastfeeding women.1-3 Therefore, contraception should be initiated before the conventional 6-week follow-up visit to prevent unintended pregnancy. Some authorities have even suggested that the postpartum visit should occur at 3 weeks after delivery to ensure that contraceptive needs are met.1 Further advantages of moving the postpartum visit include earlier screening for depression and lactational issues.

Among the many considerations when deciding on an appropriate method of postpartum contraception are the impact of the contraceptive on breastfeeding and the risk of postpartum venous thromboembolism (VTE). These two issues have influenced the recommendations of the CDC.

Whether or not a woman chooses to breastfeed, and for what period of time, will largely determine the contraceptive options available to her. The evidence surrounding the impact of various methods on lactation and infant growth has been conflicting. Recent systematic reviews may provide insight on how to counsel patients, as discussed below. Given the well-known maternal and infant benefits of breastfeeding, patients should be encouraged to breastfeed if possible and to choose a contraceptive that meets their contraceptive and lactational goals.

The main clinical concern about contraception for puerperal women is the risk of VTE. One recent review reported that the risk of VTE during the first 6 weeks postpartum ranges from 25 to 99 per 10,000 woman-years, which represents a 22- to 84-fold increase compared with controls.4 Risk of VTE may be further increased by delivery complications, anemia, inherited thrombophilias, cesarean delivery, smoking, obesity, age greater than 35 years, infection, preeclampsia, and transfusion.4-7 Fortunately, this risk declines rapidly in the first 21 days postpartum and returns to near baseline by 42 days after delivery4 (Figure 1). For nonlactating women, VTE risk is the prominent issue when deciding on a contraceptive method because the potential impact on lactation is not a consideration. Furthermore, nonlactating women will return to fertility sooner than their breastfeeding counterparts and, as stated previously, they may start ovulating as soon as 25 days after delivery. Therefore, their need for contraception is potentially more critical before the 6-week postpartum visit, and a plan should be decided upon before discharge.

This article describes the contraceptive options available to lactating and nonlactating women, taking into account the impact of the method on lactation and VTE risk and citing the recommendations in the CDC guidelines.

The plantiff alleged that because of fetal bradycardia and late decelerations, an earlier cesarean delivery should have been urgently or emergently performed, and that the failure to do so resulted in hypoxic ischemic anoxia and brain damage to the fetus. She further alleged that because she had been placed on fetal monitoring, the L&D physician and nurses may have delayed the cesarean delivery by considering a trial of labor. She also asserted that the FHR under 100 bpm at the time of delivery suggested a prolonged period of bradycardia and that the 1-minute Apgar score of 3 was consistent with perinatal asphyxia.

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The proportion of teenage girls who use hormonal contraceptive methods other than the pill during their first sexual encounter increased significantly from 2% in 2006 to 6% in 2010, according to a report from the Centers for Disease Control and Prevention. In the most recent period, 78% of females and 85% of males used contraception at their first sexual encounter. Eight in 10 males used a condom, an increase of 9% since 2002, and it remained the most common contraceptive choice. Dual contraceptive use at first sex-a condom combined with a partner's hormonal contraceptive-was 16%. an increase of 6%.

To say I am frustrated by the failure of the Joint Select Committee on Deficit Reduction (aka the "super committee") to reach a sensible plan to reduce the federal government's crushing debt is an understatement. Ostensibly fueled by conservative intransigence over tax increases and liberal immobility over entitlement reform, it seems that the net effect is continued governmental paralysis amid the greatest intergenerational wealth transfer in history.