Postpartum Contraception: Ways to avoid VTE
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.