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    Safe contraception for women with medical conditions


    An implant is Category 2 for placement earlier than 21 days postpartum and Category 1 for placement later than 30 days postpartum even in women with obesity, which is listed as another risk factor for VTE. ACOG also supports the use of immediate postpartum placement of the subdermal implant.19 The evidence of randomized trials is reassuring, showing no negative effects on breastfeeding parameters including duration or exclusivity of breastfeeding, lactation failure, time to lactogenesis, or milk composition.20,21

    DMPA is Category 2 when given within 21 days postpartum and is Category 1 when given more than 30 days postpartum even in women with obesity, which is listed as another risk factor for VTE.

    In several non-randomized trials, administration of DMPA within 48 hours of delivery did not affect breastfeeding continuation or duration or perception of insufficient milk production.22

    CHC is Category 4 when initiated in the 21 days postpartum, then becomes Category 2 when initiated after 42 days postpartum regardless of obesity or other risk factors for VTE. Clinical studies have had differing evidence about the effects on milk volume in women exposed to estrogen-containing contraceptives. The CDC MEC update states that the theoretical effects of combined hormonal contraceptives on breast milk productions are greatest in the first 3 weeks postpartum.4 Studies in the literature have provided more reassurance that CHCs do not affect the onset or duration of breastfeeding nor infant growth parameters.23 In a recent randomized, controlled trial, breastfeeding continuation at 8 weeks was similar between progestin-only and combined oral contraceptive pills when these pills were started at 2 weeks postpartum and infant growth was comparable in both groups.24 So we can conclude that starting CHCs after the recommended 21 days postpartum does not decrease lactation success.

    Postpartum and VTE risk factors

    IUDs (Category 1-2), implants (Category 1), and DMPA injection (Category 1) do not affect the VTE risk postpartum. CHC is Category 4 when started < 21 days postpartum and Category 3 when started 21 to 42 days postpartum and the patient has other risk factors for VTE such as obesity in our patient’s case. Without other risk factors for VTE, CHC is Category 2 when started after 42 days postpartum.

    During the first 6 weeks postpartum, the risk of VTE is increased to 21.5-fold to 84-fold when compared to non-postpartum women.25,26 After 42 days, CHC are Category 1 for non-breastfeeding postpartum women without other additional risk factors for VTE.4 However, a delay in initiating contraceptives should be weighed against the risk of return of ovulation and unintended pregnancy, especially in those women who are not exclusively breastfeeding for whom return of ovulation may be as early as 27 days or as late as 6 weeks.27,28

    Shawna chooses to start the etonogestrel subdermal implant. The implant is MEC Category 1 (obesity, postpartum) and 2 (breastfeeding <21 days postpartum).

    Let us see how the SPR guidelines apply on timing, need for back-up contraception after initiation of method, need for screening tests prior to with initiation of method, or follow-up.


    Neena T Qasba, MD
    Dr Qasba is Family Planning Fellow, Department of Obstetrics, Gynecology, and Reproductive Sciences at Yale School of Medicine, New ...
    Nancy L. Stanwood, MD, MPH
    Dr. Stanwood is Section Chief, Family Planning, and Director, Fellowship in Family Planning, Department of Obstetrics, Gynecology & ...

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    • UBM User
      As an accredited Fertility Educator with Natural Fertility NZ and their Clinical Supervisor it is a real disappointment to see that LAM (lactational amenorrhoea method) was not mentioned or investigated as a valid option for client 1. It has no side effects to the mother or baby and actually promotes breastfeeding.


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