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    Safe contraception for women with medical conditions

     

    Timing

    The implant can be inserted at any time the provider is reasonably certain that the woman is not pregnant.6 One of the criteria is if she is within 4 weeks postpartum.6 With changes in billing and reimbursement policies, many practices are now able to offer patients inpatient postpartum initiation of IUDs and the implant.29,30

    Need for back-up contraception

    If the implant is inserted immediately postpartum prior to hospital discharge, no back-up contraception method is required.6

    Screening before or with insertion

    In healthy women, no tests or exams such as a Pap smear or screening for sexually transmitted infections (STIS) are required prior to implant insertion. Some women may perceive weight gain after implant insertion. However, recent evidence from the CHOICE project, however, demonstrated that the implant is not associated with weight gain.8 Obtaining a baseline weight and BMI could help correlate perceived weight gain with objective data.6

    Follow-up

    No routine follow-up is required; however, a woman should seek medical advice if she wants to discuss any side effects or problems she has experienced with her contraceptive method. Assessment of a woman’s satisfaction with her contraceptive method and any changes in health status or initiation of medications should be on-going to confirm the safety of her contraceptive method. The only Category 4 condition for the implant is current breast cancer. If this patient were to develop breast cancer, the implant should be removed.4

    Shawna has the implant inserted postpartum before being discharged home with her newborn and she does well postpartum. She is reminded to attend her routine postpartum visit and well woman exams. She is reminded that the implant has enough hormones to prevent pregnancy for up to 4 years but can be removed any time before that if desired.31

    Case 2

    Jillian is a 23-year-old gravida 0 who desires to initiate a new contraception method. She uses condoms 100% of the time but 2 days ago a condom broke. Her last menstrual period was 2 weeks ago and her urine pregnancy test is negative. She has a history of migraine headaches and history of pelvic inflammatory disease (PID) 3 years ago. She does not desire to become pregnant as she just started a new job and is looking to go back to school. What are the contraceptive options available for her? She has 4 main issues in selecting safe contraception: need for emergency contraception, nulliparity, headaches, and a history of PID (Table 2).

    Emergency contraception

    Emergency contraception (EC) should be provided as soon as possible after unprotected intercourse for women wishing to prevent pregnancy. The copper IUD is the most effective form of emergency contraception. It can be inserted up to 5 days after unprotected intercourse to prevent pregnancy in women without other contraindications to IUDs and it can be used up to 10 years for ongoing contraception. Oral ulipristal acetate is another effective form of EC; effective up to 120 hours after intercourse it is available by prescription only. Oral levonorgestrel is labeled for use up to 72 hours but has decreasing efficacy from 72 to 120 hours. Levonorgestrel EC pills are available over the counter in all states for women of reproductive age. The CDC MEC identifies no conditions for which the risks of levonorgestrel emergency contraceptive pills outweigh the benefits. Provision of timely copper IUD insertion for EC may be logistically challenging.32

    Nulliparity

    Both types of IUD are Category 2 and all other methods are Category 1.

    Nulliparous women have higher levels of satisfaction with IUDs compared to oral contraceptive pills and high continuation rates.33,34 There is no increased risk of PID in nulliparous IUD users, nor is IUD use associated with subsequent infertility.35

     

    Headaches

    First, establish exactly what type of headache the patient has. The International Headache Society established criteria for migraine headaches with and without aura.36A migraine without aura needs to be a recurring headache with at least 5 episodes that fulfill the following criteria:

    • Episodes that last for 4–72 hours, and

    • At least 2 of the following: unilaterality, pulsating quality, moderate or severe pain intensity, and

    • At least 1 of the following: nausea/vomiting, photophobia, and phonophobia, not attributed to another disorder.

    Symptoms of migraines with aura include the previous list and at least 2 episodes that meet the following criteria:

    • Aura that involves at least one of following: transient visual symptoms (spots, flashes of light) or transient loss of vision or transientsensory symptoms (pins and needles) or transient speech disturbances, and

    • At least 2 of following: unilateral visual symptoms or sensory symptoms, one of more aura symptom develop gradually over 5 minutes, or each aura symptoms lasts between 5 and 60 minutes.36

    The copper IUD and the LNG IUD are Category 1. CHC is Category 4 for migraines with aura.

    A migraine headache with aura at any age is Category 4 for initiating estrogen-containing methods due to the association between estrogen, migraines, and increased risk of stroke.37

     

    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 & ...

    1 Comment

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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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