Ch. 10 - Pregnancy and STI

Question 1

Pregnancy and STIs

Answer 1

• Unprotected sex can lead to pregnancy and STIs
• ~49% of pregnancies are unintended
• 19.7 million + are infected each year with new STIs
• $16 billion in costs per year
• Repeat pregnancies may be indicative of inadequate contraception use
• 1 in 4 teenage girls are infected with 1 or more STIs
• Increase pregnancy and STI risk in older population, especially when non-monogamous

Question 2

Pregnancy/STI Pathophysiology

Answer 2

• Only when a viable eff is available to be fertilized by sperm
• Conception has a 6-day window starting 5 days after ovulation
• Risk of pregnancy from unprotected sex during period ranges from 5-45%
• STIs contracted with infected genital tissue, mucus membranes, and/or body fluids
• Women more likely to develop reproductive consequences from STIs
• Pregnancy-related complications increase with STIs
• Transmission rates differ between sexes

Question 3

HPV

Answer 3

• STI that can cause cervial, penile, anal, throat, and other cancers
• 100 different types of virus
• Type 16 & 18 cause 70% of cervical cancers, Types 6 & 11 cause 90% of genital warts
• 14 million new cases each year
• Gardasil (quadvalent) - targets types 6, 11, 16, and 18, indicated for girls and boys 9-26 y.o., 3 doses
• Cervarix (bivalent) - only targets types 16 and 18, indicated for girls/women 9-25 y.o., 3 doses
• Need all 3 doses for maximum immunization
• Works better before having intercourse
• ACIP recommends giving vaccine to 11-12 y.o. girls
• ASE: irritation, malaise, and syncope (monitor for at least 15 minutes post-injection)

Question 4

Hepatitis B

Answer 4

• Can cause long term complications including hepatitis, cirrhosis, hepatic carcinoma, and death
• Can be spread be coming in contact with blood, body fluids, or during sex
• Inactivated, injectable vaccine administered at 0, 1, and 6 months
• Recommended routine vaccination for all infants but also given to kids and adolescents
• Adults who meet risk criteria like multiple sexual partners, injection drug users, HC & ER response personnel, diabetics, end stage renal disease, or drug/HIV treatment facility dwellers can also be given the vaccine
• Can be given by pharmacist depending on state law and age limits

Question 5

Contraception

Answer 5

• Prevent unintended pregnancies and STIs with minimal adverse side effects
• No contraceptive method is 100%
• Effectiveness is reported in accidental pregnancy rate in the first year through perfect use and first year of typical use
• Perfect use is indicative of method’s theoretical effectiveness
• More realistic use includes pregnancies due to incorrect or inconsistent use
• Effectiveness increases as method use increases
• Abstaining from sex or involvement in long-term monogamous sexual relationships with an uninfected partner are most effective for not getting STIs
• Best method = preventative strategies in conjunction with selective contraceptives

Question 6

Selection of Contraception

Answer 6

• Acceptability is vital for consistent and correct use
• Factors affecting acceptability: user’s religious beliefs, future reproduction plans, product effectiveness, partner’s preference/support, degree of interruption of spontaneity, ease of use, accessibility, and cost
• Go over these factors with patients and their possible adverse reactions or affects on future conception

Question 7

Male Condoms

Answer 7

• Most important barrier defense against STIs
• Must meet FDA performance standards for strength and integrity
• Breakage may range from 0-22% and could be user or manufacturing error
• Use of lube is questionable
• Two studies reported SIGNIFICANTLY high preggo rates with non-latex condoms
• Only use non-latex in those with latex allergies
• Failure rates decrease with increased use, starts at 15%
• Spermicide condoms discourages due to possible irritation and no additional STI prevention benefits

Question 8

Latex Condoms

Answer 8

• Come in various sizes, colors, styles, shapes, etc.

- Range from 25 cents to $1.50 each

Question 9

Polyurethane condom

Answer 9

• Conducts heat well, but not as elastic as latex
• Not degraded by oil-based products
• $1.50-2.50 each

Question 10

Polyisoprene Condoms

Answer 10

• More elastic than Polyurethane
• Degraded by oil-based products
• $1.50-2.50 each

Question 11

Lamb Cecum Condoms

Answer 11

• Only for preggo prevention
• Pores may allow passage of STI viral organisms
• Conducts heat well, not degraded by oil, strong
• ~$3 each

Question 12

Behaviors Increasing Condom Breakage

Answer 12

1. Incorrect placement of condom/failure to squeeze air from the tip
2. Use of oil-lube with latex condoms
3. Reuse of condoms
4. Increased duration, intensity, or frequency of coitus
5. Prior history of condom breakage/slippage
6. History of STIs
7. Contact with sharp objects
8. Self-reported problem with condom fit

Question 13

Condom Storage/General Information

Answer 13

• Keep packaged condoms in package until use and protect from light and excessive heat
• Expiration: 3-5 years
• Discard condoms that are discolored, brittle, or sticky
• Encourage different style or brand use if condom was disliked by a patient
• Use of thin, ridged, non-latex, or natural condoms with monogamous, non-STI partner may alleviate complaints of decreased sensitivity

Question 14

Female Condoms

Answer 14

• FC2 approved in 2009, made of nitrile, took place of FC1
• Outer ring, sheath, or pouch that fits over vaginal mucosa and cervix
• One time use
• $2 each
• Higher slippage rates but less breakage
• Perfect user failure rate: 0.8-2.5%, initial rate: 12.5%
• Equal efficacy as male latex condoms for STI transmission
• Store at room temperature in unopened packages
• Can be placed up to 8 hours before sex
• Complaints: vaginal irritation, increased noise (squeaking), decreased sensitization, and increased discomfort
• Don’t use with male condom, could increase friction and breakage

Question 15

Vaginal Spermicides

Answer 15

• Surface active agents that immobilize or kill sperm
• Also a physical barrier when gel/foam
• Nonovynol-9 - in all spermicides in the U.S.
• Efficacy improves greatly when used with barrier contraception
• Not proven to reduce STI transmission, may actually increase STI risk
• May leave an unpleasant taste for oral sex
• Frequent use of high concentration spermicides may irritate or damage vaginal/cervical epithelium which could increase STI risk
• No notable increased risk of birth defects/miscarriages
• Condoms + spermicides may have similar efficacy rates as oral contraceptives and UTIs
• Don’t use in women with anatomic abnormalities

Question 16

Vaginal Gels

Answer 16

• “Jellies”
• Can use with latex condoms
• Applicators for convenience
• Can be prefilled
• Use higher concentrations for better outcomes

Question 17

Vaginal Foams

Answer 17

• Distributes more evenly and adhere better to cervix/vaginal walls
• Less lubrication
• Hard to tell when container is empty

Question 18

Vaginal Suppositories

Answer 18

• Solid or semisolid
• Activated by moisture
• Incomplete dissolution can cause a gritty sensation
• May be better to refrigerate in warm climates

Question 19

Contraceptive Film

Answer 19

• Paper thin
• Activated by vaginal secretions
• One film per intercourse
• Don’t place over dick, more likely to be improperly placed and have not enough dissolution time
• Most difficult to use but the least messy

Question 20

Contraceptive Sponge

Answer 20

• Small, circular, disposable sponge made of polyurethane and spermicide
• Mechanical barrier, spermicide, and absorbs sperm
• Ranges $5-8 per sponge
• Failure rate: 17.4-24.5%
• Increased failure rate in those who have given birth before
• If dislodged during sex, efficacy decreases
• Doesn’t protect against STIs, may increase the risk of HIV due to ulceration
• Must locate cervix and place sponge correctly over it
• Can be placed up to 24 hours before sex, must stay in 6 hours after sex
• May be hard to remove and fragment upon removal
• Vaginal dryness reported
• Increase risk of toxic shock syndrome
• Don’t use in those on period, <6 weeks postpartum, or has a history of TSS
• Don’t leave in for more than 30 hours
• Fragments may cause infection if not removed
• CI: parous women (difficulty covering cervix)

Question 21

Emergency Contraception (EC)

Answer 21

• Hormones in tablets or non-hormonal copper IUD
• Prevents pregnancy within 3-5 days of unprotected sex
• Hormones: progestin only, estrogen + progestin, or selective progesterone receptor modulator
• Currently Rx and OTC
• No progestin+estrogen products available
• Recommend health care appointment and law enforcement reporting if sexual assault involved

Question 22

Ella

Answer 22

• 30 mg ulipristal acetate
• Selective progesterone receptor modulator
• Rx only
• Works up to 5 days after sex
• Similar counseling to progestin products

Question 23

Plan B and Derrivatives

Answer 23

• Levonorgestrel tablet, 1 or 2 tablet plans
• $40-50 for single use
• Increased effectiveness when also taking birth control
• Mainly inhibits ovulation, but can also increase mucus secretions to block sperm/egg transport
• Available OTC for 18+ in 2006, 17+ in 2009, 2013 the age limitations removed and is available for all ages (under 17 need Rx)
• Need to take within 3 days of sex, may be effective at day 5 too
• Give ASAP and take 2nd dose (if there is one) in 12 hours
• ASE: N/V (more prominent when taking birth control), headaches, breast tenderness, and dizziness
• May use antiemetic 60 min. before dose to reduce this
• If you vomit within 1-2 hours of taking medication, need to retake dose

Question 24

Copper IUD

Answer 24

• Use up to 5-7 days after unprotected sex

- Can be inserted up to day 8 but usually limited to 5 days after sex by medical professionals

Question 25

Fertility Awareness Methods

Answer 25

- Don't use chemicals or barriers - Include calendar methods, cervical mucus methods, symptothermal methods, and lactation amenorrhea method (LAM) - Usually chosen since no health risks, costs, or effects on religious preferences - Lacks STI protection and efficacy - May need condoms for fertile days

Question 26

Calendar Methods

Answer 26

- Use menstrual cycle to calculate fertile periods - Since cycles vary, record them for 6-12 cycles to predict the range of fertile days - Rhythm Method: first fertile days = # days of shortest cycle - 18; last fertile day = # days of longest cycle - 11 - Not good for irregular cycles - Standard Days Method: good for only cycles between 26-32 days, avoid intercourse days 8-19 or use contraception during these days - Can use software to help track cycles

Question 27

Cervical Mucus Methods

Answer 27

-Relies on consistent cervical mucus changes to take place during menstrual cycles

Question 28

Billings Ovulation Method

Answer 28

- Observes cervical mucus daily and charts character/amount - Most get vaginal dryness post-period - 5-6 days before ovulation, estrogen increases and causes increased clear, elastic secretion similar to raw egg whites, last day of this occurs within a day of ovulation (peak symptom) - As progesterone raises with ovulation, secretions become thick, sticky, or absent - Avoid sex the first day mucus is detected after period to 4 days after peak symptom appears - Inform about gels, creams, or douches that interfere with cervical mucus

Question 29

Creighton Model

Answer 29

- Similar to Billings Ovulation but has a more standardized definition of cervical secretions - Involves the male partner - Requires training

Question 30

Two-Day Method

Answer 30

- Monitor secretions on a daily basis - Any secretions that day and the day before means likely fertile - No secretions means likely infertile - More simplistic method

Question 31

Symptothermal Method

Answer 31

- Combines fertility awareness methods - Track secretions and BBT - Secretions show onset of fertile period - BBT shows end of fertile period - Need to record temperature every morning, preferably with a digital thermometer calibrated to 0.1 degree Fahrenheit - Must record before getting out of bed at the same time every day - Need at least 3 hours of uninterrupted sleep - Can be oral, vaginal, or rectal measurements, but has to be the same EVERY time - In some, BBT drops 12-24 hours before ovulation and rises by at least 0.4 degrees at ovulation - Infertile period: 3 days of raised temperature until the end of menses - Some women don't get the temperature changes and outside factors can affect BBT - Those with rotating shifts may not be able to meet sleep and measurement requirements and should use a different method

Question 32

Home Ovulation Predictions

Answer 32

- Designed to aid in conception by detecting surge in lutenizing hormone before ovulation - Urine kits that detect this hormone's increase that occurs 8-40 hours before ovulation - Not accurate enough to use to avoid pregnancy

Question 33

LAM

Answer 33

- Used to space birth of children - In first 6 months, mom is BF and is amenorrheic, protect 98% of population from pregnancy - Need frequent, suckling action for protection so breast pumps don't provide the same protection - Use additional contraception if you get your period, are supplementing the infant's diet elsewhere, or are >6 months postpartum - Preggo rates with LAM: 0.5-2%

Question 34

Effectiveness of Fertility Methods

Answer 34

- Overall preggo rate of FAB: 24%, higher than all others - No STI protection, so better for monogamous partners - FAB with specific pre and post ovulatory descriptors have better outcomes (perfect use failure: 5%)

Question 35

Coitus Interruptus

Answer 35

- Pulling out - Withdrawal during sex when ejaculation is imminent - Can have failure from involuntary preejaculation secretions - No STI protection - Disadvantages: self-control needed by man, potential for decreased pleasure for couple - Perfect use: 4%, typical use: 22%

Question 36

Assessment

Answer 36

- Identify level of knowledge about pregnancy and STI risks - Those who prefer FAB need to understand the reproductive cycle - Non-Rx contraceptive users need to know how to use them properly and be ready to use them EVERY time - Help based on timing of use, religious restrictions, and cultural preferences

Question 37

Counseling

Answer 37

- Discuss specific diseases and prevention strategies - Consult both partners if possible - Be familiar with proper use of non-Rx contraceptives and remove conversation barriers - Provide info on pregnancy and STIs in an accessible area - Can also help them gain access to other needed medical or social services - Special efforts to get adolescents accurate information, send to specialized clinics if uncomfortable in giving this information - Recognize present stigmas and misinformation - FAB need extensive education and training and should be for stable couples, may also need special equipment for these methods