cOGText: Family Planning Flashcards

1
Q

What is the most commonly performed Gynaecological procedure in the UK?

A

abortion

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2
Q

T/F: access to contraception is associated with a reduction in maternal mortality

A

true - unplanned pregnancy is associated with poorer outcomes both for mother and baby

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3
Q

A short inter-pregnancy interval of <12 months is associated with an increased risk of which feotal complications?

A
  • preterm labour
  • foetal growth restriction
  • stillbirth
  • increase in neonatal mortality.
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4
Q

Adolescents who get pregnant have a higher risk of what complications?

A

preterm birth or have low birth-weight babies > more predisposed to neonatal mortality

(children born to adolescent mothers are more likely to get pregnant as adolescents themselves)

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5
Q

LARC methods of contraception? (from most to least effective)

A
  • Progestogen-only implant
  • Levonorgestrel-releasing intrauterine system
  • Copper intrauterine device
  • Progestogen-only injectables
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6
Q

Other methods of family planning? (i.e. non-LARC)

from most > least effective

A
  • Vasectomy
  • Female sterilisation
  • Progestogen-only pills
  • Combined hormonal contraception
  • Female diaphragm
  • Male condom
  • Fertility awareness methods
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7
Q
  1. What is ‘natural family planning’?
  2. There are a number of different indicators which can be used in combination to increase accuracy - what are these known as?
  3. For women with a regular menstrual cycle, ovulation usually occurs ___ days before the start of the next cycle. The egg can generally survive up to ___ hours after ovulation unless it is fertilised, meaning that the sperm has to reach the egg within this time frame for fertilisation to occur.
  4. Length of menstrual cycle can vary and should be measured for at least __ consecutive months.
  5. How should sex be restricted around ovulation and why?
  6. Name some FAM of contraception?
A
  1. Relies on physiological indictors of ovulation to identify when a woman is most fertile in her cycle and subsequently avoid otherwise unprotected intercourse.
  2. ‘Fertility Awareness-based Methods (FAM)’ of contraception
  3. 10-16, 24-48
  4. 3
  5. As sperm can live for up to 7 days in female genital tract, sex should be restricted 7 days before ovulation and at least 2 days after ovulation.
  6. Calendar method (as above). Temperature: ↑ temp 3 consecutive days could indicate that fertility has decreased. Billings method (cervical mucus): A rise in LH and oestrogen cause mucus to be moist, sticky, white and creamy, which indicates the start of the fertile period. Nearer ovulation the mucus becomes more watery and clearer, indicating peak fertility period.
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8
Q
  1. pros of natural family planning?
  2. cons?
A
  1. no side effects, acceptable to all faiths and cultures, avoids hormones, increased awareness of own body and cycle
  2. Less effective, high failure rate, user-dependent, lack of spontaneity in intercourse, menstrual cycle length can be irregular/ change over time (esp around menopause/ menarche), requires constant monitoring, fertility signs may be disrupted by stress, illness, travel, hormonal treatment, certain meds, no STI protection, not effective immediately post-pregnancy (regular cycles don’t resume for at least 3 months),
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9
Q
  1. name 3 barrier methods of contraception
  2. discuss the pros and cons of each
  3. .
  4. .
  5. Describe how the diaphragm is used
  6. T/F: Condoms may also be used with spermicide for additional protection
  7. How should a female condom be worn?
A
  1. male condom, female condom, diaphragm/ cap
  2. Male condom. Pros: protects against STIs, avoids use of hormones. Cons: typical use failure rate if high (18%), highly user-dependent
  3. Female condom. Pros: as above. Cons: as above, also less widely available and harder to use than male condoms and slightly higher failure rate
  4. Diaphragm. Cons: lack of spontaneity around sexual activity, highly user-dependent, no protection against STIs, increased risk of cystitis, requires new diaphragm to be fitted if >3kg weight lost/gained, baby delivered, or a miscarriage or abortion occurs, latex and spermicide can cause irritation
  5. Should always be used with spermicide. Can be inserted any time before sex, but more spermicide is needed if it has been inserted for >3hrs or having sex again (don’t remove diaphragm to reapply spermicide). Needs to be left in place for at least 6 hours after sex (overnight if easier - max 30h)
  6. False - can promote condom breakage and irritant to skin which can increase risk of STI transmission. Should also not be used with oil-based lubricants
  7. Worn inside the vagina, before contact with penis, to prevent semen from entering the cervical canal
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10
Q

Combined Oral Contraceptive Pill (COC)

  1. Describe its mechanism of action
  2. Describe how it is taken
  3. Faiulre rate with typical pill use?
  4. When in the cycle would it be necessary to take contraception at the same time
  5. What about in the post-partum period?
  6. Pill can be started up to __ days after miscarriage or abortion without additional contraceptive precautions
A
  1. Oral pill containing oestrogen and progesterone, which inhibits ovulation and thickens mucus
  2. Traditionally taken every day for 21 days and stopped for 7 days (withdrawal bleed occurs). Many women now have tailored regimens which doesn’t increase side effects and allows better bleeding control, with higher rates of amenorrhoea.
  3. 9% have unintended pregnancy in the first year
  4. If the pill is started within the first 5 days of the menstrual cycle, contraceptive effect starts immediately. After day 5, additional contraception is needed for 7 days after starting the pill.
  5. If started by day 21 post-partum it is immediately effective. If started after day 21, condoms should be used for the next 7 days.
  6. 5
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11
Q
  1. what to do if 1 COC pill is missed?
  2. what about if 2 pills are missed?
  3. what about if the pill has been missed in week 1 and unprotected sex has occurred in the pill free interval?
  4. what about if the pill is missed in week 2?
  5. week 3?
A
  1. Take the last pill, even if 2 pills are taken in 1 day - No additional contraceptive protection needed
  2. Take the last pill even if 2 pills are taken in 1 day and omit any earlier missed pills. Use condoms or abstain from sex until pill has been taken 7 days in a row -
  3. consider emergency contraception
  4. no emergency contraception needed if pill was taken 7 consecutive days before missing the pill.
  5. pills in current pack should be finished and new packed started the next day, omitting the pill free interval
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12
Q
  1. Advantages of COC?
  2. Disadvantages?
A
  1. Treatment for menorrhagia, dysmenorrhea, endometriosis and premenstrual syndrome, reversible contraceptive, reduced risk of ovarian, endometrial and colorectal cancer, may protect against PID, may reduce occurrence of ovarian cysts, benign breast disease, acne vulgaris
  2. no protection against STIs; Should be taken around the same time every day (within 24 hours of last pill); can interact with other meds- liver enzyme-inducing drugs e.g. anti-epileptics; increased risk of cervical and breast cancer, VTE, stroke and ischaemic heart disease (in women with other risk factors); hormonal side effects e.g. HA, nausea, breast tenderness, mood changes, low libido; irregular bleeding – most common in 1st 3/12 us
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13
Q

relative contraindications to COCP?

A

PMH

  • Controlled hypertension
  • Ongoing gallbladder or liver disease
  • Complicated diabetes
  • Gene mutations assoc with breast cancer eg BRACA1/2

FH

  • FH of thromboembolic disease in 1st degree relatives <45 years

SH

  • >35 years old and smoking <15cig /day
  • BMI>35kg/m2
  • Immobility
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14
Q

Absolute contraindications to COCP?

Should be avoided = UKMEC 4

A

PMH

  • Migraine with aura
  • Hx of thromboembolic disease, thrombogenic mutation, stroke or ischaemic heart disease
  • Uncontrolled HTN
  • Current breast cancer
  • Major surgery with prolonged immobilisation

SH

  • >35 y/o and smoking >15 cigarettes/day
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15
Q

Combined Transdermal Patch (CTP)

  1. Mechanism of action?
  2. How is it used?
  3. If patch is started before day __ of the menstrual cycle, contraceptive effect is immediate.
  4. What to do if the patch falls off?
  5. Pros and cons?
A
  1. Relases oestrogen and progesterone through the skin into the blood to prevent ovulation. Also thickens cervical mucus.
  2. Wear 7 days, change on day 8. Continue for 3 weeks, week 4 patch-free to allow withdrawal bleed.
  3. 5 (>day 5, condoms should be used for the first 7 days)
  4. If off for <48hrs, stick it back as soon as possible or use a new patch. Protection against pregnancy remains as long as patch was used correctly for 7 days before it was removed. If removed for >48hrs, a new patch should be started immediately, and additional contraception used for the next 7 days.
  5. as per COCP (may have slightly higher risk of VTE). Contraindications also as per COCP.
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16
Q

Combined Vaginal Ring (CVR)

  1. mechanism of action?
  2. How is it used?
  3. T/F: Sex can continue as normal with the ring in place
  4. If the ring is expelled for __ __, contraceptive protection may be reduced.
  5. What to do if this occurs during week 1 or 2 of the menstrual cycle?
  6. If expulsion occurs during week 3?
  7. T/F: No additional contraception is needed if removal of the ring is delayed up to 1 week (4 weeks of continuous use).
  8. Ring can be inserted on day __ post-partum for immediate contraception.
  9. T/F: Ring can be used immediately after a miscarriage or abortion
  10. pros and cons?
A
  1. Continuous release of oestrogen and progesterone into the bloodstream, preventing ovulation.
  2. Soft, plastic ring that is placed inside the vagina. Should be in for 21 days, removed for 7 to allow withdrawal bleed
  3. true
  4. 3 hours
  5. Additional protection should be used for the next 7 days after the ring is re-inserted.
  6. Insert new ring to start a new cycle, or allow a withdrawal bleed. New ring should be inserted no later than 7 days after the ring was expelled. If insertion of new ring is delayed at the start of a cycle, contraceptive protection is lost, and a new ring should be inserted as soon as possible while using condoms for the first 7 days.
  7. true - 7 day ring-free interval should be started after this and ring re-inserted after this interval.
  8. 21 (After 21 days, condoms should be used for 7 days after insertion)
  9. as per COCP (may have a better bleeding profile. Contraindications also the same.
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17
Q

Progesterone injection

  1. Name 2 types and their route of administration
  2. Administered how often?
  3. mechanism of action?
  4. When can injection be taken postpartum?
  5. T/F: injection can be taken immediately after a miscarriage or abortion and will immediately be effective.
A
  1. Deproprovera 150mg: IM, Sayana Press 104mg: S/C
  2. Every 13 weeks (depo by healthcare provider, sayana self-administered)
  3. Inhibits ovulation and thickens cervical mucus
  4. Injection can be taken any time post-partum if patient is not breastfeeding. If istarted <day>day 21 condoms should be used for 7 days.</day>
  5. True. However, if taken after 5 days, condoms should be used for 7 days
18
Q
  1. pros of progesterone injectables?
  2. disadvantages?
  3. T/F: their contraceptive effective is immediate
A
  1. Long-acting and less user dependent; good for those who can’t use oestrogen containing contraception; can be taken at any point in menstural cycle (long as pt isn’t pregnant); 50% women amenorrhoeic at 1yr; used in treatment of heavy menstrual bleeding, dysmenorrhoea and endometriosis
  2. Injection can’t be reversed once given, no STI protection, delayed return to fertility (up to 12 months), irregular bleeding (usually first 3/12), potential for weight gain (esp in adolescents with BMI >30), can increase risk of osteoporosis (long-term use and those at increased risk), hormonal side effects
  3. If taken in first 5 days of the menstrual cycle, contraceptive effect is immediate (>day 5, condoms needed for 7 days)
19
Q

Progesterone Only Pill (POP) - Desogestrel

  1. Mechanism of action?
  2. How it is taken?
  3. If pill is started up to day __ of the cycle, contraceptive effect is immediate.
  4. After day 5, condoms should be used for the first __ days.
  5. T/F: If switching from combined oral contraceptive, immediate protection is provided
  6. What to do if a pill is missed?
A
  1. thickens cervical mucous and prevents ovulation
  2. Should be taken at the same time every day, without a pill free break
  3. 5
  4. 2
  5. only if continued directly from the end of a pill packet (day 21)
  6. If pill is taken <12 hours later than usual, take pill as per normal. If >12 hours later, take missed pill asap and continue with rest of pack. Use condoms until pill has been taken for 48 hours.
20
Q

Progesterone Only Pill (POP) - Desogestrel

  1. Advantages?
  2. Disadvantages?
A
  1. Few contraindications - can be used by most women who are unsuitable for oestrogen. Reversible immediately on stopping
  2. Irregular bleeding; Diarrhoea, vomiting (assume missed pill); Liver enzyme inducers may reduce effectiveness; No STI protection; Cannot be used if Hx of breast cancer or active liver disease
21
Q

Subdermal Implant (Nexplanon)

  1. Inserted where?
  2. Mechanism of action?
  3. Lasts how long?
  4. Effective how quickly after implantation?
  5. Effective how quickly postpartum?
A
  1. Subdermally, upper arm
  2. Only contains progesterone (etonogestrel). Inhibits ovulation and thickens cervical mucus
  3. lasts 3 years
  4. Immediately effective if fitted within the first 5 days of menstrual cycle. If any other day, additional contraception needed for 7 days
  5. If fitted on or before 21 days post-partum, immediately effective. After day 21, additional contraception is needed for the next 7 days.

NB: Can be inserted at the time of medical or surgical abortion for immediate efficacy

22
Q

Subdermal Implant (Nexplanon)

  1. advantages?
  2. disadvantages?
  3. contraindications?
A
  1. LARC, most effective contraception available, Non-user dependent, Can be used by women unable to take oestrogen e.g. Hx of thromboembolism, migraine, Safe during breastfeeding and postpartum, Can help reduce menorrhagia and dysmenorrhea
  2. Can cause irregular bleeding, esp in first 6/12, Headache, nausea, breast pain, skin changes, Efficacy can be reduced by enzyme-inducing drugs- antiepileptic, rifampicin, No STI protection
  3. Current breast cancer, active/severe liver disease
23
Q

Intrauterine System (IUS)

  1. Mechanism of action?
  2. Effective how soon after insertion?
  3. advantages?
  4. disadvantages?
A
  1. Levonorgestrel-releasing system within the uterus; prevents endometrial proliferation & causes cervical mucous thickening > endometrium less favourable for zygote implantation and harder for the sperm to reach the egg respectively (also physical barrier effect).
  2. 7 days post insertion (immediate if 1st 5 days cycle, within 21 days postpartum, within 5 days abortion/miscarriage)
  3. LARC, amenorrhoeia common, Intermittent light menses and less dysmenorrhoea, Safe during breastfeeding and postpartum, Fertility returns to normal upon immediate removal of IUS, Fewer hormonal side effects than systemic hormonal methods
  4. Spotting weeks/months after insertion (most settle by 6/12), Uterine perforation (2/1000), Increased relative risk of ectopic pregnancy, Small risk of PID (1st 20 days after insertion), risk of expulsion within in the 1st 3/12, No STI protection
24
Q

T/F: foctors (and students) can conscientiously object to the participate in the abortion procedure

A

True

but

they will always have a duty to provide emergency care. It is also important that a woman’s access to abortion is not delayed or prevented by individual conscientious objection.

25
Q
  1. Abortion is legal in the UK under which act?
  2. The most common is Clause C which permits abortion of a foetus up to ___ weeks of gestation under what circumstances?
  3. Abortion is permitted after 24 weeks under what circumstances?
  4. how many signature are required on the legal document for the procedure to be carried out?
A
  1. the 1967 Abortion Act
  2. 24, if the continuance of the pregnancy would involve risk, greater than if the pregnancy was terminated, or injury to the physical or mental health of the pregnant woman or any existing children of her family.
  3. Woman’s life is in danger, severe foetal abnormality, or the woman is at risk of grave physical and mental injury.
  4. 2 registered medical practitioners must sign the legal document, unless it is an emergency procedure (only 1 signature needed)
26
Q

Medical Abortion

  1. achieved how?
  2. When can women choose to administer the medication themselves at home? (with access to 24/7 support)
  3. For pregnancies >10 weeks’ gestation, admission to a hospital or clinic is advised and multiple doses of ____ may be required
  4. Between 11 and 24 weeks, after an initial dose of mifepristone is given, misoprostol can be given ___ (route) or ____ 36-48 hours after up to a maximum of __ doses in 24 hours
  5. Risks of medical abortion?
A
  1. Oral mifepristone (antiprogesterone) > 48hrs later > misoprostol (prostaglandin). Dose/ regimen depends on the gestation.
  2. <10 weeks gestation
  3. misoprostol
  4. vaginally, sublingually, 5
  5. heavy and prolonged bleeding (occasionally blood transfusion), risk of incomplete/ failed procedure (<5%), pain and infection (risk The increase with gestation)
27
Q

Surgical Abortion

  1. what does this procedure involve?
  2. It can be considered up to ___ weeks gestation (differing units have differing protocols and limits)
  3. Procedure <14 weeks?
  4. Procedure >14 weeks?
  5. ______ (vaginal, buccal, sublingual) (or an alternative cervical priming agent) is given to soften and dilate the cervix. This makes the operation easier to perform and reduces risk of complications e.g. trauma to the cervix, uterine perforation.
  6. Other risks of surgical abortion?
    7.
A
  1. Dilation of the cervix and removal of uterine contents (under local/regional/general anaesthetic, or conscious sedation)
  2. 23+6
  3. vacuum aspiration
  4. dilatation and evacuation (not currently available in Scotland)
  5. Misoprostol
  6. same as medical (bleeding, incomplete/ failed, pain and infection) although bleeding and incomplete procedure risk tend to be less common
28
Q
  1. What should always be discussed and facilitated after the procedure?
  2. When should anti-D prophylaxis be recommended?
A
  1. contraception - most methods can be started on the same day as the abortion to provide immediate cover
  2. to Rhesus -ve women having a medical abortion after 9+6 weeks/ surgical abortion at any time
29
Q
  1. Name the 3 types of IUS
A
  1. Mirena, Kyleena and Jaydess
30
Q

Mirena IUS

  1. Releases _____
  2. Provides up to __ years of contraception
  3. Inserted into uterine cavity within __ days of the onset of menstruation
  4. Should only be removed when in the cycle to prevent the risk of pregnancy?
  5. How to ensure continuous contraception when removing the old system?
  6. T/F: can be inserted immediately after abortion
  7. Advantages?
    8.
A
  1. levonorgestrel
  2. 5
  3. 7
  4. within 7 days of the onset of menstruation
  5. New system should be inserted immediately after removal or alternative contraception method should have been initiated at least 7 days before removal
  6. True
  7. Can treat menorrhagia (50% amenorrhoeic after 6/12), dysmenorrhoea, endometriosis, hyperplasia. Can be used with oral/transdermal oestrogen for HRT
31
Q

Kyleena IUS

  1. Licensed for __ years
  2. Releases _____
  3. T/F: Rate of amenorrhoea is less as compared to Mirena
  4. Advantages?
  5. T/F: is also licensed for menorrhagia or as part of HRT

Jaydess IUS

  1. Licensed for __ years
  2. Releases ____
  3. LARGEST/SMALLEST device available
  4. Disadvantage?
A
  1. 5
  2. Levonorgestrel
  3. true
  4. Smaller device - less hormonal side effects
  5. false
  6. 3
  7. Levonorgestrel
  8. smallest
  9. higher rates of irregular bleeding compared to other IUS
32
Q

Copper Intrauterine device (CU-IUD)

  1. Effective how soon after insertion?
  2. Mechanism of action?
  3. Effective for how long?
  4. __% effective in preventing pregnancy
  5. When in the menstrual cycle can they be inserted?
  6. T/F: Fertility returns 2-3 months after IUD is removed
  7. Describe its use as emergency contraception
A
  1. immediately
  2. prevents fertilisation by decreasing sperm motility and survival
  3. either 5 or 10 years (depending on device)
  4. 99
  5. any point -once pregnancy is excluded (can also be fitted immediately after an abortion/ miscarriage)
  6. False - immediately
  7. Inserted with 5 days of UPSI (or up to 5 days after expected day of ovulation in regular cycle e.g. day 19)
33
Q

disadvantages of Cu-IUD?

A
  • periods can be heavier, longer, more painful in first 3-6/12
  • Intermenstrual spotting/bleeding
  • Insertion-related risks (uterine perforation, ectopic pregnancy, PID expulsion)
  • No STI protection
34
Q

Male Sterilisation

  1. called?
  2. what does it involve
  3. T/F: this also has a negative effect on libido, erections and ejaculations.
  4. Semen produced no longer contains ____
  5. Alternative contraception is needed for how long after the procedure?
  6. Failure rate = 1 in 2000
A
  1. Vasectomy
  2. cut/ seal the vas deferens > blocks transport of sperm from the testes to the urethra during ejaculation
  3. false
  4. sperm
  5. until negative semen samples confirmed (samples taken at 12 and 16 weeks post procedure)
  6. ok
35
Q

Disadvantages of male sterilisation? (vasectomy)

A
  • Permanent, should be considered irreversible (reversal procedures not always successful and unavailable on NHS)
  • Procedural-related risks e.g. scrotal pain, swelling, bruising, infection, haematoma
  • Risk of chronic scrotal pain <15%
  • No STI protection
36
Q

Female Sterilisation

  1. What does this involve
  2. Effect on sex drive and hormone levels?
  3. Contraception is necessary for how long after surgery?
  4. Disadvantages?
A
  1. Blocking/sealing the fallopian tubes (clips/ rings/ tying/ cutting) to prevent egg from reaching and fertilising the sperm. Salpingectomy can also be considered.
  2. none - menstrual periods still occur, hormone levels normal
  3. until next period
  4. Should be considered irreversible (reversal procedures less successful than for vasectomy and IVF often required for further pregnancy), Procedural risks e.g. bleeding, infection, injury to other organs, Failure (1/ 200), Relative increased risk of ectopic pregnancy, No STI protection, Menstrual problems may return on discontinuing hormonal contraceptives
37
Q

Emergency contraception (‘post-coital’ contraception)

  1. What three types of method are there
  2. which is the most effective
  3. As no method is 100% effective, what test should be performed 3 weeks after EC to ensure efficacy.
  4. T/F: oral methods have little or no effect once ovulation has occurred
A
  1. 2 oral methods, one intrauterine (Cu-IUD)
  2. Cu-IUD
  3. pregnancy test
  4. true - i.e. in the 2nd half of the cycle.
38
Q

What are the two oral methods of EC?

A

Levonorgestrel and Ulipristal (EllaOne)

39
Q

Levonorgestrel EC

  1. What type of hormone is this?
  2. How many doses are given?
  3. Mechanism of action?
  4. Should be taken how long after UPS?
  5. T/F: Can be used more than once in a menstrual cycle
  6. T/F: Hormonal contraception can be started immediately after
  7. Side effects?
A
  1. progesterone
  2. Single dose - dose doubled for BMI>26, over 70kg, taking enzyme inducing drugs
  3. Delays/prevents ovulation and reduces successful implantation
  4. As soon as possible (efficacy decreases with time). Must be taken within 72 hours
  5. True
  6. True
  7. Disturbance of menstrual cycle (menses may be earlier/ later than expected), N&V - repeat dose if it occurs within 3h of taking the pill, Dizziness, Diarrhoea, Breast tenderness
40
Q

Ulipristal (EllaOne)

  1. Mechanism of action?
  2. Should be taken how long after UPS?
  3. T/F: should be taken asap as less effective over time
  4. T/F: can be taken more than once in the same menstrual cycle
  5. Can it be taken while breastfeeding?
  6. Do not take with _____
  7. Avoid in patients with severe ___ or those taking regular ____ medication
  8. side effects?
A
  1. progesterone receptor modulator - Delays/inhibits ovulation
  2. within 5 days (120 hours)
  3. False - no reduction in efficacy over time as for LNG-EC
  4. False - not recommended
  5. Breastfeeding should be delayed for 1 week after taking EllaOne
  6. levonorgestrel
  7. asthma, antacid
  8. May reduce effectiveness of hormonal contraception (COCP/patch/ring should be started/restarted 5 days after), Menstrual cycle irregularities possible, N&V- repeat dose if it occurs within 3hrs, headache, dizziness, breast tenderness
41
Q

Lactational Amenorrhoea Method (LAM)

  1. what is this?
  2. T/F: is highly effective
  3. what criteria have to be met?
A
  1. a method of postnatal contraception whereby breastfeeding prevents unwanted pregnancy
  2. 98% protection, only if very strict criteria are met
  3. Only up to 6/12 postnatal, exclusive breastfeeding (at least every 4 hours during the day and at least every 6 hours during the night), fully amenorrhoeic
42
Q

Postnatal Contraception

  1. Which forms of hormonal contraception are safe for use during the postnatal period by both breastfeeding and non-breastfeeding women?
  2. In what women should CHC be delayed until at least six weeks postpartum?
  3. T/F: All progestogen-based contraceptives can be initiated at any time after childbirth, regardless of breastfeeding status.
  4. What is Postpartum Intrauterine Contraception insertion (PPIUC)?
  5. Beyond the first 48 hours, IUC insertion should be delayed until at least __ __
A
  1. most are safe - except CHC, should be avoided for first three weeks due to risk of VTE
  2. breastfeeding, those with additional VTE risk factors
  3. true (except depo provera if breastfeeding)
  4. Insertion of Intrauterine contraception immediately after birth – either during c/s or within 48hr of vaginal delivery (either copper or Mirena coils)
  5. 4 weeks