Contraception Flashcards
Abortions in London in 2010
Southwark–>2264 Kensington & chelsea 776
Lambeth–>2133 Kingston 675
Lewisham–>1869 Richmond & Twickenham 534
Diagnosing Pregnancy
Symptoms will start to show about 20/40
Beta-HCG can be done with urine or blood
USS is the best to date pregnancy and check for abnormalities
B-HCG
Beta-Human Chorionic Gonadotropin produced by the implanted blastocyst 3-14 days after fertilisation. A small polypeptide which maintains the corpus lutem. Half life of 24hrs and is excreted in urine
Peaks at 7-9 weeks and falls when placenta is established
Pregnancy counselling
If negative and happy - contraception advice
If positive and unhappy - termination referral
If negative and unhappy take full Hx and discuss folic acid/ alcohol/ smoking. If positive and happy as above but register with GP
Contraceptive Use in 2008/9
75% of people using–> condom 25%, COC 16%, progestogen pill 6%, IUD 6%, Withdrawal 4%, Injection 3% and IUS 2%
25% of people not–> Not in heterosexual 13%, sterile from surgery 2%, trying for baby 2%, pregnant 2%, postmenopausal 1%, infertile 1%, abstaining to avoid pregnancy 1%
PEARL index
The number of pregnancies if 100 women use a method for a year Normal use (perfect use)
No contraception
No side effects except pregnancy
85 (85)
Withdrawal
27 (4) - no side effects
Difficult to control and some sperm in precum
Condoms
15 (2) –protective against STIs
Can be difficult or people can be allergic
COC (Combined oral contraceptive pill)
8 (0.3) - reduces bleeding and period pain
Not suitable for women with cardiac RFs. Limited cancer risk (increases risk of breast Ca but reduces risk of uterine and ovarian)
POP (progestogen only pill)
8 (0.3) – can cause pause in periods
Pills must be taken in 24hr window
Can be SEs of irregular bleeding (most common), acne or weight gain
Injection (Medroxyprogesterone acetate, DMPA)
3 (0.3) causes weight gain and delay in return to fertility, mildly protective against PID and uterine Ca
Implant (Nexplanon)
0.05 (0.05) – periods stop in 1/3 women, small procedure to insert/remove
irregular bleeding in 1/3 women with risk of acne and weight gain. Inserted subdermally in the non-dominant arm. The LARC of choice in young people. Can be inserted immediately after a termination of pregnancy
IUD
0.8 (0.2) –small procedure to insert and increased infection risk for 20 days
Periods may get longer and heavier over time
Can use as emergency contraception
IUS (Mirena)
0.1 (0.1) – small procedure to insert, periods may get lighter or stop. 1/3 women get irregular bleeding. First line in menorrhagia if they want contraception.
Fraiser Guidelines
Can give a YP contraception without parental involvement if: (1) The YP can understand the advice, (2) wont talk to parents, (3) is gonna keep having sex, (4) lack of contraception is dangerous to them
Emergency IUD
Useful if timing is incorrect for any other form of contraception –> carries same risk of normal IUD insertion. Can be given 5 days after sex or up to day 19 0f the cycle
Emergency Pill (morning after pill)
can be given up to 3 days after sex but not effective after ovulation. can cause bleeding or nausea
Ullipristal Acetate
A progesterone receptor modulator which can be used up to 5 days after sex – can cause nausea, vomiting, abdo/pelvic/back pain and mood changes
Cannot be used if there was more than one episode of unprotected sex in the cycle
Average annual Cost to the NHS of Long term contraceptions
Oral contraceptive pill--> 79 IUD ---> 48 IUS ---> 70 Implant --> 103 Injection ---> 117
If you have missed 1 COC
1 - take pill as soon as poss and continue as normal
If you have missed 2 COC
If in first wk emergency contraception should be considered if UPSI occured in pill free period or first wk
In 2nd wk no need for emergency contraception
In 3rd wk omit pill free interval
POP missed pill rules
If less than 3hrs take and continue as normal (cerazette has a 12hr period) if >3/12hrs then take pill and continue but use extra precautions for 48hrs.
COC absolute contraindications (UKMEC 4)
>35yrs old smoking >15 a day Migraine with aura Personal Hx of VTE, CVA or IHD or thrombogenic mutation Uncontrolled HTN Breast feeding <6wks post-partum
COC relative contraindications (UKMEC 3)
> 35hrs old smoking35yrs
BMI >35
Thromboembolic disease in 1st degree relative 6months PP
Breast feeding >6wks postpartum
Contraindications for POP (UKMEC 3 & 4)
UKMEC 3 –> active liver disease or past tumour,
P450 inducers,
breast cancer >5yrs ago
Undiagnosed PV bleeding
UKMEC 4 –> Pregnancy or breast Cancer within 5yrs.
Interactions of the COC
Enzyme inducers (rifampacin) will stop it working as well COC will make ACEis work less well Antibiotics like doxycycline and ampicillin can impair the effectiveness because they prevent the microbial recycling of estrogen in the pill from the gut into the blood.
Empty uterus with a positive pregnancy test
A gestational sac should be visible when B-hCG is over 1000, if it is not repeat both tests in 48hrs –> may show a viable intra-uterine pregnancy. If the B-hCG is over 1000 and the uterus is empty it is likely an ectopic.
Drugs which decrease COC levels (enzyme inducers)
Antiepileptics - Carbamazepine, Phenobarbital, Phenytoin Antibiotics - Rifampicin ARVs - Ritonavir St Johns wort Also - Bosentan or aprepitant.
Drugs which increase COC levels (enzyme inhibitors)
ABx - Erythromycin, Antifungal - fluconazole (et al) ARVs - atazanavir Tacrolimus, Etoricoxib Statins - atorvastatin/rosuvastatin Sitaxentan (vasodilator)
Post-partum contraception
Should be started from day 21. Lactational is 98% effective for the first 6months if she is fully breast feeding and amenorrhoeic.
POP can be started any time and is safe in breastfeeding.
COC absolute contraindication breastfeeding <6wks, relative if breastfeeding 6wks to 6months. may reduce milk production. Immediate protection if started on day 21, after this additional protection should be used for 2days (POP) or 7days (COC).
