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Contraception > Contraception in special groups (post partum, obesity) > Flashcards

Contraception in special groups (post partum, obesity) Flashcards

1
Q

When to start contraception after childbirth

A

By 21d
Can be immediately after if med eligible

Intrauterine contraception and the implant can be inserted immediately after delivery - IUC 0-48h after birth (UKMEC 1) , limited evidence between 48h and 4w so avoid (UKMEC 3). Is UKMEC 4 in postpartum sepsis.

NB insertion after childbirth is assoc with higher expulsion rates

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2
Q

How long should a woman wait before trying to conceive again?

A

interpreg interval of less than 2mo is assoc with preterm birth, low birthweight

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3
Q

What methods can be offered after birth 0-6w

A

IUC (0-48h, >4w) and progestogen only methods (pill, injection, implant)
Safe in breast and non breast feeding women

the dmpa injection is UKMEC 2 (?VTE) in first 6w after childbirth, other progesterone methods are UKMEC 1 in first 6w

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4
Q

0-6w, breastfeeding - what is UKMEC for:
POP
Implant
DMPA
CHC

A

POP-1
Implant -1
DMPA-2
CHC-4 (wait for 6w)

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5
Q

0 - <3w, non-breastfeeding - what is UKMEC for:
POP
Implant
DMPA
CHC
with vs without other risk factors for VTE

A

POP- 1/1
Implant- 1/1
DMPA- 2/2
CHC- 4/3

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6
Q

3 - <6w, non-breastfeeding - what is UKMEC for:
POP
Implant
DMPA
CHC
with vs without other risk factors for VTE

A

POP- 1/1
Implant- 1/1
DMPA- 2/2
CHC- 3/2

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7
Q

> 6w, non-breastfeeding - what is UKMEC for:
POP
Implant
DMPA
CHC

A

POP - 1
Implant - 1
DMPA - 1
CHC - 1

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8
Q

> 6w to 6 months, breastfeeding - what is UKMEC for:
POP
Implant
DMPA
CHC

A

POP-1
Implant-1
DMPA-1
CHC-2

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9
Q

> 6mo, breastfeeding - what is UKMEC for:
POP
Implant
DMPA
CHC

A

POP - 1
Implant - 1
DMPA - 1
CHC - 1

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10
Q

What UKMEC considerations are needed for which contraceptions in which pregnancy related conditions?

A

High BP during pregnancy
Pregnancy related cholestasis
Diabetes

All methods are UKMEC 1 apart from CHC which is a UKMEC 2 for high BP and preg related cholestasis

Also need to consider the standard medical considerations e.g. obesity, hypertension, dyslipidaemias

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11
Q

Conditions needed for LAM

A

less than 6mo post partum
amenorrhoeic
fully breast feeding (every 4 hours in day and 6 hours at night)

is highly effective

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12
Q

UKMEC criteria for the different contraceptives in people who have positive antiphospholipid antibodies or thrombotic mutations

A

the only ukmec 1 is cu-iud
all the rest are ukmec 2
APART FROM CHC which is ukmec 4

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13
Q

Gestational trophoblastic disease UKMEC criteria

A

undetectable hcg levels - ukmec 1 for all
decreasing hcg levels - all IUC = UKMEC 3. Rest =1
persistently elevated hcg or malignant disease - all IUC = UKMEC 4. rest =1

this is because of an increased risk of perforation and dissemination of the tumour by insertion

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14
Q

What BMI is considered overweight and what is obesity

A

> 25-29.9 = overweight
=30 = obese

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15
Q

What specific conditions would you want to ask about in someone who is overweight?

A

They are at increased risk of:
VTE/ATE
HTN
T2DM
Some cancers - endometrial and breast

Ask if:
- they have had any previous or planned operations - bariatric surgery, extended period of immobility
- on any weight loss medications incl OTC

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16
Q

How to approach subject of increased weight?

A

Ask permission
Raise subject of weight
Enquire whether weight/ BMI is of concern
Signpost to appropriate support for weight and management if wanted

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17
Q

UKMEC category for:
- Combined contraception
1. BMI >=30-34 alone vs with additional RF for CV disease
2. BMI >=35 alone vs with additional RF for CV disease

A

BMI >=30-34 alone –> UKMEC 2
With additional RF for CV disease –> UKMEC 3

BMI >=35 alone –> UKMEC 3
With additional RF for CV disease –> UKMEC 3

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18
Q

UKMEC category for:
- POP
1. BMI >=30-34 alone vs with additional RF for CV disease
2. BMI >=35 alone vs with additional RF for CV disease

A

BMI >=30-34 alone –> UKMEC 1
With additional RF for CV disease –> UKMEC 2

BMI >=35 alone –> UKMEC 1
With additional RF for CV disease –> UKMEC 2

(Same as implant & LNG-IUS)

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19
Q

UKMEC category for:
- Implant
1. BMI >=30-34 alone vs with additional RF for CV disease
2. BMI >=35 alone vs with additional RF for CV disease

A

BMI >=30-34 alone –> UKMEC 1
With additional RF for CV disease –> UKMEC 2

BMI >=35 alone –> UKMEC 1
With additional RF for CV disease –> UKMEC 2

(same as POP & LNG-IUS)

20
Q

UKMEC category for:
- Progestogen injectable
1. BMI >=30-34 alone vs with additional RF for CV disease
2. BMI >=35 alone vs with additional RF for CV disease

A

BMI >=30-34 alone –> UKMEC 1
With additional RF for CV disease –> UKMEC 3

BMI >=35 alone –> UKMEC 1
With additional RF for CV disease –> UKMEC 3

Differs to POP and injection as UKMEC increases to 3 when add in extra RF

21
Q

UKMEC category for:
- Cu-IUD
1. BMI >=30-34 alone vs with additional RF for CV disease
2. BMI >=35 alone vs with additional RF for CV disease

A

UKMEC = 1 for all

22
Q

UKMEC category for:
- LNG-IUS
1. BMI >=30-34 alone vs with additional RF for CV disease
2. BMI >=35 alone vs with additional RF for CV disease

A

BMI >=30-34 alone –> UKMEC 1
With additional RF for CV disease –> UKMEC 2

BMI >=35 alone –> UKMEC 1
With additional RF for CV disease –> UKMEC 2

(same as Implant & LNG-IUS)

23
Q

What contraceptive methods need special consideration due to increased BMI? [6 points]

A
  1. DMPA injection (UKMEC 3 if additional CV RF) - associated with weight gain esp in under 18 and BMI >30 (NB there is no evidence relating to weight gain for the others)

CHC:
2. The patch may be less effective in women >90kg
3. Ovarian activity could be greater in women with obesity so continuous use without a HFI may be considered
4. UKMEC 3 if BMI >35

EC:
5. LNG-EC may be less effective for BMI >26 / weight >70kg
6. UPA-EC may be less effective for BMI >30 / weight >85kg.
If Cu-IUD not suitable can offer double does LNG or normal dose UPA. Evidence = not sure which is better.

These have no change in approach: IUC, progestogen implants, POP, Cu-IUD EC

24
Q

Weight loss medication and contraception - any considerations?

A
  1. Currently approved meds for weight loss are orlistat, liraglutide, naltrexone/bupoprion –> no known interactions with contraceptives
  2. Can induce diarrhoea - may have reduced absorption of OC (same with laxatives)
25
Q

If women are considering weight loss surgery what do we need to tell them?

A
  1. Have a contraceptive plan
  2. Avoid pregnancy for 12-18 months after or during significant weight loss
  3. Surgical procedures could reduce absorption of OC and oral EC = decreased contraceptive effectiveness. Use non oral methods.
  4. If on CHC - STOP FOR 4 WEEKS PRIOR - increased VTE risk! Switch.
  5. IUC and IMP = safe after surgery.**
  6. DMPA and bariatric surgery both assoc with reduced BMD so consider others
26
Q

What age should women stop contraception

A

No specific age - until menopause. Preg is rare after 50 but not impossible.

27
Q

What do women need to be warned about with regard to pregnancy at later age

A

Pregnancy and childbirth after age 40 confer a greater risk of adverse materal and neonatal outcomes that in women under 40

higher rates of
- post partum haemorrhage
- placenta praevia
- gestational diabetes
- preg induced hypertension
- c section
- miscarriage
- ectopic
- still birth, perinatal mortality

28
Q

What is the primenopausal period, and what are some perimenopausal symptoms

A

the phase preceding menopause, and ending 1 year after the LMP. Usually starts mid to late 40s and lasts 4-5 years.

Many symps assoc wit estrogen levels, some opt to take HRT.

  • vasomotor symptoms - hot flushes, night sweats, mood change, anxiety, sleep disturbance, tiredness
  • joint pain
  • severe migraines
  • irregular bleeding - REFER TO GYNAE if HMB, postcoital bleeding, intermenstrual bleeding
  • loss of libido - EXPLORE, is multifactorial - family life, stress, body image. Many women start to experience vaginal dryness, bladder problems too.
29
Q

What age related diseases can develop after 40 and need consideration w/r to contraception?

A

CVD
Breast, endometrial and ovarian cancer increase with age, cervical cancer risk decreases
Osteoporotic risk increases

30
Q

What are the age considerations and UKMEC scores for:
Cu-IUD

A

Menarche <20 years = UKMEC 2
>=20 = UKMEC 1

And you can keep it in until menopause if put in after 40y

31
Q

What are the age considerations and UKMEC scores for:
LNG-IUS

A

Menarche <20 years = UKMEC 2
>=20 = UKMEC 1

And you can keep it in until 55 if put in at age 45 or over

32
Q

What are the age considerations and UKMEC scores for:
Implant

A

After menarche = UKMEC 1

33
Q

What are the age considerations and UKMEC scores for:
DMPA

Other things of note

A

<18 = UKMEC 2
18-45 = UKMEC 1
>=45 = UKMEC 2

Assess over 40 to assess benefits and risks of use - noting BMD. Women over 50 should be counselled on alternative methods. Women >40 with additional OP RFs (smoking, low vit D, fhx) should consider other methods

Many women find it helpful in relation to bleeding patterns

34
Q

What are the age considerations and UKMEC scores for:
POP

A

After menarche = UKMEC 1

35
Q

What are the age considerations and UKMEC scores for:
CHC

Other things of note for older pts

A

menarche - 40 = UKMEC 1
>==40 = UKMEC 2
When over 50y should stop using. Can be used as an alternative to HRT prior to this.

  • Use low oestrogen preps <30mcg
  • Use preps with levonorgestrel or norethisterone (lower VTE risk)
  • Can reduce menstrual bleeding and pain
  • Can help control menopausal sx
  • May help maintain BMD
36
Q

When is menopause diagnosed

A

1 year after amenorrhoea (retrospective diagnosis)

Can have FSH serum measurements to check if on progesterone only contraception. Women on CHC or HRT have supressed levels of estradiol and gonadotrophins so cant measure

37
Q

What age can you stop contraception

A

55

38
Q

What age do you need to stop CHC

A

50

39
Q

What age do you have to stop progesterone injection

A

50 - needs to be consdiered

40
Q

What age stop POP/imp/LNG-IUS

A

55 (when natural loss of fertility can be assumed)
if women over 50 with amenorrhoaea wants to stop before 55 - can check FSH

41
Q

Does HRT act as a contraceptive

A

No - use additional

42
Q

What contraception can be used in conjuction with HRT

A

All are safe apart from CHC

43
Q

What hormones are in HRT

A

Most women take a combination of the hormones oestrogen and progestogen, although women who do not have a womb can take oestrogen on its own.

44
Q

Which contraceptions can be used as endometrial protection for women who are on oestrogen alone

A

Only mirena is licenced for this, but other prog only contraceptions are safe to use with HRT as contraception.

45
Q

What needs to be assessed when seeing a young person

A

Their capacity:
- understand
- weigh up
- retain
- communicate

Whether they are Gillick competent - can they understand the risks involved, explore other options. Are there other things affecting their judgement - pressure, MH, stress.

If under 16 need to consider Fraser guidelines.

46
Q

What are the Fraser guidelines?

A

Specific to contraception. Use if under 16:
- the young person cannot be persuaded to inform their parents or carers that they are seeking this advice or treatment (or to allow the practitioner to inform their parents or carers).
- the young person understands the advice being given.
- the young person’s physical or mental health or both are likely to suffer unless they receive the advice or treatment.
- it is in the young person’s best interests to receive the advice, treatment or both without their parents’ or carers’ consent.
- the young person is very likely to continue having sex with or without contraceptive treatment.

47
Q

What to mention when young person arrives

A

confidential, breach if worried for safety

Contraception (13 decks)

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