Contraception in special groups (post partum, obesity) Flashcards
When to start contraception after childbirth
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
How long should a woman wait before trying to conceive again?
interpreg interval of less than 2mo is assoc with preterm birth, low birthweight
What methods can be offered after birth 0-6w
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
0-6w, breastfeeding - what is UKMEC for:
POP
Implant
DMPA
CHC
POP-1
Implant -1
DMPA-2
CHC-4 (wait for 6w)
0 - <3w, non-breastfeeding - what is UKMEC for:
POP
Implant
DMPA
CHC
with vs without other risk factors for VTE
POP- 1/1
Implant- 1/1
DMPA- 2/2
CHC- 4/3
3 - <6w, non-breastfeeding - what is UKMEC for:
POP
Implant
DMPA
CHC
with vs without other risk factors for VTE
POP- 1/1
Implant- 1/1
DMPA- 2/2
CHC- 3/2
> 6w, non-breastfeeding - what is UKMEC for:
POP
Implant
DMPA
CHC
POP - 1
Implant - 1
DMPA - 1
CHC - 1
> 6w to 6 months, breastfeeding - what is UKMEC for:
POP
Implant
DMPA
CHC
POP-1
Implant-1
DMPA-1
CHC-2
> 6mo, breastfeeding - what is UKMEC for:
POP
Implant
DMPA
CHC
POP - 1
Implant - 1
DMPA - 1
CHC - 1
What UKMEC considerations are needed for which contraceptions in which pregnancy related conditions?
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
Conditions needed for LAM
less than 6mo post partum
amenorrhoeic
fully breast feeding (every 4 hours in day and 6 hours at night)
is highly effective
UKMEC criteria for the different contraceptives in people who have positive antiphospholipid antibodies or thrombotic mutations
the only ukmec 1 is cu-iud
all the rest are ukmec 2
APART FROM CHC which is ukmec 4
Gestational trophoblastic disease UKMEC criteria
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
What BMI is considered overweight and what is obesity
> 25-29.9 = overweight
=30 = obese
What specific conditions would you want to ask about in someone who is overweight?
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
How to approach subject of increased weight?
Ask permission
Raise subject of weight
Enquire whether weight/ BMI is of concern
Signpost to appropriate support for weight and management if wanted
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
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
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
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)
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
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)
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
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
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
UKMEC = 1 for all
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
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)
What contraceptive methods need special consideration due to increased BMI? [6 points]
- 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
Weight loss medication and contraception - any considerations?
- Currently approved meds for weight loss are orlistat, liraglutide, naltrexone/bupoprion –> no known interactions with contraceptives
- Can induce diarrhoea - may have reduced absorption of OC (same with laxatives)
