Fertility Control Flashcards
Anovulatory level of ENG
90pmol/l
max at day 4
UKMEC for TB
Non-pelvic= 1
Pelvic=
I= 4
C=3
UKMEC for hepatitis
acute viral=
I=3
C=2
Chronic=1
UKMEC for cirrhosis
If severe:
POC=3
CHC=4
UKMEC for transplantation
Uncomplicated= 2
Complicated
COC= 3
IUD I=3 C=2
UKMEC for chlamydia
symptomatic I=4 C=2
asymptomatic I=3 C=2
UKMEC Bariatric Surgery
1
Breast Cancer
Current= 4
Past =3
FHx=1
BRCA=2 (CHC=3)
Implant <4 years and IUD fit?
Can fit with normal E/P
DMPA and cholesterol levels
initial reduction in HDL leads to increased LDL to HDL ratio
normalise over 24/12 of us
What is Z score?
comparison of BMD ith those same age/sex as you
-2.0 or less = low
EHC and Breast Ca
Probably safe if E receptor -ve but no evidence
unlikely to have a significant impact
HC and Breast Ca
LNGIUD best avoided but can always remove if recurrence
Estretol (E1)
Drovelis
Estretol 14.2mg / DRSP 3mg
ERa > ERb
less potent that EE/E2
not significantly metabolised by CYP450
Qlaira
estradiol valerate/ dienogest
contains lactose
quadraphasic COCP
28 tablets, 9/7 EP if QS or not Day 1
What are the licenses for different coils?
52mg:
all contraception 8 years
all HMB 5 years
only mirena for endometrial protection
minimum length- benilexa/levosert is 5.5cm
insertion tube- 4.8mm benilexa/levosert. 4.4mm mirena. others 3.8mm.
frame size- 32 x 32
Jaydess/Kyleena 28 x 30
Maximum length- copper only, 9cm
T safe 32x 36
NovaT 31.9 x 35.9
What is the release rate of the LNG-IUDs?
Start:
Mirena 20mcg/24hr (benilexa/levosert 20.1)
Kyleena 17.5, Jaydess 14
End:
Mirena 7mcg/24h, benilexa/levosert 6.5
Kyleena 7.4, jaydess 5
What weight reduces effectiveness of CTP?
90kg
Contents of first line COCP
less than/equal to 30mcg EE and NET/LNG
VTE in COCP-progestogens
reduced risk with:
LNG
NET
Norgestimate
Co-cyprindiol
35mcg EE+ cyproterone acetate (anti-androgenic)
treatment for acne/hirsutism (do not need contraception on top but should not be used for contraception)
Clairette/Dianette
Contents of CHP
33.9mcg EE + 203mcg norelgestromin over 24hrs
Contents of ring
15mcg EE + 120mcg etonogestrel over 24 hrs
Norethisterone VTE risk
converted to EE if >5mg/OD
NET 10-20mg OD equivalent to 20-30mcg EE
Mechanism of CHC
D1-7 inhibits ovulation
D8-14 maintains anovulation
-may have escape ovulation in HFI as reduced suppression
Regimes of CHC
1) Standard (only licensed)
2) Shorten HFI (4/7)
3) tricycle with 4-7/7 break
4) continuous
-nil evidence of increased effectivenesss
-return to fertility within 3 months
Quickstarting limitations
<20/7 cycle- day 1 only
9/7 E/P if estradiol valerate/dienogest
LSUP-
HSUP-
1000
20 (clear blue from 10)
traditional POP to COCP
7/7 EP as primary mechanism not inhibition of ovulation
-same as LNGIUD
Enzyme Inducer
stop during treatment and 28/7 after (or use condoms)
OR use a 20mcg and 30mcg COCP with 4/7 PFIs
if >70mcg will need specialist advice as unknown VTE risk
- not rifampicin/rifabutin
Recommended to switch if >2/12 of use
Lamotrigine and COCP
CHC can reduce lamotrigine levels- ?increased seizures
potential toxicity on stopping/HFI
CHC effectiveness may also be reduced
Lamotrigine and EC
D+V with oral methods
vomit <3 hours
diarrhoea >24hrs
prolonged HFI
> 9 days since active pill (Monday to following wednesday, 2 days late to restart=ok)
-EC if UPSI in HFI
-7/7 EP
UPT 3/52
Missed pills CHC
-1 pill
NAD
CHC missed 2-7 pills week 1
EC if UPSI in HFI/week 1
take pill ASAP
E/P 7/7 and UPT 3/52
CHC missed 2-7 pills week 3
take ASAP
omit HFI
nil EC
7/7 EP
CHC missed 2-7 pills week 2
take ASAP
nil EC
7/7 EP
> 7 days missed CHC
EC and treat as new starter
Missed ring rules
> 8 days since removed
-EC if HFI/week 1
-7/7 EP
-UPT 3/52
Ring fallen out <48hrs
NFA, put back in
Ring fallen out >48hrs
week 1- EC if UPSI HFI/week1, EP 7/7 and UPT
week 2- EC not required, take pill ASAP, 7/7 EP
week 3- EC not required, take pill ASAP, omit HFI, 7/7 EP
Prolonged ring use
<28/7- NAD
<35/7- omit HFI, 7/7 EP, nil EC
>35/7, EC if UPSI during week 5, treat as new starter
CHC and Endometrial Cancer
reduced risk, further reduced with longer use, persists many years
34% reduction if >10 years use
CHC and Ovarian Cancer
reduced risk
30-50% reduction if >5 years compared to never user/<1 year use
even if BRCA carrier
CHC and Colorectal Cancer
19% reduction in risk
CHC and overall cancer risk
overall reduction in cancer and all cause mortality
CHC and <20yo
UKMEC2
CHC and VTE
Risk per 10,000 women per year
Background- 2
LNG, NET, Norgestimate- 5-7
Etonogestrel, Norelgestromin- 6-12
DRSP, DSG, Gestodene- 9-12
some evidence that reduced dose EE reduces risk
conflicting evidence re route
Antithrombin/protein C/S and CHC
risk of VTE 4 in 100
8-70 fold increased risk
CHC and Migraine
double risk of ischaemic stroke
OR 2.7-6.1
not much increase if migraines without aura
CHC and ATE
increased risk MI/stroke
increased by EE dose
does not vary by progestogen type
CHC and Breast Ca
Not significant after 10 years stopped
increased risk with longer use
slight but not significant increase
CHC and Cervical Ca
Small increased risk if used over 5 years
Not significant after 10 years stopped
CHC and Headache
Some may reduce, worsen or remain the same
may reduce after a few cycles/remove HFI
no better regime
CHC and unscheduled bleeding
10-18% per cycle (similar to baseline population)
reduce over time but not if persists at 4 months
?CVR better bleed control
Rx:
Increase EE if 20mcg
3rd >2nd>1st gen progestogen
Progesterone generations
1) NET
2) LNG
3) DSG/Gestodene/Norgestimate
4) DRSP/Dienogest/norgesterol acetate
CHC and Mood
mood change is common and often due to external factors
nil good evidence
recommend change progesterone
Length of dispensing
Increased rates of continuation if more packs given
Nuvaring needs to be in fridge >4/12- Syreni ok for 12/12 to be given
CHC and travel
minimise immobility
>4500m or 14500 ft for >7/7- switch method
Increase erythropoiesis at altitude= increased thrombosis risk
CHC and surgery
planned immobility- stop 28/7 before
restart at first menses and after 2/52 full mobilising
OR clexane
IUC failure rates
0.6-0.8% Cu-IUD
0.1-0.2% LNG-IUD
0.3% Jaydess/Kyleena
Risks with IUC
Infection <1%
Perforation 1-2 in 1000, 6x increased in BF
acne/breast tenderness/headache/mood
MoA of IUC
Mainly pre-fertilisation effects
CuIUD- reduce fertilisation
LNGIUD- mucus, endo, implantation
-mucus may stil be penetrable 5/7 after insertion
->75% still ovulate (more for non 52mg devices)
IUC and GTD
-ve HcG= 1
declining=3
persistent=4
LNGIUD and Breast Ca
current-4
past-3
BMI >30 and other RF
UKMEC 2 for LNGIUD
IUC and Cavity distortion
UKMEC3
abnormal but not distorted=UKMEC2
fibroid alone=UKMEC1
Endometrial ablation
At ablation:
increased risk complication
reduced satisfaction, increased risk of intervention
After:
By ultrasound/hysteroscopy by specialist
Can try to remove in clinic
PID and IUC
past=1
C=2
I=4
Chlamydia
symptoms:
I=4
C=2
no symptoms:
I=3
C=2
IUC and purulent cervicitis/GC
I=4
C=2
Other STI (Non GC/C4) and IUC
UKMEC2
insert once treated and asymptomatic
BV/TV/Candida- insert and treat
GBS- nil
GAS- treat and delay
Other considerations for IUC and immunity
Immunosuppressed/EDS:
D/w team
Adrenal insufficiency:
early AM, double dose before and for 24hrs following
PLWH:
IUC and Cardiac Disease
Small risk vasovagal (2% background)
antibiotics not routinely recommended
do not withold beta blocker
hospital fit:
arrhythmia
Eisenmenger
Fontan/Single ventricle
Long QT
Impaired VF
Anticoagulation and IUC
multitooth tenaculum
pressure/silver nitrate
avoid NSAIDs
Ensure INR <3.5
-within 72hours if recent change/unstable
Trough of LMWH
IUC and allergy
CuIUD is contraindicated in allergy, avoid in Wilson’s
-no difference in serum levels
may contain nickel/gold/silver
Kyleena and Jaydess have a silver ring
IUC and cysts
Not a contraindication to LNGIUD, may increase but not clinically significant
LNGIUD and amenorrhoea
At end of licence:
52mg 40%
19.5mg 23%
13.5mg 11-12%
52mg 1 in 5 by 12/12
Fitting IUC-technique
tissue forceps should usually be used
uterine sound should be used
IUC and pain
Appear to help:
-paracervical/intracervical block
-10% lidocaine spray (wait 3 minutes)
-lidocaine/prilocaine cream
No good studies on oral analgesia. NSAIDs can help post fit pain
IUC and MRI
Limited data suggest safe
steel ring not safe
IUC and menstruation
nil evidence tampons/pads
?association of cups and expulsion
IUC and ectopic (hx)
UKMEC 1
IUC and infection
<1% risk but increased for first 3 weeks
wait 48-72hrs before removal to assess response
IUC and BV/Candida
?biofilm and recurrent IUC (protects yeasts from azoles)
mixed evidence, may choose to switch
BV potentially associated with CuIUD but not LNGIUD
Malposition
> 2cm from fundus
too limited evidence to know about effectiveness
incidence 7-19%
no evidence for increased pain/pvb
> 2 expulsions:
do USS to assess cavity before fit
Postpartum/D1-8 of cycle may have higher risk
NVT
18%
30% after NVD, 50% after LSCS
SDI and ovulation
0.05% in first year
too limited evidence that this is maintained beyond year 3
maximum conc at 2 weeks
111-202 by year 3
may be over 90 for up to 5 years
-no correlation with BMI
ovulatory activity not 100% suppressed, may have some follicular development with fluctuant estradiol levels
SDI removal- fertility
undetectable levels 7/7
ovulate at 6/52 (reports of pregnancy at 14/7)
POC UKMEC 3
unexplained pvb
Hx Breast Ca
severe liver cirrhosis, hepatocellular adenoma or carcinoma
Continuation with stroke/IHD (initiation is a 2)
POC UKMEC 4
CURRENT breast Ca
SDI and Endometriosis
may lead to reduced pain, evidence limited to first year of use
Breast Ca and POC
possible association
small increase in risk but absolute risk is low
SDI and ectopic
0.2 per 100,000
4.7% of pregnancies with the implant (1% of all pregnancies)
SDI and Bleeding
median reduction when compared to: no method, CHC but less predictable
if bad 3/12, 50% chance will get better
-3/12 CHC or 5/7 MFA
Stats:
1 in 3 once a month
1 in 3 less than once a month
1 in 4 amenorrheic
<1 in 5 prolonged
-10-20% will remove device due to bleeding pattern
Analgesia for SDI
lidocaine 1% 1-2ml
ethylchloride spray- 60 second duration
SDI and bleeding
anticoagulants- NAD
Plt <50= discuss
SDi complications
1% deep
-can leave indefinitely
broken:
-increased surface area so increased hormone levels
-likely still effective but can offer replacement
SDI cost
12/12 cost effective
DMPA effectiveness
0.2%
typical 6%
Norethisterat
200mg in 1ml IM Stat (oily, warm in water before use)
slow gluteal injection
licensed for short term use whilst a/w semen analysis post vasectomy
duration 8 weeks
must have rubella vaccine
DMPA benefits
-may reduce pain of endometriosis
-may protect from ovarian/endometrial cancer
-may reduce severity of sickle cell pain
BMD and DMPA
small loss, recovered on discontinuation
<40= UKMEC1
>40= UKMEC2
Breast Ca and DMPA
small increased risk, absolute risk is small
Cervical Ca and DMPA
weak association if used for more than 5 years
reduces after discontinuation
Weight gain and DMPA
higher risk if BMI>30 and <18
if gain >5% in first 6 months may continue to gain
limited data of effectiveness if BMI >40
Injection site reactions and DMPA
Higher risk if SC (1-20% all site reactions, common)
If concerned re BMi go for deltoid
Timing of injections
13/52 supported- can give up to 14/52
(IM DMPA SPC 12, SC DMPA SPC 13)
early- 10/52 DMPA
-6/52 NET
DRSP Quick-starting
D1 of cycle/post TOP/d21 childbirth
DRSP Missed pill rules
24hr window
omit HFI if any of last 7 missed
EC if missed D1-7 and SI during HFI/week 1
Vomiting with POP
DRSP/DSG- 3-4 hours
LNG/NET- 2 hours
Extra considerations with DMPA and MHx
c/i- severe renal disease
avoid- K+ supplements, hyperkalemia, diuretics
untreated hypoaldosteronism/Addison’s/adrenal insufficiency
caution and monitor- mild renal disease/treated hypoaldosteronism
check U+E/BP before- Risk factors for CKD (HTN/CVD/DM) especially if >50yo
POP and Cancer
potential increased risk of Breast Ca
nil risk ovarian/cervical
unclear evidence on ovarian cysts
nil risk of positive impact of endometrial cancer
Bleeding and traditional POP
<1 in 10 amenorrhoeic
1 in 10 infrequent
8 in 10 normal
1 in 10 frequent
<1 in 10 prolonger
Bleeding and DRSP/DSG POP
2-3 in 10 amenorrhoeic
3 in 10 infrequent
4 in 10 normal
<1 in 10 frequent
<1 in 10 prolonged
DSG may reduce HMB
Both may reduce dysmenorrhea
How to use diaphragm/cap
reapply gel if in place over 3 hours or further SI
retain 6 hours after sex
diaphragm- max 30 hours
cap- max 48 hours
Effectiveness of barrier methods
Internal condoms:
2% and 18%
External condoms:
5% and 21%
Diaphragm:
6% and 12%
Latex condoms- lubricants
Water/silicone
oil= no
Concerns with diaphragms/caps
UKMEC 3:
Hx toxic shock
high risk HIV transmission
Nonoxynol-9
spermicidal gel, immobilises/kills sperm
-denatures lipids in acrosome->lysis of membranes->immobilisation and death
Can also change vaginal flora-> genital irritation and higher risk HIV acquisition
Caya gel
acts as a physical barrier to sperm, stabilises high vaginal pH
Advice post vasectomy
NSAIDs
rest, avoid strenuous activity
abstain 2-7/7
wear supportive underwear for 48 hours
Consenting for sterilisation
Written consent recommended
counsel at least 2 weeks prior to CS
additional care if <30 yo or nulliparous
Vasectomy- procedure details
occlusion of vas deferens
under LA (GA may worsen pain and has similar recovery)
warm LA to 37 before giving-subcuticular tissue and vas
minimum exposure-reduces complications
many methods (cautery and division best), removal of 1-3cm section must be accompanied by another method
bury one end in spermatic fascia to prevent recanalisation
histology not required
PVSA
12 weeks (may be up to 16)
-by this time 80% have no spermatazoa
need 11-20 ejaculations before sample
<10,0000 sperm/ml
PVSA- failure
motile sperm at 6-7/12
>100,00 but not motile may get given special clearance
Vasectomy- anatomical variation
absent vas is associated with ipsilateral renal agenesis
- do one side and await PVSA
if bilateral absence:
-urology referral
Double vas:
-USS to confirm ectopic ureter
Complications of vasectomy
haematoma/infection: 1-2%
Failure 1 in 2000 (1 in 100 if not waited for PVSA)
chronic pain >1%- NSAIDs/neuropathic drugs
Vasectomy reversal
Dependent on length of time
<3 years
97% but pregnancy rate 7%
9-14 years
79% but pregnancy 40-45%
> 20 years
40% but <10%
Tubal occlusion- method
Filshie should be laparoscopic method of choice
Tubal occlusion- pregnancy risk
2-3 in 1000 luteal phase pregnancies
can continue contraception 7/7 after but SDI can be removed at time of
Lifetime failure- 1 in 200
Fi
Filshie at 1 years- 2-3 in 1000
Survival times for FAM
ovum ~24 hours
sperm ~7 days (average 1-2)
fertile window 8-9/7
days conception most likely
day of ovulation and 24hrs before
FAM effectiveness
24%
0.3-0.4%
Need to record for 3 months before use
Indicators for FAM
progesterone increases basal body temp
-3/7 of temp >0.2 degrees higher than previous 6 days = post ovulatory infertile window
may be less sensitive than mucus/LH indicator sticks
Need to take T after 3 hours of rest
6.6% failure if single indicator used
Cervical secretions for FAM
1) menses
2) dryness
3) sticky secretions and cervix high (2 days before and final day of this= most fertile time)
4)thick/absent secretions
safe= 4/7 after peak
3% and 14% failure rates
Calendar method
Record for 1 year before starting
21% accuracy
Do not use if cycles <26 or >32 days
12% failure
Highest risk days
6 days before + day of ovulation
-30% risk pregnancy if SI at this time
If any SI- 25% chance during fertile time
Delayed Menses after EC
> 7/7
<10% LNG EC
20% UPA-EC (some IMB (10%), some earlier, some later (4%))
Failure of withdrawal
22%
Lactational Amenorrhoea
Exclusively BF (4 hrs day 6 hrs night)
high prolactin= low GnRH= reduced LH/SH and suppressed ovulation
2% risk (may increase if expressing/dummies)
not if teratogens
When can use dates after HC
> 3 cycles minimum
When does implantation occur?
Day 6 post ovulation
80% day 8-10
EC licenses
LNG 72 hrs (can use to 96)
UPA 120 hrs
- offer any day of cycle
Double dose LNG
BMI >26 or weight >70kg
- unknown if this or UPA is more effective
enzyme inducer
-UPA-EC not recommended
How does oral EC work
delays ovulation by at least 5 days so sperm no longer viable
UPA up to start of LH surge- LNG before only
EC Effectiveness
CuIUD <0.1% failure
UPA 1-2% (really 60-80%)
C/i to PO EC
both contain lactose
can take in severe liver disease as pregnancy much greater risk
EC and vomiting
<3 hours= another dose
EC and ectopic
same as baseline risk
UPA and menses
take UPT if delayed >7 days
75% normal/within 7 days
UPA and POC
7 days before and 5 days after
PO EC side effects
headache, nausea, dysmenorrhea
Why do we flex the elbow for implant fit?
to move ulnar nerve out the way
Which structures lie in the sulcus?
median nerve
basilic vein
brachial artery
ulnar runs below (over triceps)
Ulnar nerve injury
Median nerve injury
Pharmacokinetics of EE/P
both conjugated in liver and intestinal mucosa
excreted in feces
some EE conjugates are cleared by colonic flore- EE reabsorbed
Pharmacokinetic interactions
n+v
CYP450
gastric pH
increasing glucuronidation of lamotrigine (CHC)
Pharmacodynamic interactions
POC and UPA
DRSP/potassium
Topiramate
teratogen- need pregnancy prevention programme
IUC/DMPA + condoms
consider as enzyme inducer (regardless of dose)
Valproate
teratogen- need pregnancy prevention programme
IUC/SDI, or others + condoms
inhibits glucuronidation, if taking CHC and lamotrigine may help maintain lamotrigine levels
not an enzyme inducer
Sugammadex
used to reverse neuromuscular blockade
T 1/2 2 hours, excreted in 24 hours
treat as 1 missed pill and use E/P
- less worried if DMPA/IUC
Thyroxine
oral HRT can increase requirement by increasing TBG
- no evidence but consider the same for CHC
-transdermal has less effect as not 1st pass metabolism
check TFT 6/52 after starting CHC (may need to increase thryoxine dose)
Lamotrigine
CHC increases glucuronidation, may need to increase dose and have toxicity on discontinuation/HFI
DSG may increase levels
POC- check for signs of toxicity and measure levels when stopping
HC- condoms on top, DMPA/IUC preferred
Signs of lamotrigine toxicity
diplopia
ataxia
dizziness
Griseofulvin
not an inducer, potentially teratogenic
increased risk of bleeding changes/pregnancy with PO (condoms)
DMPA/IUC
Gastric pH
PPIs may reduce exposure to UPA, but not other HC
LNG/IUD EC
ARTs that induce CYP450
efavirenz
ritonavir boosted PIs
CYP450 inhibitors
PIs (-avirs)
Ritonavir
inhibits CYP but induces glucuronidation
- increases P, reduces EE
cobicistat
increases P and EE
elvetigravir/cobicistat
reduces EE
BMD and ART
reduced by TDF and DMPA
- may consider TAF or another contraception
NRTIs
no issue
NNRTIs
refavirenz/etravine/nevirapine= reduce
dorarivine and ripivirine= ok
INSTIs
end in -gravir
no changes except i fbooster EVG/c, may change CHC
Fostemsavir
may change CHC
Paternal valproate use
use contraception during and for 3/12 after (1 complete sperm cycle)
increase risk of neurodevelopmental disorders eg autism
F 30-40% M 5%
IUC/DMPA or others and condoms
Maternal lamotrigine/Keppra
3 in 100 Neurodevelopmentl
Orlistat/laxatives
may reduce effectiveness of POP/COC/Oral EC
Mounjaro
Tirzepatide
slows gastric emptying
reduces levels of oral methods
wait 1/12 to concieve
condoms 1/12 after each dose change
Semaglutide
Ozempic/Wegovy
does not change levels of oral HC
2/12 before ttc
St John’s Wort
CYP450 inducer
DMPA/IUC
Breast Ca treatment
many remain sexually active and fertile
treatment is teraogenic
pregnancy may delay treatment and worsen outcomes
avoid HC regardless of recepto status
Chemo can raise FSH
IUD/sterilisation
CHC and Ca can increase vTE risk
Current Breast Ca and CHC
stop immediately
increases risk, persists 5-10 years after stopping
could negate aromatase inhibitors
Current Breast Ca and POC
can continue short term until decisions re treatment are made
no evidence risk id does related, theoretically LNGIUD preferred but no evidence
DMPA may increase VTE risk
Where to look up teratogenicity of drugs
UKTIS
-teratology information service
CHC after delivery
not for 6/52 if:
immobility
PPH
LSCS
PET
BMI >30
smoking
Contraception when breastfeeding
<6 weeks
UKMEC 2 DMPA
UKMEC 4 CHC
<6/12
UKMEC 2 CHC
all others 1
Contraception not breastfeeding
<3 weeks
DMPA 2
CHC 4 if RF, 3 if nil RF
<6 weeks
DMPA 2 if RF, 1 if nil
CHC 3 if RF, 2 if nil
> 6 weeks all 1
all other 1
IUC after delivery
1 <48 hours and >4 weeks
3 between above
4 if sepsis
IUC after abortion
2 if second trimester
4 if sepsis
decreases likelihood of another abortion within 2 years
DMPA and abortion
increased risk of failure if given at time of mifepristone
Contraception and miscarriage
better outcomes if conceive within 6 months than after 6 months
Recurrent early miscarriage and CHC
consider ?APL and avoid until excluded
Contraception and GTD
previous GTD increases risk of future GTD
complete- avoid pregnancy 6/12
partial- avoid until 2 negative hCGs
chemo-avoid until 12/12 after rx
IUC when levels normal
static- 4 decreasing-3
EC- go for oral, can consider CuIUD if d/w specialist
start HC whenever
CHC and weight
patch less effective >90kg
UKMEC 2 BMI >30
UKMEC 3 BMI >35
UPA and weight
may be less effective at BMI >30 or weight >85kg
PO method and RF for CVD
UKMEC 2
DMPA and VTE
limited data to exclude causal link
HDL levels decrease, changes LDL:HDL level at 6 months, normalises at 24 months
CHC and bariatric surgery
If BMI >30 =2
>35= 3
IUC and DMPA for <18yo
UKMEC2
Advanced EC and pregnancy rate
not shown to reduce
<16yo SI
1 in 3 have
65% chlamydia
Pregnancy risk >40yo
<45 10-20%
>45 15%
higher risk of poor outcomes
30x increased than those age 20-24
> 40 and change to bleeding pattern
investigate
UKMEC >40yo
CHC = 2
DMPA = 2 >45
Stopping contraception (age)
40-50 = 2 years amenorrhea
> 50 = 1 year amenorrhoea
CHC- switch
POI- consider switching
POC- FSH >30 - stop 1 year
-FSH<30- repeat on 1 year as above
DMPA and oestrogen
hypo-oestrogenic, lowers BND
Cardiac disorders that raise stroke risk
R to L shunt (cyanotic heart disease)
pulmonary AV malformation
ASD
Patent FO
-avoid CHC
Cardiac disorders that raise vasovagal risk
single ventricle/ fontan
Eisenmenger’s
arrhythmia (tachy or brady)
- IUC in hospital
Cardiac disorders that raise infective endocarditis risk
valvular disease
valve replacement
structural changes (defects/PDA)
previous endocarditis
-liaise with cardiology
Progestogens and INR
unclear impact/evidence
Macrolides and cardiac disease
-mycins
can change long QT
so can oestrogen only HRT
Impaired conduction and contraception
caution with LA, especially LA with adrenaline
LVEF <25%
avoid pregnancy and CHC
Organ transplant
avoid pregnancy 12 months
uncomplicated:
all methods 2
complicated: eg rejection
CHC 3
IUC I is 3
all others 2
Low risk cardiac patients
not on any meds (including aspirin)
discharged or follow up every 2 years
normal sats
PPCM
last 1 month of pregnancy or 6 months
bosentan
reduces effects of P and E
IBD and fertility
reduced by flares
reduced by reconstructive surgery
active disease increases poor fetal outcomes
1 parent- 2% risk
both- 30% risk
normal dose folate unless malabsorption/sulfasalazine
Methotrexate
wait 3/12
Mycophenolate
6/52 F
3/12 M
Sulfasalazine
5 mg folate
reversible reduction of sperm count and motility
may be seen in MTX/infliximab
TNF alpha
6/12
IBD safe drugs for pregnancy
aminosalicylates- + 5mg folate
Thiopurines (mercaptopurine is maybe teratogenic)
no data on tacrolimus
Apixaban
avoid SDI/IUC in first two weeks (higher dose)
INR >3.5
IUC in hospital
SDI in community
Prolactinoma
not a c/i to any method but may wish to d/w endo
Problematic bleeding basics
do not change for 3/12
may choose to increase EE to 35mcg or change progesterone
20% COC have changes to pattern
first 3/12 SDI broadly predictive
Bleeding patterns at 12/12
CHC- CVR>COCP
DMPA- 50% amenorrhoeic
SDI- 2 in 10 prolonged
LNGIUD- 90% have a reduction
Management of problematic bleeding >3/12
Ensure: STI/UPT/Smear
pain- bimanual and refer
no pain- speculum, if normal reassure
CHC:
increase EE to 35mcg
switch P
try CVR
POP:
Change P
SDI/POI/LNGIUD:
COC 3/12
DMPA
MFA/TXA
Sterilisation and previous bowel resection
c/i
Nerve most commonly impacted SDI
ulnar
enzyme inducers and osteoporosis
increase risk
Amenorrhoea with SDI
1 in 4
Highest risk time for VTE with CHC
In the months immediately after initiation
or when restarting after a break of >1 month
reduces over first year then stable
ie stopping/starting is discouraged
