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Family planning
- 1. Prepregnancy Care & Ensuring Success For Contraception O&G Update 2014 Hospital Sarikei, Sarawak yongsoonleong@yahoo.com
- 2. Contraception is astepping stone for effective prepregnancy care especially for high risk women
- 3. Failure rates ofvarious contraceptive methods Method Typical Use Perfect Use COCP 8 0.3 POP 8 0.3 IM Depo Provera 3 0.3 IUCD - Copper 0.8 0.6 - Mirena 0.2 0.2 Implanon 0.05 0.05 Tubal Ligation (♀) 0.5 0.5 Vasectomy (♂) 0.15 0.1 Condom 15 2 Coitus Interruptus 18 4
- 4. Types of contraception ● Hormonal Oral (COCP, POP) Injectable (Depo Provera, NET) Implant (Implanon) Vaginal (NuvaRing) ● Intrauterine contraceptive devices ● Barrier method ● Permanent sterilisation (BTL, Vasectomy)
- 5. Combined Oral Contraceptives Pills (COCP) ● Contains 2 types of hormones -> estrogen & progesterone
- 6. COCP Examples ofCOCP available in Malaysia: •Regulon •Rigevidon •Microgynon •Mercilon •Marvelon
- 7. When to startCOCP? ● Day 1 – 5 of menses ● At any other time if patient is sure NOT pregnant, but with additional protection for the first 7 days ie. condom
- 8. When to startCOCP? Postpartum 1. Fully breastfeeding -> 6 months postpartum 2. Not breastfeeding -> 3weeks postpartum
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- 10. WHO medical eligibility criteria Categories Classification 1 Use the method in any circumstances 2 Generally use the method 3 Use of the method is not usually recommended unless other more appropriate methods are not available 4 Methods not to be used
- 11. Absolute Contraindication WHOCategory 4 • Pregnancy • Cerebrovascular accident • Thromboembolism • Liver diseases • Estrogen-dependent tumours (breast cancer) • Undiagnosed genital tract bleeding • Recent trophoblastic disease • Ischaemic heart disease
- 12. Relative Contraindication WHOCategory 2&3 • Age above 40 • Age >35 and smoking • Migraine • Hypertension • Diabetes • Obesity • Sickle cell disease • Varicose vein
- 13. Missed pills (COCP) 1st question to ask patient: Which type ooff CCOOCCPP tthhaann yyoouu aarree ttaakkiinngg?? 30 mcg or 20 mcg of ethinyloestradiol
- 14. Missed pills (COCP) For COCP containing 30mcg of ethinyloestradiol •If 1 or 2 pills are missed at anytime, take the pill ASAP (NO NEED EXTRA COVER, DO NOT STOP) •If 3 or more pills are missed in the: 1st week, needs emergency contraception if unprotected sex and use condoms for 7 days 2nd week, use condom for 7 days 3rd week, use condom for 7 days and continue with next packet without a break
- 15. Missed pills (COCP) For COCP containing 20mcg of ethinyloestradiol •If 2 or more pills are missed, apply the rules of missing 3 or more 30mcg pills.
- 16. Progestogen only pills(POP) - Contains synthetic progestogen only, NO ESTROGEN.
- 17. When to startPOP? • Day 1 till up to day 5 of menses • At any time when patient is sure not pregnant, but with additional protection for the next 48 hours i.e. condom
- 18. When to startPOP? • Postpartum Up to day 21 postpartum with no additional contraception After day 21 postpartum, need additional contraception (ie condom) or avoid sexual intercourse for the next 48 hours.
- 19. Side effects ofPOP • Amenorrhoea • Irregular bleeding or spotting • Weight gain or loss (change in apetite) • Breast tenderness • Headaches, acnes • Increased risk of benign functional ovarian cysts
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- 21. Missed pills (POP) Cerazette (desogestrel-only pill) - 12 hours window period (compared to conventional POP which allow only 3 hours window)
- 22. Vomit (POP) •If vomit within 2 hours of taking a POP, she should be advised to take another pill.
- 23. Injectable Progestogen •Depo Provera (DMPA) 150mg depot medroxyprogesterone acetate every 12 weeks • Noristerat (NET-EN) 200mg norethisterone enanthate every 8 weeks
- 24. When to startInjectable Progestogen? • Day 1 to 5 of menses no backup contraceptive method is necessary • Anytime during the menstrual cycle when patient is sure not pregnant additional contraceptive method should be used for the next 7 days, ie condom
- 25. When to startInjectable Progestogen? • Postpartum Maybe initiated up to day 21 postpartum with immediate contraception cover If initiated after day 21, then condom or avoid sexual intercourse for the next 7 days.
- 26. Disadvantages • Changesin menstrual cycle 20% amenorrhoeic 40% menses regularly 40% erractic bleeding • Delay in return of fertility average of 9-10 months from the date of last injection • Weight gain (evidence is not strong) • Headache & dizziness
- 27. Disadvantages • Nausea • Mood changes (depression) • Hirsutism • Hyperpigmentation over injection site • Loss of libido
- 28. Missed injection?? Comeearly/late for injection?? IM Depo Provera / IM NET-EN can be given 2 weeks earlier or late
- 29. Intrauterine contraceptive devices(IUCD) • Non-hormonal Multiload Cu-250 : 3 years Multiload Cu-375 : 5 years • Hormonal Mirena (LNG-IUS)
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- 32. Risk of IUCD • Uterine perforation 1 in 1000 • Pelvic infection 1 in 100 • Expulsion 1 in 20 particularly within 3 months of insertion • Abnormal bleeding Cu-IUD: first 3-6 months of insertion Mirena (LNG-IUS): Irregular bleeding first 6 months, amenorrhoea or light bleeding by 1 year
- 33. Contraindication • CurrentPID or in the last 3 months • STD • Distorted uterine cavity • Pregnancy • Unexplained abnormal PV bleed
- 34. Timing of insertion ● Anytime during the menstrual cycle when you can be sure that the client is not pregnant ● Postpartum Immediately after expulsion of placenta or after 4 weeks postpartum ● Post-miscarriage Within 48 hours or delay until 4 weeks later
- 35. IUCD insertion after40s When to remove? Off License Use
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- 37. Choice of contraceptionshould be tailored to her health condition & the couple wish. Counseling to her involving the spouse will ensure success for contraception & prepregnancy care.
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