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Postpartum Contraception

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					Postpartum Contraception
       Counseling




       ALLA GOLDBURT, MS4
   MATERNAL CHILD HEALTH SUB-I
               Goal of Presentation

 What is different about contraception in
    postpartum period?
   When should we counsel?
   What are the options?
   How do we use them?
   Why do we recommend using them in this way?
      What is different about contraception in
               postpartum period?


• breastfeeding


• hypercoagulable state


 different contraceptive needs
                Breastfeeding Physiology

 Pregnancy
    Prolactin secretion in pregnancy -> breast growth, milk biosynthesis
    Progesterone (and estrogen) ->interferes with prolactin binding,
     inhibits lactation
 Birth
    Rapid decline placental progesterone -> initiation of lactation
    Suckling -> oxytocin release -> contraction of the myoepithelial cells
     -> milk ejection
 Day 2-4 postpartum,
    Steroid hormones cleared -> maintenance of milk production
    High serum prolactin -> inhibits pulsatile GnRH -> prevent
     ovulation -----> maintained?
                        Breastfeeding

 Nutritional research 1970s-1980s – OCPs
    Sig changes in concentration of total protein, milk protein, and
     daily milk volume (Lonnerdal 1980)
    Magnitude of changes w/in normal range, not of nutritional
     importance to newborn (Kowetsawang 1987)

 WHO Task Force (1984)
    Prospective RCT of COC vs POP vs non-hormonal placebo.
    Milk volume: 41.9% decline in COC group vs 12.0% in POP
     group vs 6.1% in non-hormonal controls.
    Comparable prevalence of complementary feeding and
     withdrawals due to inadequate milk supply
    **No sig differences in growth of infants between treatment
     groups.
        Postpartum Hypercoagulable State


 Physiology
   coagulation factors and fibrinogen, resistance to anti-
    coagulants protein C and S


 Risk of VTE (Gherman 1999)
   22-84-fold high in first 6 weeks of postpartum period

   greatest in first 21 days, after which risk sharply drops off
                Family planning needs?


 Survey (Cwiak 2004) “extremely important qualities”
   ANTE-PARTUM: reliability, efficacy, and safety during breast-
    feeding
   POST-PARTUM SIG: ease of use, long-term protection, and no
    need for monthly pharmacy trips

     > 80% using contraception prior to pregnancy, nearly 20%
      not satisfied with the method used.
     > 40% thought IUC seemed „somewhat‟ or „much better‟ than
      their most recent method, yet < 1% chose
                When should we counsel?



 Standard part of discharge discussion? (Glazer 2010)
   77% (134) discussed contraception antepartum

   87% (153) discussed postpartum.

   1/3 discussing IUDs at any point.



 Initiation of sexual activity? (Ford 1998, Barret
 2000)
    32-66% sexually active within first month,
    62-88% within second month
       How effective are we at counseling?


 Effectiveness of antenatal counseling (Smith
 2002)
    Expert advice vs „routine standard advice‟ in prenatal period
    Pregnancy rates at 1 year not significantly different, even when
     considering intention
    Contraceptive practice differed significantly (only because
     those not intending to get pregnant chose sterilization)

    Not many great studies out there…..
       How effective are we at counseling?


 Cochrane Review of effects of postpartum
 interventions (Lopez 2002, 2010)

    Increased contraception use, decreased unplanned
     pregnancies in 2/4 interventional trials,
    More effective when interventions longer (beyond hospital stay
     period), incorporating home visits
                  Part 2




 What are the options? How do we use them?
Why do we recommend using them in this way?
                Lactational Amenorrhea

     Ovulation within 3 months in exclusive breastfeeders,
     As early as 3-6 weeks in women who are not exclusively
      breastfeeding
     May precede menstruation


 EBM
   < 2% “failure rate” in women exclusively or „mostly‟
    breastfeeding (DEF - feeding both night and day,
    ammenorheic, infant less than 6 months old and receiving
    >90% nutrition from breastmilk) (WHO)
                       LAM

          ACOG               WHO (AAFP)


NON-      NOT recommended    NOT recommended
Br Feed




Br Feed
                            LAM

 Clinical Judgment
   Menstruation/ovulation is unpredictable

   Duration of breastfeeding

   Resumption of sexual activity
 Combination contraceptives- COCs, Nuvaring,
                 Orthoevra


 EBM
   In nonlactating women-risk of pregnancy related thrombosis
    reduced to acceptable level after three weeks (Gherman 1999)
   Decreases median lactating period (WHO 1984)

   Effectiveness varies by method
           Combination Contraceptives

          ACOG                    WHO (AAFP)               AAP

NON-      > 4 weeks               < 3 wks not rec unless   No earlier than 3-6
Br Feed                           no other method avail    weeks
                                  > 3 wks use freely



Br Feed   > 4 weeks, waiting      < 6 wks do NOT use       No earlier than 3 to
          until br feeding well   6 wks- 6 mo not rec      6 wks, wait until
          established             unless no other method   infant not relying
                                  avail                    pred on br milk
                                  > 6 mo use freely
             Combination contraception

 Clinical Judgment
   Acceptable reduction of risk of thrombosis

   Perceived effect on establishment of breastfeeding patterns

   Ease of use for mother
Progesterone only: Minipill, Depo-Provera,
Mirena IUD, Implanon

     Theoretical effect based on understanding of physiology
     Existing data of poor quality


 EBM
   Progesterone little effect on coagulation factors, BP, lipids

   NOT been shown to effect milk quality sig, NO effect on infant
    growth and development (Truitt 2003,WHO 1994,)
   Early initiation had NO effect on short-term breastfeeding
    patterns (Halderman 2003)
                        Mirena-
                 Progesterone only IUD

 Expulsion rates?
   Use: insert 20 minutes within delivery of placenta, using
    special technique OR 4-6 weeks postpartum, once uterus has
    involuted (24-48 hour interval not recommended)
   0.1%/0.1% one year failure rate (WHO)

   RCT of post-NVD insertion- Postplacental group 24%
    expulsion rate, Interval group 4.4% expulsion rate (Chen 2010)
                     Depo-Provera-
               Progesterone only injection


 Breastfeeding (Hannon, 1997)
   NON-sig effect on duration or frequency of lactation

   NON-sig effect on timing of introduction of formula



 Adolescents (Templeton 2000)
   55% Depo vs 24% OC users continued method at 1 year.

   Total incidence of repeat pregnancy 10.6% at 1 year.

   24% in OC users and 2.6% in Depo users pregnant at 1 year.
                       Progesterone only

          ACOG                            WHO 2008                  PPFA
                                          (AAFP)
NON-      Anytime                         Anytime                   Anytime
Br Feed

Br Feed   > 3 weeks if partially br       < 6 weeks not rec         Anytime
          feeding                         unless no other method
                                          avail
          > 6 weeks if fully br feeding   > 6 weeks use freely


MIRENA                                    < 48 hrs not rec unless
Br Feed                                   no other method avail
                                          48hrs- 4 weeks not rec
                                          unless no other method
                                          avail
                                          > 4 weeks use freely
                     Progesterone only

 Clinical judgment
   Concerns for newborn – potential effects on newborn brain,
    liver unknown (animal studies)
   Ease of use- timing of POPs

   Rate of expulsion of Mirena- timing of insertion?

   Complication rate for postplacental insertion- no quality data

   Prolonged/irregular bleeding
               ParaGaurd- Copper IUD

 EBM
   May insert 20 minutes within delivery of placenta, using
    manual insertion OR 4-6 weeks postpartum once uterus has
    involuted
   0.6%/0.8% first year failure rate (WHO)

   No effect on breastmilk production, nutritional value

   Expulsion rate at six months 6.7 times more likely when placed
    postplacentaly (7-15%) vs interval (Kapp 2009, Cochrane
    database 2010)
           Paraguard Copper IUD

          ACOG        WHO (AAFP)

NON-                  < 48 hrs generally use
Br Feed
                      48hrs- 4 weeks not rec unless no other
                      method avail

                      > 4 weeks use freely



Br Feed               < 48 hrs generally use

                      48hrs- 4 weeks not rec unless no other
                      method avail

                      > 4 weeks use freely
               ParaGaurd- Copper IUD

 Clinical Judgment
   Review of safety of postpartum insertion based off of poor to
    fair quality trials (Kapp 2009)
   Expulsion risks
                      Other methods

 Sterilization (Tubal, Essure, Vasectomy)-
   Can be done at any immediatly after delivery/CS, within 24-48
    hours or at an interval of 4-6 weeks, effective immediately, no
    effect on breast milk, NOT reversible


 Condoms-
   Can be used at any time, effective immediately, no effect on
    breast milk, protects against STIs, NOT always practical?
              Plan B (and now ella….)


 EBM
   No increased risk of VTEs for mom

   No effect on breastmilk



 Clinical Judgment
   Availability
                    In summary

 What is different about contraception in
    postpartum period?
   When should we counsel?
   What are the options?
   How do we use them?
   Why do we recommend using them in this way?
                                                  Resources

Barrett, G., Pendry, E., Peacock, J., Victor, C., Thakar, R. and Manyonda, I. (2000), Women's sexual health after childbirth.
    BJOG: An International Journal of Obstetrics & Gynaecology, 107: 186–195.

Chen BA Reeves MF, Hayes JL, Perriera LK, Creinin MD. Postplacental or delayed insertion of the levonorgestrel
   intrauterine device after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2010 Nov;116(5):1079-87.

Cwiak C, Gellasch T, Zieman M. Peripartum contraceptive attitudes and practices. Contraception. 2004 Nov;70(5):383-6.

Gherman RB, Goodwin TM, Leung B, Byrne J, Hethemumi R, Montoro M. Incidence, Clinical Characteristics, and
   Timing of Objectively Diagnosed Venous Thromboembolism During Pregnancy. Obstetrics & Gynecology:
   1999 Nov ; 94, 5. 730-4

Glazer, AB, Wolf A, Gorby N. Contraception: needs vs. reality.

Guiloff E, Ibarra A, Zanartu J, Toscanini C, Mischler TW, Gomez-Rogers C. Effect of contraception on lactation. Am J Obstet
    Gynecol. 1974 Jan 1;118(1):42-5.

Halderman LD, Nelson AL.. Am Impact of early postpartum administration of progestin-only hormonal contraceptives
    compared with nonhormonal contraceptives on short-term breast-feeding patterns. J Obstet Gynecol
    2002;186:1250–6; discussion 1256–8. (Level

Hannon PR, Guddan AK, Serwing JR, Vogelhut JW, Witter F, DeAngelis C. The influence of medroxyprogesterone on the
   duration of breast-feeding in mothers in an urban community. Arch Pediatr Adolesc Med. 1997 May;151(5):490-6.

Kapp N, Curtis KM. Intrauterine device insertion during the postpartum period: a systematic review. Contraception.
   2009 Oct;80(4):327-36. Epub 2009 Aug 29.

Koetsawang S. The effects of contraceptive methods on the quality and quantity of breast milk. Int J Gynaecol Obstet
    1987;25 suppl:115–27.
                                     Resources, contd.

Lonnerdal B, Forsum E, Hambraeus L. Effect of oral contraceptives on composition and volume of breast milk.
   Am J Clin Nutr. 1980 Apr;33(4):816-24.

Lopez LM Hiller JE, Grimes DA. Postpartum education for contraception: a systematic review. Obstet Gynecol
   Surv. 2010 May;65(5):325-31.

Lopez LM Hiller JE, Grimes DA Education for contraceptive use by women after childbirth. Cochrane Database
   Syst Rev. 2010 Jan 20;(1):CD001863.

Progestogen-only contraceptives during lactation: I. Infant growth. World Health Organization Task Force
   for Epidemiological Research on Reproductive Health; Special Programme of Research, Development,
   and Research Training in Human Reproduction. Contraception . 1994;50:35–53.

Smith KE, vad der Spuv ZM, Cheng I, Elton R, Glasier AF. Is postpartum contraceptive advice given antenatally of
   value? Contraception. 2002 Mar;65(3):237-43.

Tankeyoon M, Dusitsin N, Chalapati S, Koetsawang S, Saibiang S, Sas M, Gellen JJ, Ayeni O, Gray R, Pinol A, et al. Effects
   of hormonal contraceptives on milk volume and infant growth. WHO Special Programme of Research
   , Development and Research Training in Human Reproduction Task Force on Oral Contraceptives.
   Contraception. 1984 Dec;30(6):505-22.

Templeman CL, Cook V, Goldsmith LJ, Powell J, Hertweck SP. Postpartum contraceptive use among adolescent
   mothers. Obstet Gynecol. 2000 May;95(5):770-6

Truitt ST, Fraser AB, Grimes DA, Gallo MF, Schulz KF. Hormonal contraception during lactation: systematic
    review of randomized controlled trials. Contraception 2003;68:233–8.

				
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