Postpartum Contraception by mikeholy


									Postpartum Contraception

        ALLA GOLD BU RT , M S 4
               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?

 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
        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-
    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
    32-66% sexually active within first month,
    62-88% within second month
       How effective are we at counseling?

 Effectiveness of antenatal counseling (Smith
    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
    May precede menstruation

    < 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)

          ACOG               WHO (AAFP)

NON-      NOT recommended    NOT recommended
Br Feed

Br Feed

 Clinical Judgment
    Menstruation/ovulation is unpredictable
    Duration of breastfeeding
    Resumption of sexual activity
 Combination contraceptives- COCs, Nuvaring,

    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

    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)
                  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)
               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
NON-      Anytime                         Anytime                   Anytime
Br Feed

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

    May insert 20 minutes within delivery of placenta, using
     manual insertion OR 4-6 weeks postpartum once uterus has
    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….)

    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?

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Chen BA Reeves MF, Hayes JL, Perriera LK, Creinin MD. Postplacental or delayed insertion of the levonorgestrel
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                                     Resources, contd.

Lonnerdal B, Forsum E, Hambraeus L. Effect of oral contraceptives on composition and volume of breast milk.
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