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February Case Journal Case 1

Does are failures in hormonal contraception higher in obese patients?

We reviewed an article which described an analysis of a larger contraception CHOICE project. This is a prospective cohort of 9,256 reproductive-age females in the St. Louis area that was designed to promote long-acting reversible contraceptive methods by reducing barriers and by increasing knowledge. Participants received the contraceptive method of their choice. This study analyzed differences in failure rates for oral contraceptive pills, the patch and the ring for participants who were stratified by BMI on first visit. This question arose because hormonal contraception is used by a majority of the population for reliable birth control. These are often taken by patients to prevent pregnancy. As the American population is dealing with an epidemic of obesity we must better understand the effect of obesity on the medications are patients are taking. The evidence for the effect of obesity on contraception is unclear. Is the bioavailability of the active drugs altered such that incomplete ovarian suppression leads to more frequent ovulation or perhaps variable rates of metabolism affect clearance and steroid absorption. This study prospectively collected data on contraceptive failures. The method used at the time of failure was documented along with the BMI on first visit. This information was used to show that there was no statistically significant difference between the groups in contraceptive failure rates. This result is interesting because it conflicts with some other research findings in the past. Although this was a prospective analysis it consisted of a cohort which primarily being analyzed for another study - this was a secondary analysis. Another weakness was the small sample sizes. Since the authors noted there was no difference in failure rates by method use for different BMI they decided to combine the three methods of birth control for their analyses. There were differences between the group demographics however which were statistically significant. The conclusion of this article is that increasing degrees of obesity were not found to be associated with contraceptive failure. It suggests that obese patients who are using a hormonal contraceptive method may not be at increased risk of failure. This is helpful in counseling these patients. Case 2

Conde-Agudelo produced a meta-analysis of 67 studies which demonstrated that birth intervals less than 18 months or greater than 59 months following live birth were associated with adverse maternal and perinatal outcomes in the next pregnancy. We often hear >3 months or >6 months however there is little consensus.449 records. If the first pregnancy ended in a miscarriage there was a higher risk of the same outcome in the second (irrespective of interval). The WHO still states waiting >6months should be recommended however the supporting data is not sufficient to make that statement. They will ask us when they can resume trying for another pregnancy. the WHO published a report of a technical consultation on birth spacing based on a large study conducted in Latin America.We often have a patient how has a miscarriage of a desired pregnancy these patients are eager to try for another pregnancy. I found no clear guideline however I do see that following the WHO recommendation may not be the best course of action at this time. Basso et al. reported that risk of adverse pregnancy outcomes increased with increasing inter pregnancy intervals following miscarriage. This population based study of the Danish birth registry had 45. The recommendation was that couples wait at least 6 months before trying to conceive after a miscarriage. It is still difficult of find a consensus regarding the best recommendation for patients who have had a miscarriage. I decided to look at the current recommendations and their sources/ data. This study was not directed to prior miscarriage however Love et al showed that the best outcomes in the second pregnancy were associated with interpregancy intervals of less than 6 months. In my practice I would stick to making each decision based on the patient rather than a set rule . Conde-Agudelo's study found that an interval of less than 6 months following abortion (spontaneous and induced) were associated with adverse perinatal outcomes in the next pregnancy. Goldstein et al did not find any associated adverse outcome for birth intervals of less than 100 days. DaVanzo published a report on demographic surveillance in Bangladesh which found inter pregnancy intervals of 15-75 months were associated with reduced chance of fetal loss in the next pregnancy. Pregnancies following miscarriage are conflicting however. In 2005.