Case 4

Case
• 19 yo, obese, with GDM and preeclampsia during
pregnancy

• delivered to a live baby boy via SVD 2 weeks ago.

• On postpartum ffup at your clinic

• Seeking advice regarding family planning
• What are your options?
• What do you need to ask?
1. Natural Family Planning Methods
2. Mechanical Contraception
3. Hormonal Contraception
 First Requests

History
• Existing medical problems
• Regular medication
• Family history
• Menstrual history
• Obstetric history
• Previous contraceptive use
 First Requests
Issues to cover for each method
• Efficacy
• Individual suitability
• Absolute contraindications
• Side effects
• Adverse reactions
 First Requests
• Advantages other than contraception
• Mode of use
• Onset of action
• Follow-up arrangements
• Timing of return to fertility
• Protection against sexually transmitted
disease
 Methods Are Not All Alike—Attributes
that Matter to Clients
Ease and Comfort of Use Mode of Action Control of Method
• Does/does not require a • Hormonal • Client
pelvic exam • Nonhormonal • Partner
• Frequency of use/of clinic • Barrier • Provider
visits
• Does/does not require Duration of Effectiveness Ease of Discontinuation
touching one’s genitals
• Short-acting
• Has/has no impact on
pleasure • Long-acting reversible Cultural Acceptability
• Side effects • Permanent
• Nonsurgical or surgical Affordability
Ease of Access
• Risks
• Public sector
• Discreetness
• Private sector
• Kiosk
• Clinic or hospital
• Home distributor
 WHO Medical Eligibility Criteria

Classification

1 Use method in any circumstances

2 Generally use the method -

advantages outweigh risks
3 Usually not recommended unless more
appropriate methods are not available
4 Method not to be used-
Condition represents an unacceptable risk

Medical Eligibility Criteria For Contraceptive Use. Fourth Edition. WHO, 2009
• On PE
• VS- BP 155/94 HR88 RR 22
• Multiple varicosities noted

• Patient has history of repeated cervicovaginitis

• Irregular menses, reports that she is
“makakalimutin”
• What family planning method will you offer?
1. Natural Family Planning Methods
2. Hormonal Contraception
3. Mechanical Contraception
 Lactational Amenorrhea Method
(LAM): Recommendations
• All breastfeeding women should be counseled
that LAM can safely be used provided all three
requirements are met:
1. The mother’s monthly menstrual cycle has not
returned
2. The mother is fully or nearly fully breastfeeding her
baby.
3. The baby is less than six months old.
 Lactational Amenorrhea Method
(LAM): Recommendations
• If any of the above is not met, the client
should be advised to use another family
planning method.
(GRADE C)
• Women with HIV, active untreated TB disease,
or herpes simplex lesion on the breast can
transmit the causative organisms to her infant
through breastfeeding.
• Explain the pathophysiology of LAM
 Lactation

 Lactation involves both milk

production and milk “let-
down.”
 During pregnancy, the
placenta secretes high levels
of estrogen and
progesterone to prepare the
breasts for lactation.
• Lacto genesis is initially
triggered by the delivery of
the placenta (E↓P↓and
prolactin).
 Lactation

• Infant suckling stimulates the

posterior pituitary gland to
produce the hormone oxytocin
which allows milk to “let
• down” (release of milk from
the alveoli to the milk ducts).
• Without continued infant
suckling, milk production and
let down will cease within one
to 2 weeks
 Human milk is ideal food for newborns.

Advantages
• Nutritional
• Immunological
• Developmental
• economical.
Women who breastfeed:
• has a lower risk of breast and
reproductive cancer
• less postpartum weight retention
• lower risk of coronary heart
disease.
 Contraindication to breastfeeding

• Those who take street drugs and who

cannot control alcohol use
• Infants with galactosemia
• Women with HIV infection
• With active, untreated tuberculosis
• Undergoing breast cancer treatment
• Drugs to be avoided include
cyclophosphamide & methotrexate.
 Calendar Rhythm Method:
Recommendations
• Refrain from vaginal intercourse during the
woman’s fertile period computed as:
 Shortest recorded cycle minus 18 (start of the fertile
period)
 Longest recorded cycle minus 11 (end of the fertile
period)
(GRADE C)
 Standard Days Method:
Recommendations
• Abstain from vaginal intercourse from
menstrual days 8-19 among women with
cycles of 26-32 days
(GRADE C)
 Symptothermal Method:
Recommendations
• Recommended for any reproductive age
woman who:
1. is willing to take and chart her BBT daily,
2. has the patience and diligence to chart her daily
observations of her cervical mucus
3. can make a daily record of all these
4. willing to practice abstinence during the fertile
period
 Symptothermal Method:
Recommendations
The woman should:
• Refrain from vaginal intercourse when she
senses cervical secretions, until both the
fourth day after peak cervical secretions and
the third full day after the rise in BBT.
(GRADE C)
• The patient asks “Doc, marami kasi akong
pimples. Gusto kong kuminis. Yung
kapitbahay ko sabi mag pills daw ako.”

• What will you tell the patient?

Hormonal Contraception
Combined Oral Contraceptives
(COC)
 Recommendations
• 3rd and 2nd generation COCs are better tolerated than
the 1st generation COCs
(GRADE A)
• Monophasic pills - first choice for women starting
oral contraceptive use.
(GRADE C)
• Health provider - guided by the WHO Medical
Eligibility Criteria (MEC) when prescribing/
dispensing COCs.
(GPP)
Category 1 and 2 Examples (not inclusive):
Who Can Use COCs
WHO Category Conditions (selected examples)
Category 1 Menarche to 39yrs; nulliparous ;
endometriosis; endometrial or ovarian
cancer; uterine fibroids; family history of
breast cancer; varicose veins; irregular,
heavy, or prolonged bleeding; anemia;
STI/PID; hepatitis(chronic/carrier)
Category 2 > 40yrs; breastfeeding > 6 months
postpartum; superficial
thrombophlebitis; uncomplicated
diabetes; cervical cancer; unexplained
vaginal bleeding; undiagnosed breast
mass
 Category 3 Examples (not inclusive): Who
Should Generally Not Use COCs
WHO Conditions (selected examples)
Category
Category 3 Postpartum:
• Breastfeeding between 6 weeks and 6 months
• Non-Breastfeeding < 21 days (if no additional risk
factors for blood clots)
Vascular conditions:
• Hypertension (history of or BP 140-159/90-99)
• Migraine without aura (older than 35yrs)
Gastrointestinal conditions:
• Symptomatic gall bladder diseases (current and
medically-treated)
Drug interactions:
• Use of rifampicin, rifabutin, ritonavir
 Category 4 examples (not inclusive):
Who should generally not use COCs
WHO category Conditions (selected examples)
Category 4 Breastfeeding: <6 weeks postpartum
Smoking: > 15 cigarettes/day and > 35yrs old
Vascular conditions:
• Hypertension (>160/>100)
• Migraines with aura
• Ischemic heart disease or stroke
• Diabetes with vascular complications
• Deep venous thrombosis (history of acute)
• Pulmonary embolism (history of acute)
Liver conditions:
• Acute hepatitis
• Sever liver disease and most liver tumors
Breast cancer: current or within 5yrs
• Examples of Different brands of OCPs in the
Philippines
Generic Brand
Ethinyl estradiol 30 mcg, Levonorgestrel 125 mcg, Trust
Ferrous fumarate 75 mg

Ethinyl estradiol 30 mcg, Levonorgestrel 150 mcg, Lady

Lactose 7 tabs

Lynestrenol 500 mcg Daphne

Cyproterone Acetate 2mg, Ethinyl estradiol 35 mcg Althea

Ethinyl estradiol 30 mcg, Levonorgestrel 150 mcg, Charlize

Ferrous fumarate 75 mg
 Recommendations
• For fully/nearly fully breastfeeding clients for 6
months,
 Start anytime if still amenorrheic but within the first 5
days of menses if menstruation has resumed.
(GPP)
• Started immediately after an abortion. No back up
contraceptive is needed (if begun on first 7 days post
abortion).
(GRADE B)
Case

• Obese, GDM with preeclampsia during first

pregnancy
• On PE
• VS- BP 155/94 HR88 RR 22
• Multiple varicosities noted

• Patient has history of repeated cervicovaginitis

• Irregular menses, reports that she is
“makakalimutin”
Progestin Only Contraceptives
 Recommendations
• Recommended for breastfeeding women, for
those with cardiovascular problems, & women
who are smokers.
(Grade A)
• Should be taken on a continuous daily basis
with no pill-free interval, preferably at the
same time every day.
(Grade A)
 Recommendations
• Can be started at any time during the
menstrual cycle; however, if not started during
the first day of menses, a back-up
contraceptive is required for 2 days
• Take on the same hour of every day
(Grade C)
 Recommendations
• In case of missed pills, take it as soon as
possible and use a back up method for the
next 2 days.
• Should not be taken concurrently with
medications known to decrease its
effectiveness.
(Grade C)
 Recommendations
• Most common side effect is altered bleeding
pattern and is the most common reason for
discontinuation
• Fertility returns immediately upon
discontinuation of the POP

(Grade C)
 Recommendations
• Preferred contraceptive method for lactating
mothers (no known adverse effect on the
infant or on lactation)
(Grade B)
• postpartum non-breastfeeding women may
be started on progestin-only pills at anytime
within 4 weeks after giving birth.
(Grade C)
 Recommendations
• Breastfeeding women can be started anytime
between 6 weeks to 6 months postpartum as
long as menstruation has not yet returned.
(Grade C)
 Recommendations
• Injectable progestins are suitable for women
who have hypertension, diabetes,
cardiovascular disease, kidney disease,
migraine headaches without aura, varicose
veins or thrombophlebitis. It is also given to
postpartum and post-abortal patients.
(Grade C)
 Recommendations
• Most common side effect of DMPA is
unscheduled bleeding  variable pattern in
the first 6-9 months of use.
(Grade B)
• DMPA can be used without restriction among
women ages 18-45 years old.
(Grade B)
 Recommendations
• Progestin implants must be inserted by trained
individuals.
(GPP)
• Progestin implant may be removed anytime, with
fertility returning as early as 42 hours after
removal.
(Grade B)
• Progestin implants are suitable for adolescents.
(Grade C)
The client opted to have the implant.
She asks “Ano po ba yung implant?”

What is the mechanism of action of the implant?

What are the side effects of the implants?

Can the client have the implant in this visit?

 What is the implant (Implanon)?

— Is a sub- dermal, long acting, progestin-only

hormonal contraceptive that is effective for 3 years

— The white flexible implant contains 68 mg of

etonogestrel and released at a rate of 60-70
micrograms/day by 5-6 weeks and gradually
decreases to 35-45 micrograms/day at the end of
the first year, 30-40 micrograms/day at the end of
the second year and finally to 25-30 micrograms at
the end of the third year.

8
What is the mechanism of action of the
etonogestrel implant?

— Single rod subdermal implant inhibits ovulation. No

ovulation occurs in the first 2 years and in the third
year it may happen but rarely

— It thickens the cervical mucus and makes it

impenetrable to the spermatozoa

9
 What are the side effects of the
etonogestrel implant?

— The adverse events that may develop from

Implanon NXT are altered menstrual pattern,
headache, weight gain, acne, breast pain/
discomfort, emotional lability, and abdominal
pain.

10
 Can this client have the etonogestrel
implant in this visit?

When is the implant inserted?

— on an interval basis within the first 5 days of the
woman’s menstrual cycle
— anytime as long as the provider is reasonably
certain that the client is not pregnant
— in the immediate postpartum period in a mother
who is either breastfeeding or not

12
• What other family planning methods can you
offer?
Intrauterine Device (IUD) Intrauterine
System (IUS)
 Recommendations
• Risk assessment for STI should be done for all
prospective IUD/IUS users but there is no
need for routine STI screening tests prior to
insertion of IUD/IUS.
(Grade C)
 Recommendations
• IUD/IUS can be inserted:
1. At any time during the menstrual bleeding (Day 1-7)
2. At anytime during the menstrual cycle provided that
it is reasonably certain that the woman is not
pregnant (See Appendix for pregnancy check list),
3. Immediately after the first- or second- trimester non-
septic abortion
 Recommendations
• IUD/IUS can be inserted:
4) At any time within 48 hours after child birth
5) Immediately after cesarean delivery
6) From 4 weeks postpartum
7) Immediately when shifting to another method
which was used correctly and accurately.
(Grade A)
 Recommendations
• Heavy menstrual bleeding and/or
dysmenorrhea are likely with IUD use.
(Grade A)
• During the first 6 months following LNG-IUS
insertion, irregular bleeding and spotting are
common while oligomenorrhea or
amenorrhea is likely by the end of the first
year of its use.
(Grade A)
 Recommendations
• Symptoms of uterine perforation or infection that
would warrant an immediate consultation.
(Grade C)
• In an intrauterine pregnancy with an IUD/IUS in
situ, removal should be done provided the tail is
visible, after thorough counseling about the risk
of miscarriage, preterm delivery and infection. If
the tail is not accessible, close follow up and
observation is warranted.
(Grade B)
 Recommendations
• No evidence of a delay in the return of fertility
following removal or expulsion of IUDs
(Grade B)
• Women in any reproductive age may use IUDs
(Grade B)
• Can be safely used during breastfeeding
(Grade B)
 Recommendations
• Copper IUDs and LNG-IUS may be used by
women with BMI over 30.
(Grade C)
• LNG-IUS is effective for patients with heavy
menstrual bleeding and dysmenorrhea
associated with endometriosis.
(Grade A)
Barrier Methods
 Male Condom:
Recommendations
• Efficacy in preventing pregnancy
Perfect use: 98%
Typical use: 85%
(GRADE A)
• Effective in preventing the transmission of HIV
and reducing the risks of other STIs
(GRADE B)
Sterilization
 Tubal Ligation:
Recommendations
• Sterilization is not associated with a decrease
in sexual interest and pleasure.
(Grade B)
• Post-partum sterilization is preferably done
between 2 to 7 days post delivery.
(Grade C)
 Vasectomy:
Recommendations
• has no negative effects on sexual performance
or frequency of sexual intercourse
(Grade B)
• Recommended technique is a no-scalpel
approach  lower rate of complications
(Grade A)
 Vasectomy:
Recommendations
• The client should wait 3 months before relying
on his vasectomy for contraception, during
which he and his partner may use other forms
of contraception. Semen analysis, where
available, can confirm contraceptive
effectiveness after the 3–month waiting
period.
(Grade B)