Choice of Contraceptive

Method in Special Cases

dr. Cepi Teguh Pramayadi, Sp.OG(K), MARS
24 September 2022
Cakupan peserta KB Aktif di sebagian besar provinsi masih berada di bawah rata-rata cakupan nasional
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KB suntik masih menjadi pilihan KB yang paling banyak digunakan

3
Maternal
Mortality in
Indonesia
Total maternal mortality rate in
2020:

4.627 cases

Total maternal mortality rate in

2019:

4.221 cases

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 Bleeding remains one of
most common cause of
maternal death. 99% of
bleeding cases
originates from unsafe
abortions.

9/3/20XX Presentation Title 5

 Pelayanan kontrasepsi pasca
persalinan termasuk dalam
kegiatan pelayanan Kesehatan ibu
Permenkes 97 pada masa sesudah melahirkan

tahun 2014
Postpartum birth control is included
in postpartum maternal healthcare
programme

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 Definition
The use of contraceptive methods
during postpartum period up to 42
days after delivery
Postpartum • Lowering maternal mortality
rate
contraception • Lowering infant mortality
focus points rate

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Preventing Maternal Mortaliity
SDG 3.1 from WHO
Suppresing maternal mortality rate under 70 for every 100.000 live
birth
No countries with maternal mortality rate of 140 for every 100.000
live birth

9/3/20XX Presentation Title 9

Ending Preventable
Maternal
Mortality- UNFPA
& WHO

9/3/20XX Presentation Title 10

 Contraceptive Eligibility Criteria Category

Category 1 No contraindication for contraception

Category 2 Conditions where the benefits of contraception

outweighs its downsides

Category 3 Conditions where the downsides of

contraception outweighs its benefits

Category 4 Any conditions where the use of contraception

is forbidden due to adverse effects on the
patient’s health conditions
Buku KLOP halaman 131
Why Postpartum Contraception?
• Reducing missed opportunities
• Lowering unmet need number  client had made contact
with healthcare providers since antenatal, delivery, and
postpartum
• Increasing new contraception users and increasing CPR
• Suppressing one of “four too-”’s component
• Post placental IUD has the biggest potential to prevent
contraception missed opportunity
Postpartum IUD
• IUDs are commonly placed at postpartum visits, typically 4 to
6 weeks after delivery but increasingly are being placed
immediately post partum, within 3 days of delivery
• Immediate postpartum IUD placement differs from interval
insertion technique.
• Best practice for immediate postpartum IUD insertion =
within 10 minutes of placental delivery in vaginal and
cesarean births, when possible.
 Cooper 7
Berbentuk angka “7”
Diameter 32 mm
Lilitan kawat tembaga 200
mm2
Bentuk memudahkan
pemasangan

Sumber: Putri RP, Oktaria D. Efektivitas Intra Uterine Devices (IUD) Sebagai Alat Kontrasepsi. Majority. 2016;5(4): 138-41
 Multi-load
Lengan plastik kiri dan
kanan
Panjang 3,6 cm
Lilitan kawat tembaga
256-375 mm2

Sumber: Putri RP, Oktaria D. Efektivitas Intra Uterine Devices (IUD) Sebagai Alat Kontrasepsi. Majority. 2016;5(4): 138-41
 IUD Hormonal
• Tipe yang paling banyak
tersedia: LNG-IUS 20/ Mirena
• Hormon LNG meningkatkan
ketebalan mukus serviks uteri
• Protektif terhadap PID
• Kegagalan lebih rendah
disbanding IUD tembaga

Sumber: Costescu, D. (2016). Levonorgestrel-releasing intrauterine systems for long-acting contraception: current perspectives, safety, and patient counseling. International Journal of Women’s Health, Volume 8, 589–598.
Postpartum IUD

Pfitzer, A., Mackenzie, D., Blanchard, H., Hyjazi, Y., Kumar, S., Lisanework Kassa, S., … Smith, J. M. (2015). A facility birth can be the time to start family planning: Postpartum
intrauterine device experiences from six countries. International Journal of Gynecology & Obstetrics, 130, S54–S61. doi:10.1016/j.ijgo.2015.03.008
Postpartum IUD
• After vaginal delivery, IUD insertion can be accomplished
manually or with a ring or Kelly forceps.
• The IUD is removed from the inserter and the strings are cut to
10 cm.
• The wings of the IUD are grasped gently with a ring forceps, and
the IUD is passed through the cervix and placed at the fundus.
• After initiating closure of the uterine incision, the IUD is placed
at the fundus with the inserter, manually, or with a ring forceps,
and the string gently placed manually or with ring forceps into
the cervix
Postpartum IUD
Postpartum IUD
Postpartum IUD

Contra- Intrauterine infection at time of

indications delivery
Postpartum hemorrhage

Puerperal sepsis
 IUD tembaga vs Levonogestrel

Sumber: Faculty of Sexual & Reproductive Healthcare. 2015 (Amended September 2019) Intrauterine contraception: clinical effectiveness unit. Faculty of Sexual & Reproductive Healthcare
 IUD tembaga vs Levonogestrel

Sumber: Faculty of Sexual & Reproductive Healthcare. 2015 (Amended September 2019) Intrauterine contraception: clinical effectiveness unit. Faculty of Sexual & Reproductive Healthcare
 IUD tembaga vs Levonogestrel

Sumber: Faculty of Sexual & Reproductive Healthcare. 2015 (Amended September 2019) Intrauterine contraception: clinical effectiveness unit. Faculty of Sexual & Reproductive Healthcare
 IUD tembaga vs Levonogestrel
• IUD tembaga: berhenti karena perdarahan menstruasi yang banyak
dan dismenorea
• Levonogestrel: berhenti karena amenorrhea dan spotting

Sumber: Faculty of Sexual & Reproductive Healthcare. 2015 (Amended September 2019) Intrauterine contraception: clinical effectiveness unit. Faculty of Sexual & Reproductive Healthcare
 IUD tembaga vs Levonogestrel
• IUD tembaga akan lebih rentan menyebabkan perdarahan dan kram
 perlu edukasi pasien
• Insidensi berkurang seiring berjalannya waktu
• Dapat diatasi dengan NSAID

Sumber: Faculty of Sexual & Reproductive Healthcare. 2015 (Amended September 2019) Intrauterine contraception: clinical effectiveness unit. Faculty of Sexual & Reproductive Healthcare
Postpartum IUD
Postpartum Implants
• Contraceptive implant may be
inserted in the delivery room
or at any other time before
hospital discharge.
• No contraindications or risks
specific to the postpartum
period apart from
breastfeeding
• The technique does not differ
from that for interval insertion
Postpartum Implants and Breastfeeding
• Observational studies of progestin-only contraceptives
suggest they have no effect on successful initiation and
continuation of breastfeeding or on infant growth and
development.
Postpartum Implants and Breastfeeding
 Postpartum Implants- Nexplanon
• Nexplanon® contains 68 mg
etonogestrel with 3% barium
sulphate.
• Same colour, has the same flexibility
and overall dimensions as Implanon.
Postpartum Implants- Nexplanon
 1. Postpartum OVULATION may
happen in 21 days
FACTS 2. Postabortion OVULATION may
happen in 11 days

Contraceptive choices for breastfeeding women .Journal of Family Planning and Reproductive Health Care 2004; 30(3): 181–189
Postabortion Contraception

Buku KLOP halaman 258

ABPK
 Angka Kehamilan per 100 Wanita pada Angka Kehamilan per 100 Wanita
Tahun Pertama pada Tahun Pertama

Dipakai secara tepat Dipakai secara

Dipakai secara
Metode Kontrasepsi dan konsisten Dipakai secara biasa Metode Kontrasepsi tepat dan
biasa
konsisten

Implan 0.05 0.05 Kondom Pria 2 15

EFEKTIVITAS
Vasektomi

AKDR LNG
0.1

0.2
0.15

0.2
Metode Penilaian Ovulasi

Metode Dua Hari (Menilai Sekret

3

METODE
Serviks)

Tubektomi 0.5 0.5 Metode Kalender 5

KONTRASEPS
AKDR Cu

Metode Amenore
0.6

0.9
0.8

2
Diafragma dengan Spermisida

Kondom Wanita
6

5
16

21

I
Laktasi (6 bulan)

Suntikan kombinasi
0.05 2 Metode alamiah lain 25
sebulan sekali

Suntikan progestin 0.3 3 Senggama Terputus 4 27

Pil kombinasi 0.3 8 Spermisida 18 29
Pil Progestin 0.3 8 Tudung serviks 26;9 32;16
Koyo kombinasi 0.3 8 Tidak menggunakan Kontrasepsi 85 85
Cincin vagina kombinasi 0.3 8

0 - 0,9 1-9 10 - 25 26 - 32
Sangat Efektif Efektif Cukup Efektif Kurang Efektif
Emergency Contraception
Methods of contraception that can be used to prevent pregnancy after sexual
intercourse
Emergency Contraception
• Recommended for use within 5 days but are more effective the
sooner they are used after the act of intercourse
• These methods prevent or delay ovulation and do not induce an
abortion
• No age limits
Emergency Contraception

• Levonogestrel, ulipristal acetate,

Pill mifepristone
• Taken within 120 hours or 3 days

• Cooper IUD
IUD • LNG-IUD
Emergency
Contraception
The use of emergency contraceptive pills
Emergency Contraception- Pills
WHO recommends:
• ECPs with UPA, taken as a single dose of 30 mg;
• ECPs with LNG taken as a single dose of 1.5 mg, or
alternatively, LNG taken in 2 doses of 0.75 mg each, 12
hours apart.
• COCs, taken as a split dose, one dose of 100 μg of ethinyl
estradiol plus 0.50 mg of LNG, followed by a second dose
of 100 μg of ethinyl estradiol plus 0.50 mg of LNG 12
hours later. (Yuzpe method)
Emergency Contraception- Pills
• Not applicable for pregnant women
• Women who are breastfeeding can use COCs or LNG
regimens for ECPs without restriction (MEC Category
1)
• Breastfeeding is not recommended for one week
after taking UPA since it is excreted in breastmilk.
Emergency Contraception- Pills
• Women who have experienced past ectopic
pregnancies can use COCs, LNG or UPA for ECPs
without restriction (MEC Category 1).
• Women with history of severe cardiovascular disease,
including ischaemic heart disease, cerebrovascular
attack, or other thromboembolic conditions, can
generally use COCs, LNG or UPA for ECPs (MEC
Category 2).
Emergency Contraception- Pills
• Women with migraines can generally use COCs, LNG or UPA
for ECPs (MEC Category 2).
• Women with severe liver disease, including jaundice, can
generally use COCs, LNG or UPA for ECPs (MEC Category 2).
• Women using CYP3A4 inducers can use COCs, LNG or UPA for
ECPs without restriction (MEC Category 1). Strong CYP3A4
inducers may reduce the effectiveness of ECPs.
Emergency Contraception- Pills
• No restrictions on repeated ECP use for COCs, LNG or UPA (MEC
Category 1).
• Recurrent ECP use is an indication that the woman requires
further counselling on other contraceptive options
• No restrictions for use of COCs, LNG or UPA for ECPs in cases of
rape (MEC Category 1).
• Women who are obese can use COCs, LNG or UPA for ECPs
without restriction (MEC Category 1). ECPs may be less effective
among women with BMI ≥ 30 kg/m2 than among women with
BMI < 25 kg/m2
Emergency Contraception- IUD
• Most effective method of emergency contraception –
less than 1% of women who use the IUD get pregnant.
• Most women can use an IUD, including those who are
HIV positive
• A Cu-IUD can be inserted within five days of unprotected
intercourse.
• A safe form of emergency contraception. Less than 2
cases of Pelvic Inflammatory Disease (PID) per 1000 users
Emergency Contraception- IUD
Emergency Contraception- IUD
• Most effective method of emergency contraception –
less than 1% of women who use the IUD get pregnant.
• Most women can use an IUD, including those who are
HIV positive
• A Cu-IUD can be inserted within five days of
unprotected intercourse.