Dr. Rabinarayan Satapathy

Asst. Professor

Dept. of Obst.& Gynae

S.C.B. Medical College,Cuttack

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?

• breastfeeding

• hypercoagulable state

different contraceptive needs

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 groups.

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

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

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

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…..

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

What are the options? How do we use them?

Why do we recommend using them in this

way?

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)

ACOG WHO (AAFP)

NON-

Br Feed

NOT recommended NOT recommended

Br Feed

Clinical Judgment

Menstruation/ovulation is unpredictable

Duration of breastfeeding

Resumption of sexual activity

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

ACOG WHO (AAFP) AAP

NON-

Br Feed

> 4 weeks < 3 wks not rec unless

no other method avail

> 3 wks use freely

No earlier than 3-6

weeks

Br Feed > 4 weeks, waiting

until br feeding

well established

< 6 wks do NOT use

6 wks- 6 mo not rec

unless no other method

avail

> 6 mo use freely

No earlier than 3 to

6 wks, wait until

infant not relying

pred on br milk

Clinical Judgment

Acceptable reduction of risk of thrombosis

Perceived effect on establishment of

breastfeeding patterns

Ease of use for mother

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)

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)

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.

ACOG WHO 2008 (AAFP) PPFA

NON-

Br Feed

Anytime Anytime Anytime

Br Feed > 3 weeks if partially br

feeding

> 6 weeks if fully br

feeding

< 6 weeks not rec

unless no other method

avail

> 6 weeks use freely

Anytime

MIRENA

Br Feed

< 48 hrs not rec unless

no other method avail

48hrs- 4 weeks not rec

unless no other method

avail

> 4 weeks use freely

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

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)

ACOG WHO (AAFP)

NON-

Br Feed

< 48 hrs generally use

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

Clinical Judgment

Review of safety of postpartum insertion based

off of poor to fair quality trials (Kapp 2009)

Expulsion risks

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?

EBM

No increased risk of VTEs for mom

No effect on breastmilk

Clinical Judgment

Availability

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?