Contraception Full

8/8/2019 Contraception Full

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CONTRACEPTION


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Introduction

It is a control of fertility and patient seek

contraception for many reasons.

An ideal contraceptive should be effective,easy to use, reliable, cheap and have minimal

complication.


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Classification

Of Method

Not requiring medical

consultationRequiring medical

consultation

1. Coitus interruptus

2. Rhythm method

3. Barriers method

4. Spermicides

1. Hormonal

contraception

2. Occlusive

diaphragm or

caps

3. Intrauterine

devices

4. Tubal ligation

5. Vasectomy


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Methods Not Requiring Medical Consultation

Coitus interruptus

Withdrawal of the entire penis from the vagina before ejaculation.

Fertilization is prevented by lack of contact between spermatozoa and the

ovum

Efficacy:

Effectiveness depends largely on mans capability to withdraw prior to

ejaculation. Failures is due to the escape of spermatozoa into the vagina

either because withdrawal is mistimed or because premature escape of

sperms occur before ejaculation in some men.

Advantages:

Immediate availability, requires no devices, no cost, does not involve

chemicals and theoretical reduce risk of STDs

Disadvantages:

A high probability of pregnancy exists with incorrect or inconsistent use.


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Safe Period (avoid having intercourse during womens fertile period)

Calendar Method Ovum is capable of fertilization only for about 24hours after ovulation.Spermatozoa can retain their fertilization ability

for 48 hours after coitus.

Ovulation occurs 12-16 days before the onset of

subsequent menses.

-The women counts the calendar days to identify

the start and end of the fertile period.

- This period starts about 10 days after the onset

of her period and end 10 days before first day of

the next anticipated menstrual period.

-To be efficient, regular menses monthly cycle areneeded


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Basal Body Temperature

Method

The basal body temp of a women is

relatively low during the follicular

phase and rises in luteal phase inresponse of thermogenic effect of

progesterone.

Ovulation is said to have occurred

once the body temp rises. In

anticipation of this rise, sexual

intercourse is avoided

Cervical secreation

method

The woman places her hand into

the vagina, feels for the cervix,

and after removing her handassesses for the spinbarkeit

phenomena, i.e a clear stringy

nature of the mucus.

if it is present, sexual

intercourse is abstained.


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Lactational

Ammenorrhe

Method (LAM)

The patient uses breast feeding as a

temporary form of family planning.

LAM provides natural protection against

pregnancy for a woman provided that her baby

gets 85% of feeds as breast milk and her

menstrual periods have not returned.


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Barrier Method Create either physical or chemical barrier that prevent sperm

from reaching the ovum.

Condoms are example of physical barrier

spermicides are chemical barriers and delivered using foam,cream, jeally.

Advantages

Its safe

No systemic side effects

Easy to initiate or discontinue and there is an immediatereturn to fertility

Does not require expert help or frequent visits to the clinic

Affords some protection against STDs


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Disadvantages

Not as effective as other methods

my be difficult to use consistently and correctly

my require partner participation and hence interrupt sexualactivity


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Spermicide

Besides being toxic to sperm, it have advantage ofreducing the

transmission ofSTDs such as gonorrhea or clamydia infection

But it can cause mild discomfort and minor allergic reactions.

They may also cause vaginal infection ifused frequently.

The correct way to use spermicides is to wash one hands before use anduse a clean applicator to place it high in the vagina.

For maximum effectiveness, it should be used with another barriermethod.

No douching should be done for six hours after the last intercourse.


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Diaphragm

A shallow latex cup with spring mechanism inits rim to hold it in place in vagina.

Requires pelvic examination andmeasurement vaginal canal to get corrcectdiaphragm size.

Inserted before intercourse and spermicidal

cream is applied inside the dome. Prevents passage of semen into cervix.

Provides effective contraception for 6 hours.


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Combined oral contraceptive pills.

ostrogens

- ethinyl estradiol

Common dose: 30-35

microgram)

Mestranol

progestogen

Second generation:

- Norethisterone acetate

- Levonorgestrel

Third generation

-gestodene

-desogestrel


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21 pills

One pill taken daily.

Followed by 7-day pill

free interval.

Or 7 placebo pills.

For maximum action:

Taken regularly at

roughly the same time

each day.


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Mode of action

Centrally

Inhibit ovulation.

Estrogen and

progestogen suppress

the release FSH and LH.

Hence no follicular

development andovulation.

Peripherally

Endometrium atrophic.

Alter consistency of

cervical mucus- hostile


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Side effects

1. venous

thromboembolism

(VTE)

Estrogen activate bloodclotting mechanism.

Progestogen 3rd

generation can sustain

VTE.

2. Arterial disease.

-significant in smoking

women. increase the

risks.

For women who smoke,

it is advised to stop COC

at 35 years old.


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3. breast cancer

Insignificant in young

women.

But can increase the

risk in age above 40s.

Efficacy

Depends on

compliance.

Perfect use- higher

susccesful rate


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contraindication

Absolute contraindication

- circulatory diseases: ischaemic diseases,

significant hyoertension, arterial & venousthrombosis.

-acute or severe liver disease.

B

reast cancer


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Positive health benefits

To treat menstruation irregularity.

Can manipulate the cycle to avoid menses

during certain occasion : performing hajj Reduce risk of pelvic inflammatory diseases.

Acne treatment

Long term protection of ovarian andendometrial cancer


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Management

1. detailed patient past medical history/ familyhistory.

2.careful explanation and consultation.

3. check BP

4. give 3-months supply of COC in the firstinstance and then 6 monthly review

thereafter. 5. advice on what to do if they miss taking

pills. refer 10 teachers text book.


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Progestogen only contraception

Does not contain estrogen

Safe and can be used bywomen with CVS risk factors.

Methods: A) progestogen-only pill/ mini-pill.

B) Subdermal implantImplanon.

C) Injectables

D) Hormone releasingintrauterine system.

Mode ofaction

A) mucus production- hostilefor sperm movement

B) atrophic endometrium.

Efficacy

Less than COC

Contraindications:

E

rratic / absent menstrualbleeding

Functional ovarian cyst

Breast tenderness


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Progestogen-only pills.

Indications:

CVS risk

Breastfeeding Older age

Diabetes

Taken daily without break.


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Injectable

types:

A) Depo- Provera / DMPA)

B) noristerat.

Depo Provera

Highly effective.

Deep IM injection.

MOA: suppress FSH & LH

Useful to give women with difficulty to complywith COC.


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Subdermal implants

Subdermal implants

Consists of a single silastic rod that is insertedsubdermally under local anaesthetic into

upper arm.

Releases progestrel daily. Useful for women with poor compliance with

COC and long term contraception.


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Intra uterine devices.

Contains copper and progesterone releasing form.

T shape and 7 shape.

Can be compressed in order to be inserted. When thedevice is placed in uterine cavity, it opens out, so it

retained.

Mode of action

Copper IUD- toxic effect on sperm.

L

evonorgestrel releasing intrauterine system-

hormonaleffect on cervical mucus- thicker.

Induce inflammatory response in endometrium whichprevents implantation.


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A few types

Levonogestrel IUS

Mirena.

T shape frame

Placed in uterus

Releases LNG daily

Visible on x ray

Gynaefix

Frameless

6 copper beads on a

prolene thread.

The upper end of

thread is anchored intofundal of myometrium.


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LNG Mirena Gynaefix


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contraindications

Previous PID

Previous ectopic pregnancy

Known malformation of uterus. Copper allergy


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Female sterilisation

Fallopian tube ligation divided into those performed at thetime of delivery or shortly thereafter, and those performed at

another time.

Minilaparotomy (Irving , Pomeroy, or Parkland technique) is

the most common procedure in the immediate postpartum

period, performed via periumbilical incision following vaginal

delivery.

The proximity of the uterine fundus in relation to the

umbilicus during the immediate postpartum period facilitates

this approach. The laparoscopic approach may be used at any time other

than the postpartum period and involves a smaller umbilical

camera port and a secondary suprapubic port through which

the various devices are introduced.


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Advantages permanent

No change in libido

No change in menstrual cycle

No change in lactation

Disadvantage GA involved

Regret decision

Does not protect from STD


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Minilaparaotomy tubalsterilisation

Pom

eroy

Parkland

Irving


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Pomeroy

Simplest and most commonly used

The mid portion of the fallopian tube is grasped with aBabcock clamp, creating a loop which is tied with 2-0 or 0plain catgut suture, and each limb of the tubal knuckle is

cut separately. Specimens are submitted to pathology.

The endosalpinx at the cut ends may be cauterised(optional).

The ligation sutures are held while the tube is cut to

prevent retraction of the cut tubal stumps into thperitoneal cavity before they can be adequately examinedfor hemostasis.

Failure rate = 1 in 300-500 patients


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Parkland

The parkland technique is midsegmentalresection similar to the pomeroytechnique.except each leg of the loop is tied

separately. Designed to avoid the intimate approximation of

the tubal cut ends, as occurs with the pomeroytechnique,

Eliminating the risk of secondary adherens andsubsequent recanalisation

Failure 1 in 400


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Irving

Used conjunction with cesarean delivery

A mesosalpingeal window is created beneath thetube approximately 4cm from the uterotubal

junction. The tube is doubly ligated with 0 or 00 absorbale

suture and severed, with the suture on theproximal end left long

The proximal tubal stump may requiremobilisation by dissecting it free frommesosalpinx.


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A small nick is made into serosa on the posterior oranterior uterine wall near the uterotubal junction.

A tonsil or hemostat is used to deepen the incisioncreating a pocket in the myometrium tunnelapproximately 1-2 cm deep

The 2 free ends of the proximal stump ligature are thenindividually threaded onto a curved needle and

brought deep into the myometrium tunnel and outthrough the uterine serosa.

Traction on the sutures draws the proximal tubal stumpdeep into the myometrial tunnel, and the suture aretied.

The serosal opening of the tunnel is then closedaround the tube with fine absorble suture

Failure rate < 1 case in 1000 patients


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Laparoscopic strelisation

Instumental visualisation of the abdominal

organs through the abdominal wall using the

laparoscope

Incorporated with operating accessory in the

instrument.

Tubal occlusion is accomplished by

electrocautery,application of silastic ring or

application of clips


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Advantages

Small incision

Rapid excess to the fallopian tube

Rapid recovery

The ability to inspect intraperitoneal organs

disadvantages Maintenance of fragile and expensive equipment

Risks of vessel/ viscera injury with needle

insufflation entry 30-50% of all laproscopic sterilisation

complications


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Electrocoagulation method

Ring techniques (falope)

Clip techniques Hulka

Filshie


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