GYN Module 2 Exam PDF

GYN Exam 2 Blueprint Unit 6: Contraception Definitions -Pearl index: number of unintended pregnancy/ year of exposure to risk of unintended pregnancies x # of people in study Effectiveness...

GYN Exam 2 Blueprint Unit 6: Contraception Definitions -Pearl index: number of unintended pregnancy/ year of exposure to risk of unintended pregnancies x # of people in study Effectiveness: success of a method in preventing pregnancy when used typically including pregnancies that occur because of incorrect or inconsistent use. (Typical use) Efficacy: chance that conception will occur despite consistent and correct use of a given method. (Perfect use) True method failure  NON Hormonal Behavioral Methods Abstinence -cost free, controlled by the individual, does not require a healthcare provider. Free of side effects and is available at any time. Complete abstinence if 100% effective and preventives exposure to STIs as well as pregnancy, Coitus interruptus Indications: pregnancy prevention Contraindications: None MOA: penis is completely removed from the vagina and away from the labia and external genitalia before ejaculation Efficacy perfect: 4% typical: 12%-20% Education: Does not prevent STIs, provide education about emergency contraception as a back up if indicated, Pre-ejaculate may contain sperm Barriers to access: Man has to agree on plan for withdrawal Return to fertility: NA Warning signs (potential risks/adverse effects): None Trouble shooting/treating current methods the side effects: None Lactational amenorrhea Indications: pregnancy prevention Contraindications: HIV positive not recommended MOA: prevention of ovulation. High levels of prolactin due to breastfeeding inhibit secretion of GnRH from the hypothalamus—thereby inhibiting ovulation. Efficacy: up to 98-99.5% during the first 6 months postpartum Education decreased risk of ovarian/endometrial/breast cancer Barriers to access: only an option for 6 months postpartum if able to follow criteria. (Daycare, returning back to work) Return to fertility: likely to start ovulating after 6 months of age and be unaware of return of fertility Advantages: readily available, free, can be used immediately postpartum Warning signs (potential risks/adverse effects): does not provide protection against STIs Trouble shooting/treating current methods the side effects: SE associated with breastfeeding as sore nipples Fertility awareness method severe different approaches to this method in understanding where you are in your cycle Indications: pregnancy prevention Contraindications: irregular cycles MOA/ Efficacy Education 1. Commitment by both sexual partners to consistently use method month after month 2. Comfort in observing for signs of fertility including touching the vulva 3. Commitment to recognize and document any subtle signs of fertility 4. Ability to practice absistence for at least one month during which time baseline signs of fertility are observed and documented before initiating the method Barriers: dont wanna use in early menarche, perimenopause, PP, post abortion and medications may alter regularity of cycles or fertility signs Return to fertility: never lost it Warning signs (potential risks/adverse effects): doesn’t protect against STIs Trouble shooting/treating current methods the side effects: learning your body  Barrier methods Male condoms Indications: pregnancy prevention and protection against STIs Contraindications: latex allergy, oil based lubricants (petrol)-will break down the latex MOA: barrier Efficacy perfect: 0.4% typical: 13% Education: dont use too much spermacide-can cause slippage of condom can be used dry or with lubricants pinch the tip Emergency contraception in the case of breakage or slippage dual use with other contraceptive methods for those with multiple or new sex partners to reduce risk of STIs Barriers to access: cost Return to fertility: never lost Warning signs (potential risks/adverse effects): can cause irritation or discomfort, perceived reduced sensitivity, required planning, application before intercourse, breakage or slippage Advantages: no hormonal, available without prescription, does require daily action, STI protection Trouble shooting/treating current methods the side effects Spermacides Indications: pregnancy prevention Contraindications: high risk of exposure of HIV MOA: chemical barrier, containing Nonoxynol-9 surfactant that destroys the sperm cell membrane Efficacy perfect: 16% typical: 21% Education: NO STI prevention, should not be used by women who engage in multiple day acts of intercourse (sex workers) post-coital leakage dont use rectally Barriers to access: prescription for sponge Return to fertility: never lost it Warning signs (potential risks/adverse effects): sponge: toxic shock (staph A or Strep p), contact dermatitis, local irritation of vulva, penis, vaginal, Trouble shooting/treating current methods the side effects: NA Diaphragm Indications: pregnancy prevention Contraindications: high risk of HIV or AIDS (used with spermacide), UTI MOA: kill and block the sperm Efficacy perfect: 16% typical: 17% Education: 1 tsp spermacide goes inside the dome and on the rim, inserted less than 3 hours prior to coitus, and left in place for at least 6 hours after coitus (no more than 24 hours if another act of sex occurs, dont have to take it out but put more spermacide intravaginally May need to be refit if gained 15lbs, a birth or second trimester abortion should not be used after giving birth until uterine involutions is complete and it has regained its tone Barriers to access: visit to get sized (except for Caya-one size fits most) Return to fertility: never lost it Warning signs (potential risks/adverse effects): UTIs (rim pushes against urethra + spermacides alter bacteria flora—increased E.Coli), MEC 3 history of toxic shock Trouble shooting/treating current methods the side effects: if recurrent UTIS occurs—may need to refit. Cervical caps Indications: pregnancy prevention Contraindications: HIV, cervical cancer, cervical intraepithelial neoplasia, or marked abnormally shaped cervix should use another form of contraceptions. Dont use during menstruation—increase of TSS MOA: barrier + kills sperm (spermacide) Efficacy- not as effective as diaphragm, less effective in women of have had children perfect typical failure rate: 20% Education: should be replaced after each year of use, size change needed in event of pregnancy, birth, or SAB or IAB, can be placed jul to 42 hours before intercourse, can be left in place for at least 6 hours after intercourse Barriers to access: prescription is required, need to be fitted, Return to fertility: never lost it Warning signs (potential risks/adverse effects): same as diaphragm but decrease risk of UTI, does not protect against STI Trouble shooting/treating current methods the side effects: size change as listed above Vaginal sponge Indications: pregnancy prevention Contraindications: same as above, HIV MOA: single use, releases spermacide over 24 hrs, can be used for multiple sex acts without having to add more spermacide. Barrier + kills sperm Efficacy Parous perfect: 20% typical: 27% Nullip perfect: 9% typical: 14% Education: remove after 24 hours, moistens with tap water until suds appear prior to use, leave in place for 6 hours after coitus, no longer than 30 hours. Barriers to access: none Disadvantages: tend to DC at higher rates than those who use the diaphragm. Return to fertility: never lost it Warning signs (potential risks/adverse effects): contact dermatitis (same as diaphragm), Toxic shock syndrome (recent childbirth, longer than 24 hr use, leaving pieces inside when removing) Pros: available OTC, dont need to be fitted Trouble shooting/treating current methods the side effects: stop using if causes contact dermatitis Internal condom (female) Indications: pregnancy prevention Contraindications: spermacide-HIV MOA Efficacy perfect 5% typical failure rate 20% Education: dont use with male condom-increases risk of breakage, don’t use with a diaphragm, cervical cap, or contraceptive vaginal ring because the inner ring of the internal condom fits into the same place the cervix as those landmarks. Not made of latex. Can be inserted up to 8 hours before sexual intercourse. Lubricate with spermacide Non contraceptive benefits: Protective against some UTIs Barriers to access: none Return to fertility: anytime it is not used Warning signs (potential risks/adverse effects): discomfort for both parties involved. Adhere to penis, outer ring pressing against vulva. Does not protect against STIs Trouble shooting/treating current methods the side effects Copper IUD Indications: pregnancy prevention, emergency contraception, FDA approved for 10 years Contraindications: Wilson’s, SLE with severe thrombocytopenia MOA: alters sperm tubal transport, has toxic effects on ovum, impairs normal sperm activity by slowing motility, reduces capacitation, increases sperm destruction. Localized reaction in endometrial tissue — uterine endometrium unfavorable to implantation. Efficacy perfect: 0.6% typical failure rate: 0.8% Education: increased vaginal bleeding, increased dysmenorrhea, make anemia worse, not a good choice for those with heavy menstrual bleeding. Good for those who are okay with bleeding, foreign object and want nonhormonal contraceptions, feel for strings Barriers to access: cost, provider prescription, Return to fertility: rapidly reversible Warning signs (potential risks/adverse effects): if contraception failure occurs—increased risk for ectopic pregnancy, allergy to copper, Trouble shooting/treating current methods the side effects: take out  Permanent sterilization Tubal sterilization Indications: permanent sterilization Contraindications: NA MOA: tubal occlusion Efficacy perfect: 0.5% typical failure rate: 0.5% Education: does not protect against STIs, increased risk of ovarian cancer, lower risk of PID, no effects on menstrual cycle Barriers to access: procedure, physician bias, state requirements, cost, apt, Return to fertility: reversal is expansive, not guaranteed too work, reanastomosis works 50-80% of the time Warning signs (potential risks/adverse effects): if pregnancy occurs—increased risk for ectopic pregnancy, surgery complications Trouble shooting/treating current methods the side effects: NA Hysteroscopic sterilization (Transcervical) Indications: permanent prevention Contraindications: NA MOA: irritation and growth of new tissue that results in permanent occlusion of the uterine tubes as the tubes respond to the polyester fibers within the micro-inserts Efficacy perfect typical failure rate: 98% Education: not effective until approx 3 months after procedure preformed Barriers to access: cost, apt Return to fertility: none Warning signs (potential risks/adverse effects): chronic pelvic pain, migration of the device, perforation of the uterus and/r uterine tubes, autoimmune like reactions, sensitivity to device Trouble shooting/treating current methods the side effects: can’t Vasectomy Indications: sterilization Contraindications: if you desire pregnancy MOA: cutting or occluding the vas deferns so that sperm can no longer pass out of the body in the ejaculate, not immediately affective, may take 12 weeks or more or between 12-20 ejaculations Efficacy perfect: 0.1% typical failure rate: 0.15% Education: no effect on sex drive, pregnancy rates decrease as interval from procedure increased, does not increase risk for prostate cancer Barriers to access: cost, procedure Return to fertility: reversal improved if done within 10 years Warning signs (potential risks/adverse effects): regrets, infection and scrotal hematoma, chronic testicular pain Trouble shooting/treating current methods the side effects Hormonal methods Efficacy & Perfect/ Education for Use Return of Indication & Typical Warning Troubleshooting/Side MOA Risks & Benefits and Barriers to Fertility Time Contraindication Use Signs Effects Access Frame Failure Rate COC - work by Benefits: Contraindicated -Perfect -Must take -quick return Repor -Whenever a woman (estrogen inhibiting –decrease risk of –HTN, stoke, 0.3 everyday within 1 to 2 table begins a new COC, and ovulation. They ovarian and headache with -Typical -The most cycles conditi she should be progestin) thicken cervical endometrial aura, MI, 7.0 important pills to ons advised to contact the mucus, creating cancer. thrombolytic dz, take in each (ACH clinician prior to SARC a barrier that –Preserve fertility severe liver dz, cycle are the first ES) discontinuing the pills (3 cycles as prevents sperm through breast cancer, and last active -Abdo if she experiences average per from entering the decreased PID, lupus, diabetes COCs, which minal unwanted side varney 474) uterus, and the ectopic with neuropathy, ensure that the pain effects. endometrial pregnancies, and and vascular hormone-free -Ches -In such a case, a lining is not built lower rates of disease interval does not t pain different pill may be up as much endometriosis. -COCs have the exceed 7 days. -Head substituted without leading to less –Improvement of -Patient ache interrupting effective bleeding during acne and largest number instructions must (sever contraception. menstruation. hirsutism of cat. 3-4 on stress the e) -All COCs increase –reduced the MEC of all importance of -Eye the risk of VTE -Inhibit pituitary incidence of starting a new proble -it suggests that benign breast SARCs pack on time and ms or counseling women production and secretion of FSH conditions not taking more loss of about potential side and LH, which –regulate -Medications that than 7 days off vision effects, such as results in menstrual cycles can reduce the from the active -Seve headaches, nausea, inhibition of –help with effectiveness of pills. If a woman re leg breast pain, and follicular irregular bleeding COCs include does extend the pain mood changes, may development, patterns, lighter –antiretroviral hormone-free or be unethical. ovulation and periods (helps therapy, interval beyond 7 swelli -The prevalence of development of anemia) –rifampin days, she should ng in these nonspecific the corpus –effective trx for –griseofulvin be instructed to calf or symptoms is high in luteum; mittelschmerz, –some abstain from thigh the general dysmenorrhea, anticonvulsants intercourse or population of Most contain endometriosis, (carbamazepine, use additional reproductive-age 10-35mg Ethinyl premenstrual phenytoin, contraception women, and several Estradiol symptoms, and barbiturates, until seven trials show no Mestanol dose is vasomotor primidone, consecutive pills difference in these 50mg but with symptoms of topiramate, have been taken. side effects when an only 35mg perimenopause oxcarbazepine, oral hormonal bioavailability. lamotrigine), contraceptive is  Efficacy & Perfect/ Education for Use Return of Indication & Typical Warning Troubleshooting/Side MOA Risks & Benefits and Barriers to Fertility Time Contraindication Use Signs Effects Access Frame Failure Rate Risks: –some OTC herbal compared with thrombosis risk supplements, such placebo. greater with as St. John’s wort. family history of thrombosis or personal increased risk (Factor V. Leiden)  Efficacy & Perfect/ Education for Use Return of Indication & Typical Warning Troubleshooting/Side MOA Risks & Benefits and Barriers to Fertility Time Contraindication Use Signs Effects Access Frame Failure Rate POP -Do not Indications -Each package Pill must be Average 3 Repor Irregular spotting and consistently –Often used in contains one type taken at the cycles ( table bleeding are prevent breastfeeding of pill same time varney 474) conditi expected because SARC ovulation moms in the -Safe option for everyday (within ons: progestin alone does -Progesterone postpartum those who cannot 3 hours) to -ACH a poor job at creates cervical period take estrogen,safe maintain steady ES stabilizing the mucus that is option when BF. state progestin endometrium hostile to sperm, -Contraceptive level resulting in little effect end as soon to no sperm as stop taking pill Irregular penetration into spotting/bleeding the uterus should be expected not just -Meds that affect possible. effectiveness –rifampin –anticonvulsants, Abdominal –potentially St. John’s wort pain Chest pain MEC cat 4-current Headaches breast CA (severe) Eye problems MEC cat 3-anticonvulsant or loss of therapy, breast CA vision hx + no evidence Severe leg of current dx for 5 yrs, hx bariatric pain or surgery with swelling in malabsorptive calves. procedures, ischemic heart dx, liver tumors, If two periods rifampin or rifabutin are missed therapy, stroke, SLE with + or even with  Efficacy & Perfect/ Education for Use Return of Indication & Typical Warning Troubleshooting/Side MOA Risks & Benefits and Barriers to Fertility Time Contraindication Use Signs Effects Access Frame Failure Rate unknown taking pills on antiphospholipid antibodies time pregnancy test Fewest should be contraindications for this with MEC taken. When taken in combination with lactation effect is nearly 100%  Efficacy & Perfect/ Education for Use Return of Indication & Typical Warning Troubleshooting/Side MOA Risks & Benefits and Barriers to Fertility Time Contraindication Use Signs Effects Access Frame Failure Rate Transdermal -a medicated -Perfect -Four approved Average 4 Assess patient for Patch adhesive patch Advantages = 0.3 application sites: cycles previous skin Combined that delivers a -Typical the buttocks, the allergies such as hormonal specific dose of 7.0 upper outer arm, reactions to contracepti medication -Steady Drug the abdomen and bandages or on through the skin Delivery: the upper torso medicated patches. –Provides a -If their and into the weight —not bloodstream. controlled release recommend for Headaches, breast exceeds SARC -The patch of medication, 198lbs, use on breast d/t pain contains a avoiding peaks risk of hormone and troughs in advise reservoir that patient exposure on Higher risk of VTE holds the drug levels. breast tissue than COCs but still that the medication, effective- -A new patch can less risk than which can be in -Convenience: be applied pregnancy. ness is the form of a gel, –Easy to apply weekly for up to less liquid, or solid and remove, 3 months straight matrix. improving patient before a 1 week Rate-Control compliance. hormone free Membrane period is needed (optional): -Avoidance of – In some Gastrointestinal After the first patches, there is Tract: week of use a rate-controlling –Reduces there is a 2-3 day membrane that gastrointestinal period where you regulates the rate side effects and may still have at which the drug first-pass effective is released from metabolism by contraception the reservoir and the liver. when left in into the skin. place. MOA: inhibits Must replace ovulation by patch even if just suppressing the a bit of the patch release of becomes gonadotropins disconnected. within the HPO-axis. Also  Efficacy & Perfect/ Education for Use Return of Indication & Typical Warning Troubleshooting/Side MOA Risks & Benefits and Barriers to Fertility Time Contraindication Use Signs Effects Access Frame Failure Rate alters the cervical mucous and endometrial lining as a secondary form of contraception. Vaginal -The vaginal ring -Perfect Average 3 Most common side Ring is a type of 0.3 -The vaginal ring cycles effects: headache, Combined hormonal -Typical is typically worn dysmenorrhea, and hormonal contraceptive 7.0 for three weeks, breast discomfort. contracepti that is inserted followed by a Can also cause on into the vagina. one-week vaginal irritation and ring-free interval an increase in Release of during which the discharge SARC Hormones: user may –The vaginal ring experience is designed to withdrawal slowly release a bleeding (similar continuous, low to a menstrual dose of estrogen period). and progestin -After this over a one-week break, three-week a new ring is period. inserted to begin the next cycle. Prevention of Ovulation: Can be removed –The primary for up to 3 hours mechanism by without affecting which the vaginal contraception ring prevents pregnancy is by Not position inhibiting dependent ovulation. –The hormones Do not have to released by the remove for sex or ring prevent the tampon use ovaries from releasing an egg Temperature each month. extremes can effect the ring Thickening of Cervical Mucus: If in place up to –Progestin 28 days start the causes the next week cervical mucus to without a ring thicken, making it free week more difficult for sperm to travel  Efficacy & Perfect/ Education for Use Return of Indication & Typical Warning Troubleshooting/Side MOA Risks & Benefits and Barriers to Fertility Time Contraindication Use Signs Effects Access Frame Failure Rate through the If in place longer cervix and reach than 28 days an egg. start the next week ring Thinning of the immediately and Endometrial use back up Lining: method may still –The hormones have some also cause the withdrawal lining of the bleeding and not uterus safe from (endometrium) to pregnancy for thin, which first 7 days. reduces the likelihood of implantation of a fertilized egg.  Efficacy & Perfect/ Education for Use Return of Indication & Typical Warning Troubleshooting/Side MOA Risks & Benefits and Barriers to Fertility Time Contraindication Use Signs Effects Access Frame Failure Rate Progestin Inhibition of Benefits Black box -Perfect Encourage -Longest Side effects: Injection Ovulation: –Once every 3 warning 0.2 return to –weight gain (thought (Depo - –The primary months –adolescence -Typical calcium and fertility; most to be d/t progestin Provera) mechanism is the -Does not have a should not take 7.0 Vit. D for women get causing retention of suppression of concomitant longer than 2 years bone health. pregnant fluid) ovulation by effect with given the effects within 7 –irregular bleeding SARC prevention of anticonvulsants, on bone density at months –headaches (should follicular good option for a time when bone d/c if headache with maturation those with mineralization is -5–8 being aura d/t increased –Progestin seizure disorders maximal average on risk of stroke) prevents the Risks —not varney 474 -Delayed return to release of an egg Injection site recommended by fertility from the ovaries reaction,and all professional by inhibiting the fainting associations but secretion of should be gonadotropins Osteoporosis considered (follicle-stimulatin g hormone (FSH) -THose at and luteinizing increased risk for hormone (LH)) osteoporosis from the pituitary gland. -Current breast –Without these cancer hormones, ovulation does not occur. Thickening of Cervical Mucus: –Progestin thickens the mucus produced by the cervix, making it more difficult for sperm to enter the  Efficacy & Perfect/ Education for Use Return of Indication & Typical Warning Troubleshooting/Side MOA Risks & Benefits and Barriers to Fertility Time Contraindication Use Signs Effects Access Frame Failure Rate uterus and fertilize an egg. Thinning of the Endometrial Lining: –Progestin causes the lining of the uterus (endometrium) to become thinner, which reduces the likelihood of a fertilized egg implanting and developing. Alteration of Fallopian Tube Motility: –The hormone may also affect the motility of the fallopian tubes, which can hinder the movement of the egg and sperm through the tubes, reducing the chances of fertilization.  Efficacy & Perfect/ Education for Use Return of Indication & Typical Warning Troubleshooting/Side MOA Risks & Benefits and Barriers to Fertility Time Contraindication Use Signs Effects Access Frame Failure Rate Implant -Thickening -Benefits: -Perfect Requires a Immediat-ely Irregular bleeding (progestin Cervical Mucus: No risk of user 0.1 provider trained reversible (NSAIDS for 5-7 days only) Progestin error -Typical in placement and or Ulipristal acetate thickens the -ACOG 0.1 removal 15mg for 7 days can mucus. recommends as reduce the number of 1st line method. S/S of infection bleeding days if more LARC -Ovulation: Progestin can -Discrete but at insertion site than one episode in also prevent palpable 28 days) eggs from Changes noted leaving the at the insertion site ovaries (ovulation), ensuring there’s no egg available for fertilization -Implanted under the skin of upper arm; contains progestin and barium sulfate. -The barium sulfate makes the device detectable on xray  Efficacy & Perfect/ Education for Use Return of Indication & Typical Warning Troubleshooting/Side MOA Risks & Benefits and Barriers to Fertility Time Contraindication Use Signs Effects Access Frame Failure Rate LNG-IUD -Releases a -Benefits: Contraindicated: -Perfect Barriers: Missin small amount of long-term, up to 8 –PID 0.1 expensive, g levonorgestrel years of –breast cancer -Typical insurance string daily, thickening contraceptive –endometrial 0.1 coverage, wait s LARC cervical mucus coverage, no cancer times for and inhibiting need for daily –severe cirrhosis receiving device sperm movement dosing and viability. –Mirena is -The inside of the approved by FDA Education: uterus becomes for menorrhagia progesterone uninhabitable for (cheaper option only sperm, than contraceptive preventing hysterectomy) fertilization. -Prevents fertilization -Risk: perforation of the uterus, expulsion, break through bleeding -Minimal risk of perforation during insertion, infection (within 21 days of insertion), and ectopic pregnancy if fertilization occurs -Levonorgestrel (LNG) –Mirena-8 years –Skyla -3 years –Kyleena-5 years  How to Switch Birth Control Methods No Gaps What’s the best way to switch from one birth control method to another? To lower the chance of getting pregnant, avoid a gap between methods. Go straight from one method to the next, with no gaps between methods. Do not wait for a period before you stop the old method or start the new one. Overlap Method In some cases, you should have a few days of overlap – this means starting the new method before stopping the old method. This gives the new method time to start working before the old one wears off. The chart below explains which methods should overlap. It also explains how long the overlap should be. The overlap length appears in bold print. Back-up Method If you prefer not to overlap the old method and the new method, you can use a back-up method instead. Back-up methods include condoms and spermicide. For example, if you don’t want to keep taking the pill after you get your first progestin shot, you can use condoms instead. You should use the back-up method for the same number of days listed in bold print in the chart on the reverse side. To prevent HIV and other sexually transmitted infections (STIs), always use condoms. Safe Switching Method Not sure how to use the chart on the other side of this sheet? Do this: safely switch from one type of birth control to another by going straight from one method to the next one – no gap! – and use condoms or spermicide for the first 7 days. Pill Packs One note about switching from pills: you don’t need to finish the birth control pill pack before switching. You can stop taking your pill at any point in the pack. If you are switching to pills, you should start by taking the first pill in the pack. You may have changes in your period after switching. This is normal and safe. Reproductive Health Access Project / June 2015 www.reproductiveaccess.org  Switching to: Progestin Progestin Hormone Copper Pill Patch Ring shot implant IUD IUD (“Depo”) Switching from: Pill No gap: Start patch No gap: First shot 7 Insert Insert Can insert take 1st pill 1 day insert ring days before implant hormone copper IUD of new pack before the day stopping pill 4 days IUD 7 days up to 5 the day stopping pill after taking before before days after after taking any pill in stopping pill stopping pill stopping pill any pill in pack old pack Patch Start pill No gap: First shot 7 Insert Insert Can insert 1 day insert ring days before implant hormone copper IUD before and remove stopping 4 days IUD 7 days up to 5 stopping patch on the patch before before days after patch same day stopping stopping stopping patch patch patch Ring Start pill Start patch First shot 7 Insert Insert Can insert 1 day 2 days days before implant hormone copper IUD before before stopping 4 days IUD 7 days up to 5 stopping stopping ring before before days after ring ring stopping stopping stopping ring ring ring Progestin shot Can take 1st Can start Can insert Can insert Can insert Can insert (“Depo”) pill up to 15 patch up to ring up to implant up hormone copper IUD weeks after 15 weeks 15 weeks to 15 weeks IUD up to up to 16 the last shot after the after the after the 15 weeks weeks after last shot last shot last shot after the the last shot last shot Progestin implant Start pill Start patch Start ring First shot Insert Can insert 7 days 7 days 7 days 7 days hormone copper IUD before before before before IUD 7 days up to 5 implant is implant is implant is implant is before days after removed removed removed removed implant is implant is removed removed Hormone IUD Start pill Start patch Start ring First shot Insert Can insert 7 days 7 days 7 days 7 days implant copper IUD before IUD before IUD before IUD before IUD 4 days right after is removed is removed is removed is removed before IUD hormone is removed IUD is removed Copper IUD Start pill Start patch Start ring First shot Insert Insert 7 days 7 days 7 days 7 days implant hormone before IUD before IUD before IUD before IUD 4 days IUD right is removed is removed is removed is removed before IUD after copper is removed IUD is removed and use back-up method for 7 days Reproductive Health Access Project / June 2015 www.reproductiveaccess.org Emergency contraception Oral contraceptives and LNG formulations for pregnancy prevention do not effectively prevent follicular rupture if used in the late pre ovulatory stage; thus; these two methods are most effectively if used prior to ovulation and as soon as possible after unprotected intercourse. UPA does prevent follicular rupture if taken before the onset of the LH surge and recudes endometrial thickness, thereby making the endometrium less hospitable for implantation of an embryo Hormonal emergency contraception methods do not interfere with conceptos that has already implanted and present no risk to that embryo Unit 7: Preconception care Identify clinical opportunities for and provide preconception care/ planning. the preconception period is generally referred to the period of 3-4 months before conception Ideally the patient would schedule a preconception counseling appointment but this doesn’t usually happen Preconception counseling can be integrated into other visits. Such as well women visits or birth control visits. This doesn’t just have to be on a midwives or OB. This is also the responsibility of the primary care provider. Facilitate patient-centered evaluation of reproductive life- planning including the concept of One Key Question. Im not quite sure I understand what this is asking. I think it’s asking how do you bring this up with patients? Essentially, the one key question asks “Do you want to be pregnant in the next year?” what this does is screens women for pregnancy intention. It screens women for what they want instead of what they plan, allowing for an informed conversation to happen between the provider and the patient based on what the patient answers. It allows for a continuum of answers such as “ i dont know” or “i dont really care”. It ties each of these responses to patient-centered follow-up protocols that focus on contraception and/or preconception care and that may be implemented in a variety of care settings When a woman responds “yes”, follow up includes: When a woman responds “No”, follow up includes: Undiagnosed, untreated or poorly controlled medical Follow up for women who respond to OKQ with conditions a clear “no,” who are of reproductive age, are Immunization history sexually active (or may in the foreseeable future Medication and radiation exposure in early pregnancy become sexually-active) and are at risk for Nutritional issues—including folic acid supplementation pregnancy calls for a discussion about current Family history and genetic risk use of a contraceptive method Tobacco and substance use and other high risk ascertaining whether a woman is using behaviors contraception, is satisfied with her method choice Occupational and environmental exposures and is using it consistently and accurately is Social issues critical. Mental health Furthermore, providers should discuss all These things can be discussed at a later appointment, contraceptive options with women, including however certain aspects such as folic acid intake should be long-acting reversible contraceptives (LARCs) discussed then. Anticipatory guidance should be given either which offer the highest continuation rates among in the form of a conversation or handouts. methods When a woman responds “I don’t know”or “Im okay either way” Follow-up for a woman who expresses ambivalence about pregnancy calls for particular sensitivity to the individual woman’s needs. uncertainty in desire for children/additional children in relation to family aspirations, want but financial hardships exist, chronic conditions that complicate pregnancy, and religious influence or objection Women who are uncertain about their pregnancy intention are more likely not to be using any form of contraception, or to discontinue contraceptive use for an extended period of time, putting them at a higher risk for unintended pregnancy. May need to start on folic acid supplement Collaboratively develop plans for risk modification for future pregnancies focusing on BMI/ nutrition/ lifestyle, substance/ physical abuse/ smoking cessation, vaccination, folic acid use, environmental exposure, pregnancy spacing/ timing, teratogen avoidance, fertility, medication use, and genetic screening. Nutrition 24 hr diet recall optimal diet for preconception is high in vegetables and fruits, plant-based proteins (e.g., nuts, legumes), whole grains, healthy fish, and healthy fats, with moderate consumption of lean meats and poultry and avoidance of highly processed foods, fatty meats, and added sugars. Adherence to this way of eating is known as the Mediterranean diet, and it has broad health benefits for pregnant and nonpregnant people, including reduced risk of heart disease, diabetes, and other chronic diseases, reduced risk of gestational diabetes and excessive gestational weight gain in pregnancy and improved success with in vitro fertilization and other assisted reproductive technologies. Folic acid supplementation is the most important aspect of nutrition in preconception counseling. We do not get enough in our diet so it is imperative to get it with supplementation. 400mcg to 1mg Supplementation with 400 mcg of folate should begin at least 1 month prior to attempting conception and continue through the first trimester Some women are at higher risk of neural tube defects and need additional folate supplementation. These women should supplement with 4 mg of folate daily starting 3 months prior to pregnancy Avoid vitamins or multivitamin supplementations that exceed current recommendation daily allowances because of potential adverse effects with higher doses. Regular screening for vitamin D supplementation is not recommended BMI/Lifestyle regular aerobic exercise is important to overall health and can improve fertility. At least 150 minutes of moderate to vigorous exercise weekly is recommended, or about 20 to 25 minutes daily, with continued regular exercise while pregnant to improve pregnancy outcome. In women who exercise heavily and/or are underweight, excessive exercise may disrupt ovulation. Counsel individuals to avoid vigorous exercise exceeding 60 minutes per day if they are concerned about the impact of exercise on fertility High levels of salivary stress biomarkers are associated with a longer time to pregnancy for women trying to conceive and a twofold risk of infertility, compared with women who have low stress. Identify areas where stress can be reduced, Women who are obese should be counseled that health benefits begin with losing just 5 to 10 percent of one’s weight. Like all patients, women who are obese should be screened for nutritional deficiencies and excesses using a validated screening tool, such as a food frequency questionnaire or a 24-hour diet recall. bariatric surgery is not recommended as a first-line weight loss strategy for women planning pregnancy. Ideally, women who have had recent bariatric surgery should avoid pregnancy for 12 to 24 months during the initial phase of rapid weight loss and metabolic shifts. Avoid “weight loss meds”. Substance abuse All women should be screened at regular intervals for nicotine and unhealthy alcohol use, as well as marijuana, illicit drugs, opioids, and other medications used for nonmedical purposes encourage women identified as being at risk for, or diagnosed with, a substance use disorder to seek treatment, and facilitate a referral for services if desire Tobacco/Nicotine use pharm treatments can be used for cessation: nicotine replacement therapy, Wellbutrin and varenicline (Chantel) are first line treatment for tobacco use disorder Alcohol USPSTF recommends screening all adults for unhealthy alcohol use in primary care settings and providing those who screen positive with brief counseling interventions Provide education that alcohol is a known teratogen Marijuana counsel to avoid in pregnancy and lactation, effects may be as harmful as tobacco use Opioids screen all women for opioid use-those with a positive screen should receive a brief intervention and referral to services as indicated Treatment prior to pregnancy is optimal bc withdrawal can precipitate a miscarriage Treatment includes Stadol and Methadone. Safe to use during pregnancy IPV Screen all women for current and past intimate partner violence, sexual abuse, and sexual assault; this screening may be done on paper or in person If a woman discloses violence, coercion, or fear, assess her safety and provide community resources and intervention services Vaccination MMR and Hep B vaccines prior to pregnancy is highly recommended Other potential preconception immunizations include: HPV, Varicella, FLu, TDAP, pneumococcal, Hep A and meningococcal Advised women to avoid pregnancy for 4 weeks following MMR vaccine, Varicella vaccine Environmental exposure Screening should include both male and female workplace environmental exposures from industries that expose workers to heavy metals, radiation, solvents, pesticides, and other toxic agents. May consider referral to an occupational medicine specialist to help the individual understand the specific risks and establish a plan to reduce exposures. General awareness of toxic agents specific to the geographic area or key local industries is helpful.  Pregnancy spacing/timing Research suggests that optimal pregnancy spacing involves an interval of at least 18 months but not greater than 60 months Through provision of effective contraception and counseling, pregnancy spacing is a modifiable risk factor for inequitable health outcomes The majority of pregnancies conceived within the first year postpartum are unintended. Prenatal and postpartum contraceptive counseling has been shown to increase postpartum contraception use, as has placing long-acting reversible contraception in the immediate or early postpartum period, rather than at or after the 6-week postpartum visit optimal interval for women with a history of cesarean birth is at least 18 months between the birth of one child and the birth of the next, especially if they are considering a trial of labor after cesarean Fertility An infertility evaluation is indicated for women with a history of two or more early pregnancy losses..Several health conditions also increase a woman’s risk of miscarriage. Antiphospholipid syndrome is an autoimmune disorder that is associated with an increased risk of miscarriage, stillbirth, and VTE. Screen women with a history of one fetal loss past 10 weeks’ gestation, or three or more early pregnancy losses, for antiphospholipid syndrome. Heparin and low-dose aspirin throughout pregnancy and 6 weeks postpartum are recommended for women with recurrent pregnancy loss who have been diagnosed with antiphospholipid syndrome, regardless of whether they have had a VTE. Women with preexisting diabetes are at higher risk of miscarriage. Counsel these women on optimal glycemic control prior to pregnancy and, for those with type 2 diabetes, the importance of lifestyle changes. Women with obesity and PCOS are also at higher risk of miscarriage. These women should be counseled that weight loss can optimize their chances of a healthy pregnancy and should be referred for fertility services after recurrent miscarriages. Genetic screening Medications All meds, including supplements and herbs need to be evaluated for teratogenic effects as well as how needed they are dont counsel to automatically dc medications as this can have severe side effects on both physical and mental health Offer alternatives risks vs. benefits Identify health and lab screening needed in preconception planning. OBESITY: should be counceled on benefit of losing just HYPERTENSION: Lab tests (if poorly controlled): should 5-10% of weight be completed to assess for DM, when considering bariatrics surgery or already Dyslipidemia, and thyroid function had it, wait 14-24 months to achieve pregnancy. consider also ECHO, renal function, and serum creatinine with spot Urine DIABETES: P:Cr. Tight control blood sugar reccomended If using ACE/ARB need to change to preconception HA1C under 6.5 labetalol/nifedipine/methyldopa Lab Testing: HA1C, TSH, creatinine, and Consider low dose ASA after 12 weeks urine P:CR to decrease risk for pre-e Consider low dose ASA after 12 weeks to decrease risk of pre-e PCOS: Understand the possible need for Encourage even modest wt. loss to decreased Insulin during the first trimester increase fertility r/t increased insulin sensitivity. Check Encourage exercise and healthy diet fasting and PP sugar levels diligently Smoking cessation and limit ETOH following PPT Labs: Screen for DM II and CV risk factors Seizure disorders: Goal is to minimize fetal exposure to medication while keeping symptoms Thyroid Disease: controlled. Labs: TSH Monotherapy at the lowest dose is Ideally euthyroid for several considered the safest. months before conceiving Avoid: Valporic acid, phenobarbital, For those electing for phenytoin, and carbamazepine thyroidectomy or iodine ablation Lamotrigine is associated with the lowest achieve euthyroid before rates of malformation. concieving and wait for 6 months Neurologist should be involved in care following radioactive ablation. Folate should be taken regardless of their intentions for pregnancy. ADHD: Medications are not linked to and significant adverse outcomes to the women/infant. MENTAL HEALTH DISORDERS: Ideally woman are stable with/without medication before conception For moderate to severe illness with risk for relapse should remain on medication. Behavioral therapy is strongly reccomended if woman desires medication withdrawl. Manage preconception/interconception care with comorbid/ chronic conditions. Unit 8: Pregnancy discovery Counseling options for patient options: parenting, adoption, abortion Confidentiality is important Establish rapport, use neutral language and ask open ended questions Steps 1. Explore how the women feels about the pregnancy feels and her options 2. Help identify support systems and assess risk 3. Provide decision-making support or discuss a timetable for decision making 4. Provide or refer woman to the desired services Ask how she feels about the pregnancy in the first prenatal apt, don’t ask about if pregnancy was intended. List pros and cons of each option Asking the women if she has told anyone about the pregnancy can help identify the need for additional support Women who reports they are unable to tell anyone about the pregnancy warrant a follow-up and many benefit from a referral too a counselor Assess for IPV or reproductive coercion. Ensure women is aware of gestational age of pregnancy A delay in decision making may result in in late initiation prenatal care which has been associated with poorer pregnancy outcomes and missed opportunities for early fetal risk assessments  Present all options available to patients for undesired, mistimed, or unexpected pregnancy and facilitate their decision making as needed, this includes abortion, adoption, or parenting. Stay familiarized with all the options and have resources available to the patient Use open ended questions Don’t delay finding a pt resources for an abortion based on personal bias Be prepared for the situation so you are prepared to handle it with sensitivity. Understand that pts might not want any help with this. Continuing the pregnancy: parenting or adoption The decision to parent or make an adoption plan can be made at any point of pregnancy Adoptions may be open or closed Abortion 4 approaches: aspiration, medication, labor induction and surgery (hysterectomy or hysterotomy) Abortion can be preformed as soon as pregnancy is detected Clinicians who do not or are not able to provide abortion services must be able to relay pertinent information specific referrals sites, including the types of abortion available, gestational age limits, cost, insurance acceptance, language spoken, and likelihood of encountering protesters Know laws regarding adolescents Contrast medication abortion and aspiration abortion Medication: