King Edward Memorial Hospital - Department : Obstetrics and Gynaecology

Obstetrics and Gynaecology

CONTRACEPTION IN MEDICAL DISORDERS

Medical disorders complicating pregnancy can have far reaching serious critical repercussions, many of which can be circumvented if women accept adequate contraceptive measures.

All the 1157 women who delivered in one unit of K.E.M. Hospital, which is a tertiary care centre, from Oct 2002 - Sept. 2003 were screened. 218 women presented with some kind of Medical disorder.

Break up of Medical Disorders

PIH & Hypertension (103)	Heart Disease (33)
Anaemia (28)	Respiratory disease (17)
Liver disease (17)	Renal Disease (4)
Abruption (13)	HIV +ve (11)
Epilepsy (6)	Diabetes (5)
Thyroid (3)	Others (13)

An attempt was made to trace these women and follow up regarding their use of contraceptive method.

116 follow up visits were done. 72 women were contacted.

Method	No	FUP Done	Continued Method	Discont method	Changed Method
Changed Method	89(40.8%)	33	7	17	7 → 2 inj. 2 OC 2 IUD 1 TL
Inj.	57(26.1%)	23	8	13	2 → 2 condom
CuT	13(6%)	8	8	-	-
OC	1.5%	0	-	-	-
TL	18(8.3%)	2	2	-	-
NIL	40(18.3%)	6	2	-	3 → 1 condom, 1 IUD & 1 TL

Only 11 women continued to take treatment for their medical problems. RHD (3), Resp. Disease (3), PIH (2), Epilepsy (1), Thyroid (1), Anaemia (1)

When asked, Do you want to have more children
Yes - 42
No - 19
Can't say - 11

Answers depended on no. of living children and not on type & severity of Medical Disorder

CARDIOVASCULAR DISEASE

Helping to choose the correct contraceptive is a successful balancing of 2 factors
-extra load on the cardiovascular system if the contraceptive fails
- potential adverse circulatary effects from contraceptive used.
Any woman with cholestrol level above 200 mg/dl with 2 or more risk factors should undergo triglyceride & HDLC level determination.

LDL-mg/dl	Risk Factors
	< 35 yrs		>35 yrs
	0-1	2 or more	0-1	2 or more
<130	Yes	Yes	Yes	Yes
130-160	Yes	Yes with diet	Yes with diet	No
160-190	Yes with diet	No	No	No
>190	No	No	No	No

HYPERTENSION:

Mild (140-159/90-99) - All methods permitted except COC which may be used as a last resort.
Moderate (160-179/100-109) COC - CONTRA INDICATED others hormonal methods to be used only with due precaution.
Severe >180/110 - As above + avoid injectables, progesterone contraceptives

VAlVULAR HEART DISEASES:

Uncomplicated Vascular Heart Disease - ALL types of contraceptives permitted
VHD with complications - COC contraindicated, use other method with due caution.
Ischemic Heart Diseases - (past and present)
- IUD, Barrier - indicated
- Combined Oral Contaraceptives - contraindicated
- Progesterone only contraceptives permitted as a last resort under strict supervision.

VENOUS THROMBOEMBOLISM - (past and present)

- Combined COC contraindicated
- others permitted

DIABETES

Importance of contraception

Subsequent pregnancies may TRIPLE the risk of development of diabetes.
Good Diabetic control BEFORE & DURING pregnancy will minimize fetal malformation, morbidity & mortality in mother and child.
Contraception should discussed in every preconceptional visit

History of elevated blood sugar level in pregnancy	- No contraindication to any method of contraception
Diabetes without vascular complication	- All methods permissible but with enhanced follow up (Norplant may predispose potential diabetes to frank diabetes)
Diabetes + Vascular complication	- Advise early child bearing but always with good preconceptional diabetic control Combined Hormonal contraceptives are contra indicated. Progesterone only contraceptive, IUD, barrier methods & sterilization can be used with caution & care.

NEUROLOGICAL DISORDERS

Epilepsy

As per WHO guidelines

- Epileptics may be prescribed all types of contraceptives but
- sterilization should be carried out with all due caution
- during use of anti convulsants AVOID hormonal contraceptives because drug interaction with anti epileptic drugs can lower eficacy of hormonal contraceptive

Headache

Non Vascular Headache	- No method contraindicated
Vascular Headache Migraine without focal neurological Symptoms	- Non hormonal method & progestin only contraceptive permitted freely Other hormonal contraceptives to be used with caution
Migraine with focal neurological Symptoms	- Non hormonal method can be used SAFELY Combined oral contraceptives absolutely contraindicated Other hormonal methods only to be used as a last resort

Anaemia

All methods permissible, oral contraceptives very useful in decreasing menstrual blood loss.
CuT bearing IUDs may increase menstrual blood loss.
Sickle Cell Disease & Thalassaemia - are not contraindications for use of any contraceptive

Malaria
Malaria is not a contraindication to any method

Liver Disease
Non hormonal methods of contraception should be methods of first choice

History of Jaundice
Associated with pregnancy - All methods permissible (COC with enhanced follow up)
Associated with OC use - All methods permissible but avoid COC

Carrier status in viral Hepatitis	- All methods permitted
Viral Hepatitis and Severe Cirrhosis	-Contraindication - COCs, POCs, Injectable, Implants. - Permissible - IUCDs, Barrier method - Delay - Sterilization
Mild Cirrhosis	- Avoid Hormonal methods, may be used as a last resort

Tuberculosis
Rifampicin reduces efficiency of hormonal preparations & they should be avoided or used with a back up method.
Pelvic tuberculosis - IUCDs should not be inserted.

Thyroid Disease
No method contraindicated
Sterilization should be done in well eqipped centre
Before starting hormonal contraception baseline measurement of thyroid hormones is recommended.

STD

Current STD or in last 3 months	- IUDs contraindicated. Sterilization should be delayed
Simple vaginitis without cervitis	- IUDs also permitted with caution
Increased risk of STD (including HIV+ve & subject with AIDS)	- IUDs to be used only as a last resort.
Non contraceptive benefit of barrier method esp CONDOMS in preventing transmission of STD is very significant
Perimenopause

Though complaisance sets in contraception at this juncture IS IMPORTANT as a pregnancy is fraught with complications. Method may be selected on woman's needs, choice and other medical consideration.

Malignancy

- Breast Cancer (current and in last five years)	- only IUD/barrier permitted
- Undiagnosed breast lump benign breast disease & Family History of breast cancer	- All methods permissible
- Cervical Uterine Ovarian malignancy	-IUD contraindicated

Conclusion:

The choice of method of contraception in India depends on many factors: Availability, Convention, Provider's choice, Acceptability (especially Husband and Family). Desire of privacy and not least of all medical eligibility.
When finalizing the choice of contraceptive method the provider must take into account medical eligibility to use method and choice of women and long term acceptability.
Sympathetic and informed counseling sessions will go a long way in helping women to choose contraceptive methods best suited to their medical obstetric and social requirements.