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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