Spontaneous rupture of a primigravid uterus.

The spontaneous rupture of the primigravid uterus is an obstetric rarity prior to the onset of labor. Invariably there is a history of antecedent scarring. A case of uterine rupture is reported on where the only antecedent history was damage by the second trocar during laparoscopy. The use of electrocautery and the immediacy of subsequent conception are probably implicated in the pathogenesis. It is recommended that should the fundus be damaged during laparoscopy as part of a subfertility investigation, barrier contraception should be advised for a two-month period.     

Do's and don'ts in post-partum contraception

It is sometimes difficult to plan contraception with a woman who has just delivered a baby, because she is sometime not motivated in the week following delivery, feeling unable to contemplate intercourse because of perineal pain and other discomforts. Effective contraception should be used beginning with the 25th postpartum day because of the subsequent strong possibility of ovulation before the return of menstruation. The woman should be provided with as much information on contraception as possible during this period, and possible contraindications to specific methods should be sought, such as thromboembolic accidents, hyperlipidemia, hypertension, diabetes, infection, ectopic pregnancy, abortion, and desire for subsequent pregnancy. No request for contraception should be ignored and the same method should not be imposed on all women. The topic of contraception should not be deferred until the postpartum check-up in the 2nd month, because 50% of women will have had intercourse by the end of the 2nd month, often unprotected. Local methods such as spermicides and condoms are effective when the couple is motivated and they are well accepted. The thromboembolic risk appears minimal when oral contraceptives (OCs) are begun on the 15th postpartum day for non-breastfeeding women. OCs should not be prescribed for women after prolonged bedrest, and women who previously used pills should have lipid and glucose tests before the 2nd month postpartum consultation. The low dose progestin pill should be preferred to the low dose combined pill if a potential thromboembolic risk exists. Infants of breastfeeding women using pills receive 1/500 of the estrogen dose administered to the mother and 1/1000 of the progestin dose. No effects of these doses have been found on the growth or genital development of infants, and modifications of milk composition are not constant. A low dose progestin pill beginning on postpartum day 20 may however be preferred. It is better to await the return of menses before inserting an IUD because of the danger of expulsion prior to that time. Local methods should not be the only ones recommended in the immediate postpartum period because of the possibility of poor acceptance and unwanted pregnancy resulting from incorrect use. Very high dose OCs should not be prescribed. Long acting injectable progestins should be avoided for breastfeeding women except in cases of serious psychic disturbance because the quantity of hormones entering the milk is much greater than with pills.     

Postpartum IUCD: Rediscovering a Languishing Innovation

The National Family Planning Programme of India, since its inception in 1951, has been able to successfully achieve significant reductions in maternal mortality and fertility. Over the past decade, the need for contraception has changed dramatically in India. Couples no longer desire sterilization, but prefer modern reversible long-term methods of contraception. The ideal time to discuss contraception is in the antenatal period when there is a good rapport between the doctor and the patient. The window period when the patient is admitted in the hospital during delivery can be used effectively to offer postpartum contraception. It has been found that the highest chance of unwanted pregnancy is in the first year after delivery, when women do not report to the doctor if this window period is missed. Postpartum intrauterine contraceptive devices are ideal for a country like India and it can be used to cover the unmet need of contraception if inserted immediately after delivery. There are two types of insertion: post placental, within 10 min of delivery of placenta and postpartum, within 48 h of delivery. Although there is a greater chance of expulsion in the postpartum insertions, it can be significantly reduced with proper training and user experience. Postpartum IUCD should be routinely offered to all patients delivering in institutions to provide complete care to a parturient and to achieve safe motherhood.     

Why do university students use hormonal emergency contraception?

OBJECTIVES: To establish why university students in Finland, who have easy access to well-affordable health services, still use hormonal emergency contraception. METHOD: All students who sought emergency contraception in the Tampere Student Health Station during the period from 1 September 2000 to 31 December 2001 received a questionnaire on their use of it. Of the total, 114 (67%) were returned. RESULTS: Two-thirds of respondents experienced condom failure, and the remainder used no contraception. In open answers, respondents gave many explanations as to why they had used no contraception, e.g. having been over-passionate or drunk. CONCLUSION: Finnish students use emergency contraception, but to no great extent. Our results indicate that service providers should pay attention to sexual health in the full sense but not omit to give detailed advice on condom use during counselling.     

Family planning in the postpartum period

Contraception during the postpartum period presents additional problems in view of physiologic and psychodynamic considerations that are unique at this time. Focus is on these special considerations in the following review of contraceptive technology. Most recent evaluations of continued lactation for contraception have indicated that the risk of ovulatory activity within 9 weeks of delivery is 1:1250. Although this figure suggests that full-time breastfeeding functions as a better contraceptive method than do more sophisticated techniques within the first 6 weeks postpartum, supplemental feedings significantly decrease the effectiveness of this method. Oral contraception (OC), the most effective contraceptive method for the contemporary female if no contraindications to its use, should be avoided in the breastfeeding mother. It does remain the method of choice for the not breastfeeding mother. Due to the fact that the postpartum period has been recognized as a hypercoagulable state, the use of OCs in the immediate postpartum period can be questioned. The IUD probably represents the most effective contraceptive method for the breastfeeding mother. Fitting of the diaphragm is best deferred until the 6-week postpartum examination. Since a high percentage of patients resume coital activity by 3-4 weeks postpartum, a combination of foam and condom contraception is recommended on a temporary basis. Sterilization in the immediate postpartum period is the most effective method of fertility control other than total abstinence.     

Assessment of contraceptive services in a maternity unit of a district general hospital in the UK.

A survey was undertaken to assess the quality of contraceptive services provided to women delivering in a District General Hospital. Separate questionnaires were given to the women and the midwives giving the contraceptive advice. Response rate of the survey was 87%. Thirty eight per cent of women reported having some discussion on contraception during antenatal period. All the women had received contraceptive advises during the postpartum period. Eighty one per cent of women felt that sufficient information and enough time was given to discuss contraception. However analysis of questionnaires indicated that most received information only on short-term contraceptive methods. Out of 64 midwives surveyed, 52 had attended a family planning course. However 37 of them had attended the course at least 3 years earlier. Thirty eight midwives felt that they have adequate knowledge to give advice but all of them reported that they should receive further training. There should be provision for comprehensive discussion regarding contraceptive options during both antenatal and postpartum periods. Midwives require regular training in family planning.     

Contraception during perimenopause

Perimenopause marks the transition from normal ovulation to anovulation and ultimately to permanent loss of ovarian function. Fecundity, the average monthly probability of conception, declines by half as early as the mid-forties, however women during the perimenopause still need effective contraception. Issues arising at this period such as menstrual cycle abnormalities, vasomotor instability, the need for osteoporosis and cardiovascular disease prevention, as well as the increased risk of gynecological cancer, should be taken into consideration before the initiation of a specific method of contraception. Various contraceptive options may be offered to perimenopausal women, including oral contraceptives, tubal ligation, intrauterine devices, barrier methods, hormonal injectables and implants. Recently, new methods of contraception have been introduced presenting high efficacy rates and minor side-effects, such as the monthly injectable system, the contraceptive vaginal ring and the transdermal contraceptive system. However, these new methods have to be further tested in perimenopausal women, and more definite data are required to confirm their advantages as effective contraceptive alternatives in this specific age group. The use of the various contraceptive methods during perimenopause holds special benefits and risks that should be carefully balanced, after a thorough consultation and according to each woman's contraceptive needs.     

Contraception during perimenopause.

Perimenopause marks the transition from normal ovulation to anovulation and ultimately to permanent loss of ovarian function. Fecundity, the average monthly probability of conception, declines by half as early as the mid-forties, however women during the perimenopause still need effective contraception. Issues arising at this period such as menstrual cycle abnormalities, vasomotor instability, the need for osteoporosis and cardiovascular disease prevention, as well as the increased risk of gynecological cancer, should be taken into consideration before the initiation of a specific method of contraception. Various contraceptive options may be offered to perimenopausal women, including oral contraceptives, tubal ligation, intrauterine devices, barrier methods, hormonal injectables and implants. Recently, new methods of contraception have been introduced presenting high efficacy rates and minor side-effects, such as the monthly injectable system, the contraceptive vaginal ring and the transdermal contraceptive system. However, these new methods have to be further tested in perimenopausal women, and more definite data are required to confirm their advantages as effective contraceptive alternatives in this specific age group. The use of the various contraceptive methods during perimenopause holds special benefits and risks that should be carefully balanced, after a thorough consultation and according to each woman's contraceptive needs.     

Why do university students use hormonal emergency contraception?

Objectives: To establish why university students in Finland, who have easy access to well-affordable health services, still use hormonal emergency contraception. Method: All students who sought emergency contraception in the Tampere Student Health Station during the period from 1 September 2000 to 31 December 2001 received a questionnaire on their use of it. Of the total, 114 (67%) were returned. Results: Two-thirds of respondents experienced condom failure, and the remainder used no contraception. In open answers, respondents gave many explanations as to why they had used no contraception, e.g. having been over-passionate or drunk. Conclusion: Finnish students use emergency contraception, but to no great extent. Our results indicate that service providers should pay attention to sexual health in the full sense but not omit to give detailed advice on condom use during counselling.     

Oral contraception and thrombophilia

PURPOSE OF REVIEW: To describe current knowledge related to the association between oral contraception and the thrombophilias. RECENT FINDINGS: The use of oral contraception increases the risk of venous thromboembolism as well as arterial thrombosis. Third-generation pills seem to increase the risk of venous thromboembolism compared with second-generation pills. This effect seems to be reversed or absent for the risk of arterial thrombosis. The effect of oral contraception on the risk of venous thromboembolism is more pronounced during the first year of use. All these risks are further increased in patients with an inborn or acquired tendency for coagulation (thrombophilia). SUMMARY: Prospective users of oral contraception are potential candidates for screening/testing, because a positive screen may substantially decrease the risk of a thrombotic event. At present, the available testing methods are not cost effective, and the absolute risk is not defined for each thrombophilia. Until these shortcomings are solved, it is not recommended to test every woman who wishes to use oral contraception. Nevertheless, before starting on oral contraception, each patient should be carefully screened by a physician who should identify an increased risk of thrombophilia and tailor the laboratory testing.     

Male and female sterilisation

Male and female sterilisation are important forms of contraception worldwide despite declining popularity in developed countries and limited access during the Covid-19 global pandemic. Vasectomy is the only highly reliable form of male contraception. Appropriate counselling about permanent methods of contraception in both sexes is vital and should include information about irreversibility, failure rates and complications. The alternatives to sterilisation, particularly long-acting reversible contraception (LARC), should be discussed in detail as they are at least as effective and have the advantage of reversibility. Hysteroscopic techniques for female sterilisation are no longer available. In males the no-scalpel technique vasectomy requires minimal operating time and results in less post-operative discomfort than the incisional method. Regret after sterilisation and requests for reversal are more common in patients under 30 years and in men with no children.     

Post pregnancy contraception

Ovulation resumes as quickly as 21 days after birth in a non-fully breastfeeding woman. Traditionally, contraceptive services have been offered 6 weeks post-partum. This is far from ideal and results in unnecessary abortions or inadequate birth spacing which both carry an increased risk of morbidity to mother and potential newborn as well as costs to the health care service. It is now clear that contraception should be discussed during the pregnancy so that the method of choice can be offered immediately post pregnancy prior to discharge from hospital. Long acting reversible contraceptive methods such as implants and IUDs are highly effective as they are user-independent. Large studies have demonstrated that they can be safely inserted during the immediate post-partum period with no increase in complication rates. Policy makers should strive to overcome barriers to offering quality post pregnancy contraceptive services.     

The use of hormonal contraception in perimenopause is still a hazard?]

The need for contraception in a period of life characterized by irregular menstrual cycles as the perimenopause represents a social and biological event for each woman and a challenge for the gynecologist. The use of oral contraceptives in perimenopause has been vastly discussed in the last decade. Several investigators have focused their attention on the risks related to hormonal administration to older women neglecting all the advantages. The introduction of new lower-dose formulations and progestin-only preparations as implants or intra-uterine system has deeply changed the indications for hormonal contraception allowing their use in patients in whom it was previously contraindicated. Cumulative evidence has demonstrated that the use of hormonal contraception during the perimenopausal period does not offer only advantages in term of cycle control but also gives an important protection against the development of gynecological malignancies. However, in clinical practice the use of hormonal contraceptives in older women has not been accepted by a large number of physicians who continue to consider hormonal contraception in women over forties a tabù. The aim of this review is to discuss lights and shadows of the use of hormonal contraception in perimenopause.     

Contraception within six-month postpartum in rural Vietnam: implications on family planning and maternity services.

OBJECTIVES: This longitudinal study documents contraception practice and factors influencing contraception decision within the first six months postpartum, amongst women residing in the rural Northern Central region of Vietnam. METHODS: A sample of 463 rural women who gave birth during August-October 2002 were recruited and interviewed at one, 16 and 24 weeks postpartum. RESULTS: The proportion of contraceptive users at weeks 16 and 24 were 17% and 43% respectively. At week 24, of contraceptive users, 57% used IUD, 25% used condom, and 14% used traditional methods. Logistic regression analysis found age, sufficient knowledge on contraceptives and husband/partner opinion can significantly affect the contraception decision. CONCLUSIONS: In order to improve the situation, health authorities should be encouraged to provide counselling on postpartum contraceptive methods during ante- and postnatal care visits. Health education on family planning and breastfeeding should also involve the husband/partner group taking into account local socio-cultural features.     

Induced abortion,contraceptive use,and dual protection among female sex workers in Moscow,Russia

ObjectiveTo describe abortion history and current contraceptive use among female sex workers (FSWs) in Moscow, Russia.MethodsA clinic-based survey was conducted among 147 FSWs in Moscow during an 8-month period in 2005.ResultsIn total, 83 of 143 (58.0%) FSWs reported a history of abortion, with 45 of 143 (31.5%) indicating multiple abortions. Condoms were the primary form of contraception (145/146 [99.3%]); just 17 of 142 (12.0%) FSWs reported using non-barrier modern contraception. All women who reported using a non-barrier modern method also indicated condom use (i.e. dual protection). Non-barrier contraceptive use was associated with inconsistent condom use (odds ratio [OR] 3.10; 95% confidence interval [CI], 1.07–9.02) and multiple abortions (OR 4.71; 95% CI, 1.19–18.62).ConclusionThe results illustrate substantial risk for unintended pregnancy among FSWs. Further research is needed regarding the dynamics of non-barrier contraception and condom use. Efforts to improve the health and wellbeing of FSWs should include access to safe and effective contraception, in addition to HIV prevention.     

Factors Influencing Contraceptive Choice During the Postpartum Period: A Qualitative Systematic Review

Introduction

The objective of this article is to identify the factors that influence the choice of contraceptive methods in the postpartum period.

Methods

We conducted a qualitative systematic review including articles published between 2000 and 2021 on postpartum contraception and its related influential factors. Relying on Preferred Reporting Items for Systematic Reviews and Meta-Analyses and synthesis without meta-analysis checklists, the search strategy relied on a combination of 2 lists of keywords applied to 9 databases. A bias assessment was carried out with the help of the Cochrane's randomized controlled trial tool, the checklist from Downs and Black, and Consolidated criteria for reporting qualitative research (CoreQ). A thematic analysis was performed to identify categories of influential factors.

Results

A total of 34 studies met our inclusion criteria and enabled us to isolate 4 categories of factors: (1) demographic and economic factors (geographic and ethnic origin, age, living environment, education/wealth), (2) clinical elements (parity, evolution of pregnancy, childbirth and afterwards, contraception used previously and its mechanism, pregnancy planning), (3) health care delivery (pregnancy monitoring, sessions about contraception, health care system, place of delivery), and (4) sociocultural factors (knowledge and beliefs about contraception, religion, the influence of family and society). The decision process related to postpartum contraception is influenced by a combination of socioenvironmental factors and clinical elements.

Discussion

The main influential factors (parity, level of education, knowledge and beliefs about contraception, and influence of family) need to be addressed by clinicians during consultations. Further multivariate research should provide quantitative data on this topic.     

Contraception in women with medical conditions

Pregnancy in women with certain medical conditions can result in significant fetal and maternal morbidity and mortality. It is therefore crucial that these women are able to plan and space their pregnancies appropriately through the use of contraception. Obstetricians and gynaecologists will often encounter these women in the inpatient and outpatient setting and be asked to give advice about the suitability of contraception. In this case-based learning article we will consider how to assess a woman seeking contraception. We will also discuss the medical eligibility, efficacy and acceptability of contraception as well as when contraception should be started after pregnancy and stopped at menopause.     

ACOG Committee Opinion No. 524: Opioid abuse, dependence, and addiction in pregnancy

Opioid use in pregnancy is not uncommon, and the use of illicit opioids during pregnancy is associated with an increased risk of adverse outcomes. The current standard of care for pregnant women with opioid dependence is referral for opioid-assisted therapy with methadone, but emerging evidence suggests that buprenorphine also should be considered. Medically supervised tapered doses of opioids during pregnancy often result in relapse to former use. Abrupt discontinuation of opioids in an opioid-dependent pregnant woman can result in preterm labor, fetal distress, or fetal demise. During the intrapartum and postpartum period, special considerations are needed for women who are opioid dependent to ensure appropriate pain management, to prevent postpartum relapse and a risk of overdose, and to ensure adequate contraception to prevent unintended pregnancies. Patient stabilization with opioid-assisted therapy is compatible with breastfeeding. Neonatal abstinence syndrome is an expected and treatable condition that follows prenatal exposure to opioid agonists.     

Emergency contraception: the state of the art

Emergency contraception, otherwise known as post-coital contraception, is part of the continuum of contraceptive methods that women and couples can use for pregnancy prevention. Although emergency contraception should not be used as a regular, plan-ahead contraceptive method, it gives a woman one last-ditch effort to prevent unwanted pregnancy. This paper reviews the history of emergency contraception, the need for further studies, and results of studies conducted at the World Health Organization. Various methods used for emergency contraception are discussed, as well as their efficacies and side effects.