Timing of postpartum etonogestrel-releasing implant insertion and bleeding patterns, weight change, 12-month continuation and satisfaction rates: a randomized controlled trial

Satisfaction With the Use of Subdermal Contraceptive Implant in Women Attending the Specialized Polyclinic Primary Health Care Center in Jeddah City: A Cross-Sectional Study

Background Subdermal contraceptive implants are a convenient method of contraception for many women due to the ease of insertion and removal and because they require less follow-up with their health facility. In addition to the contraceptive benefits, women's satisfaction with such devices is essential, as this can affect their quality of life. This study aims to measure women's satisfaction with the subdermal contraceptive implant, Implanon® (Organon & Co., Jersey City, New Jersey, United States), its main side effects, and reasons for removal.  Methods A cross-sectional study was conducted on women between the ages of 19 and 65 years who visited the Family Planning Clinic at the Specialized Polyclinic Primary Health Care Center in Jeddah, Saudi Arabia, between January 2018 and December 2021. An online questionnaire was distributed to the women who had Implanon inserted and 84 responded. Demographic and contraceptive data were collected, including the dates of insertion and removal of Implanon and side effects experienced while on Implanon.  Results Of the 84 women, 65.84% were satisfied with Implanon, while only 19.04% were unsatisfied with the implant. The most common side effect reported was weight gain (54.76%), followed by menstrual Irregularity. (39.29%). The most common reason for removal was the end of the implant's contraceptive duration (42.86%).  Conclusion Most of the women treated at this primary healthcare clinic were satisfied with Implanon. In addition, most of the women removed the implant only due to its reaching the end of its contraceptive duration despite experiencing side effects, and most women said that they would recommend it to their family and friends.

One-year follow-up of immediate postpartum contraceptive implant insertion in adolescents

PURPOSE

Our study aimed to evaluate the acceptability, adverse effects and continuation rates among adolescents who accepted the etonogestrel (ENG) subdermal implant and compared to adolescents who chose other methods during the immediate postpartum period before hospital discharge, with one year follow-up up.

MATERIALS AND METHODS

We conducted a cohort non-randomised study at the Women's Hospital, University of Campinas. All women up to 19 years of age, who gave birth at the hospital between July 2019 and April 2020, were invited to participate and were offered the ENG-implant or the routine contraceptive methods. They were followed for one year postpartum.

RESULTS

We included 100 teenagers and 72 accepted the ENG-implant. Students are more likely to accept the ENG-implant than non-students (PR: 1.25 [95%CI 0.99-1.59]). Up to one year of follow-up, survival analysis showed that the time of adherence to the method was longer for the ENG-implant users (p = 0.0049). More than 90% of the adolescents were satisfied with the implant; however, five requested early removal due to menstrual irregularity and local discomfort.

CONCLUSION

Provision ENG-implant for adolescents in the immediate postpartum demonstrated high acceptance and ensured effective contraception. After one year, most of them were satisfied, with a high continuation rate and without unplanned pregnancies.

Immediate versus delayed postpartum insertion of contraceptive implant and IUD for contraception

BACKGROUND

Long-acting reversible contraception (LARC), including intrauterine devices (IUDs) and contraceptive implants, are highly effective, reversible methods of contraception. Providing LARC methods during the postpartum period is important to support contraceptive choice, and to prevent unintended pregnancy and short interpregnancy intervals. Delaying offering contraception to postpartum people until the first comprehensive postpartum visit, traditionally at around six weeks postpartum, may put some postpartum people at risk of unintended pregnancy, either due to loss to follow-up or because of initiation of sexual intercourse prior to receiving contraception. Therefore, immediate provision of highly effective contraception, prior to discharge from hospital, has the potential to improve contraceptive use and prevent unintended pregnancies and short interpregnancy intervals.

OBJECTIVES

To compare the initiation rate, utilization rates (at six months and 12 months after delivery), effectiveness, and adverse effects of immediate versus delayed postpartum insertion of implants and IUDs for contraception.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and POPLINE for eligible studies up to December 2020. We examined review articles and contacted investigators. We checked registers of ongoing clinical trials, citation lists of included studies, key textbooks, grey literature, and previous systematic reviews for potentially relevant studies.

SELECTION CRITERIA

We sought randomized controlled trials (RCTs) that compared immediate postpartum versus delayed insertion of contraceptive implant and IUDs for contraception.

DATA COLLECTION AND ANALYSIS

Two review authors (JS, SK) independently screened titles and abstracts of the search results, and assessed the full-text articles of potentially relevant studies for inclusion. They extracted data from the included studies, assessed risk of bias, compared results, and resolved disagreements by consulting a third review author (PL, SA or PP). We contacted investigators for additional data, where possible. We computed the Mantel-Haenszel or inverse variance risk ratio (RR) with 95% confidence interval (CI) for binary outcomes and the mean difference (MD) with 95% CI for continuous variables.

MAIN RESULTS

In this updated review, 16 studies met the inclusion criteria; five were studies of contraceptive implants (715 participants) and 11 were studies of IUDs (1894 participants). We identified 12 ongoing studies. We applied GRADE judgements to our results; the overall certainty of the evidence for each outcome ranged from moderate to very low, with the main limitations being risk of bias, inconsistency, and imprecision. Contraceptive implants Immediate insertion probably improves the initiation rate for contraceptive implants compared with delayed insertion (RR 1.48, 95% CI 1.11 to 1.98; 5 studies, 715 participants; I2 = 95%; moderate-certainty evidence). We are uncertain if there was a difference between the two groups for the utilization rate of contraceptive implants at six months after delivery (RR 1.16, 95% CI 0.90 to 1.50; 3 studies, 330 participants; I2 = 89%; very low-certainty evidence) or at 12 months after insertion (RR 0.98, 95% CI 0.93 to 1.04; 2 studies, 164 participants; I2 = 0%; very low-certainty evidence). People who received an immediate postpartum contraceptive implant insertion may have had a higher mean number of days of prolonged vaginal bleeding within six weeks postpartum (mean difference (MD) 2.98 days, 95% CI -2.71 to 8.66; 2 studies, 420 participants; I2 = 91%; low-certainty evidence) and a higher rate of other adverse effects in the first six weeks after birth (RR 2.06, 95% CI 1.38 to 3.06; 1 study, 215 participants; low-certainty evidence) than those who received a delayed postpartum insertion. We are uncertain if there was a difference between the two groups for prolonged bleeding at six months after delivery (RR 1.19, 95% CI 0.29 to 4.94; 2 studies, 252 participants; I2 = 0%; very low-certainty evidence). There may be little or no difference between the two groups for rates of unintended pregnancy at six months (RR 0.20, 95% CI 0.01 to 4.08; one study, 205 participants; low-certainty evidence). We are uncertain whether there was a difference in rates of unintended pregnancy at 12 months postpartum (RR 1.82, 95% CI 0.38 to 8.71; 1 study, 64 participants; very low-certainty evidence). There may be little or no difference between the two groups for any breastfeeding rates at six months (RR 0.97, 95% CI 0.92 to 1.01; 2 studies, 225 participants; I2 = 48%; low-certainty evidence). IUDs Immediate insertion of IUDs probably improves the initiation rate compared with delayed insertion, regardless of type of IUD (RR 1.27, 95% CI 1.07 to 1.51; 10 studies, 1894 participants; I2 = 98%; moderate-certainty evidence). However, people who received an immediate postpartum IUD insertion may have had a higher expulsion rate at six months after delivery (RR 4.55, 95% CI 2.52 to 8.19; 8 studies, 1206 participants; I2 = 31%; low-certainty evidence) than those who received a delayed postpartum insertion. We are uncertain if there was a difference between the two groups in the utilization of IUDs at six months after insertion (RR 1.02, 95% CI 0.65 to 1.62; 6 studies, 971 participants; I2 = 96%; very low-certainty evidence) or at 12 months after insertion (RR 0.86, 95% CI 0.5 to 1.47; 3 studies, 796 participants; I2 = 92%; very low-certainty evidence). Immediate IUDs insertion may reduce unintended pregnancy at 12 months (RR 0.26, 95% CI 0.17 to 0.41; 1 study, 1000 participants; low-certainty evidence). We are uncertain whether there was difference in any breastfeeding rates at six months in people receiving progestin-releasing IUDs (RR 0.90, 95% CI 0.63 to 1.30; 5 studies, 435 participants; I2 = 54%; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Evidence from this updated review indicates that immediate postpartum insertion improves the initiation rate of both contraceptive implants and IUDs by the first postpartum visit compared to delayed insertion. However, it is not clear whether that there are differences in utilization rates at six and 12 months postpartum. We are uncertain whether there is any difference in the unintended pregnancy rate at 12 months. Provision of progestin-releasing implants and IUDs immediately postpartum may have little or no negative impact on breastfeeding. However, the expulsion rate of IUDs and prolonged vaginal bleeding associated with immediate implants appears to be higher.

Timing theory continuous nursing, resistance training: Rehabilitation and mental health of caregivers and stroke patients with traumatic fractures

BACKGROUND

Stroke is the leading cause of adult lifelong disability worldwide. A stroke is an acute cerebrovascular disease with a variety of causes and corresponding clinical symptoms. Around 75% of surviving stroke patients experience impaired nerve function, and some suffer from traumatic fractures, which can lead to special care needs.

AIM

To determine the effect of timing theory continuous care, with resistance training, on the rehabilitation and mental health of caregivers and stroke patients with traumatic fractures.

METHODS

Between January 2017 to March 2021, we selected 100 hospital admissions with post-stroke hemiplegia complicated with a traumatic fracture. Two participant groups were created: (1) Control group: given resistance training; and (2) Observation group: given timing theory continuous care combined with resistance training. The degree of satisfaction and differences in bone and phosphorus metabolism indexes between the two groups were compared. The self-perceived burden scale (SPBS) and caregiver burden questionnaire were used to evaluate the psychological health of patients and caregivers. The Harris hip function score, ability of daily living (ADL) scale, and global quality of life questionnaire (GQOL-74) were used to evaluate hip function, ability of daily living, and quality of life.

RESULTS

Data were collected prior to and after intervention. Alkaline phosphatase (ALP), osteocalcin, and vitamin D3 in the observation group and control group increased after intervention (P < 0.05), and carboxy-terminal peptide of type I collagen β Special sequence (β-CTX) decreased (P < 0.05). ALP and osteocalcin in the observation group were higher than in the control group (P < 0.05). There was no significant difference in β-CTX and vitamin D3 between the two groups (P > 0.05). The SPBS score of the observation group was lower and the ADL score was higher than the control group. The burden score was lower and the Harris hip function and GQOL-74 scores were higher than that of the control group (P < 0.05). The observation group’s satisfaction rating was 94.00%, which was higher than the rating from the control group (P < 0.05).

CONCLUSION

Timing theory continuous nursing with resistance training can reduce hip dysfunction in stroke patients with a traumatic fracture and enhance quality of life and mental health of patients and caregivers.

Safety and Benefits of Contraceptives Implants: A Systematic Review

Progestin-only contraceptive implants provide long-acting, highly effective reversible contraception. We searched the medical publications in PubMed, CENTRAL, and EMBASE for relevant articles on hormonal implants published in English between 1990 and 2021. Levonorgestrel (LNG) 6-capsule subdermal implants represented the first effective system approved for reversible contraception. The etonogestrel (ENG) single rod dispositive has been widely employed in clinical practice, since it is a highly effective and safe contraceptive method. Abnormal menstrual bleeding is a common ENG side effect, representing the main reason for its premature discontinuation. Emerging evidence demonstrated that it is possible to extend the use of the ENG implant beyond the three-year period for which it is approved. The ENG implant could be an effective and discrete alternative to the IUD in young girls, such as post-partum/post-abortion. Implants should be inserted by trained skilled clinicians who previously provide adequate counselling about their contraceptive effect, benefits, and any possible adverse events. More studies are needed to validate the extended use of the ENG implant for up to 5 years.

Acceptability of ENG-releasing subdermal implants among postpartum Brazilian young women during the COVID-19 pandemic

OBJECTIVE

To evaluate etonogestrel (ENG)-implant acceptance during the immediate postnatal period among adolescents and young women during the COVID-19 pandemic, and to compare variables according to choice and discuss possible implications of this measure during the pandemic period.

METHODS

A cross-sectional study was designed. All women aged up to 24 years, who delivered between April 25, 2020, and June 24, 2020, at Women's Hospital, University of Campinas, São Paulo, Brazil were considered. The ENG-implant or other contraceptive methods were offered prior to hospital discharge. The participants were split into two groups: (1) those who chose the ENG-implant and (2) those that refused the implant. Descriptive, bivariate, and multivariate analyses were performed.

RESULTS

151 women were included, with 76.2% selecting the ENG-implant. The average age was 19.5 years; 73.2% of pregnancies were unplanned, 32.5% already had a previous pregnancy, 74% were single, and 75.5% were not in full time education. Further, 70.5% had previously used contraceptives, with 89.1% unsatisfied with their previous method that opted for the ENG-implant (P = 0.07).

CONCLUSION

Offering the ENG-implant to youths during the immediate postnatal period is evidence-based care, and contraceptive provision is an essential health promotion tool, even during a pandemic. Thinking quickly about public policies in times of crisis is important to guarantee sexual and reproductive rights.

Contraception for the Cardiac Patient: a Cardiologist’s Primer

Purpose of review

Cardiovascular disease (CVD) is the number one cause of maternal mortality in the USA. There are many cardiac conditions which pose significant risk to maternal health, and these women should be offered options to avoid unwanted pregnancies. Individualized contraceptive counseling focusing on woman’s desire for future pregnancy, comorbid conditions, and desire for hormone or non-hormonal (contraceptive) options is paramount to avoid adverse or unwanted side effects. The purpose of this review is to give general guidance on prescribing both hormonal and non-hormonal contraceptives for providers caring for women with heart disease.

Recent findings

Specific recommendation for the use of either non-hormonal or hormonal contraception requires knowledge of the types of contraceptive options available, cost, failure rates, and contraindications to use. Newer progestin-only options have become available and should be considered first-line therapy for women with cardiovascular disease.

Summary

The physiologic burden of pregnancy on the cardiovascular system can cause significant maternal morbidity and mortality for women with underlying CVD. These women should be offered safe and effective options for birth control, and both cardiology and obstetrical providers alike should possess fundamental knowledge of appropriate options.