Contraceptive choices in women with coagulation disorders

ACOG Practice Bulletin No. 197: Inherited Thrombophilias in Pregnancy

Inherited thrombophilias are associated with an increased risk of venous thromboembolism and have been linked to adverse outcomes in pregnancy. However, there is limited evidence to guide screening for and management of these conditions in pregnancy. The purpose of this document is to review common thrombophilias and their association with maternal venous thromboembolism risk and adverse pregnancy outcomes, indications for screening to detect these conditions, and management options in pregnancy. This Practice Bulletin has been revised to provide additional information on recommendations for candidates for thrombophilia evaluation, updated consensus guidelines regarding the need for prophylaxis in women with an inherited thrombophilia during pregnancy and the postpartum period, and discussion of new published consensus guidelines from the Society for Obstetric Anesthesia and Perinatology addressing thromboprophylaxis and neuraxial anesthetic considerations in the obstetric population.

Reproductive and contraceptive issues in chronically ill adolescents

OBJECTIVES

To address reproductive and contraceptive issues in adolescent girls with chronic medical conditions in order to assist health-care providers when they counsel teenagers about contraceptive methods.

METHODS

The review is based on a literature search in Medline (1973-2010) about specific contraceptive use by adolescents with obesity, endocrine, cardiovascular, haematologic, oncologic, neurological, psychiatric, gastrointestinal, hepatobiliary, autoimmune, renal, pulmonary conditions and disabilities. The latest recommendations from the World Health Organisation for adolescents are also added. Contraceptive methods studied were combined hormonal contraceptives, progestogen-only contraceptives, and intrauterine contraceptives.

RESULTS

Adolescents are eligible to use any method of contraception. Contraceptive choices of chronically ill adolescents have changed over time. Given new developments in the field of adolescent sexual and reproductive health care, safe and effective forms of contraception are available for almost every adolescent with a chronic condition. When selecting a method, the nature of the medical illness and the expressed desires of the teenager must be taken into account.

CONCLUSIONS

Adolescents, including those with chronic conditions, are sexual beings; they are entitled to sexual and reproductive health care. Decisions on appropriate contraception must be based upon informed choice, after adequate sexual health education.

Concepts of contraception for adolescent and young adult women with chronic illness and disability

Sexual behavior is common in adolescents and young adults with or without chronic illness or disability, resulting in high levels of unplanned pregnancy and STDs. Individuals with chronic illness or disability should not receive suboptimal preventive health care. These individuals have a need for counseling regarding issues of sexuality and contraception. Sexually active adolescent and young adult women can be offered safe and effective contraception if they wish to avoid pregnancy. Women with chronic illnesses and disabilities who are sexually active should also be offered contraception based on their specific medical issues. Condoms are also recommended to reduce STD risks. Table 36 summarizes basic principles of contraception application for specific illnesses, which have been identified since the release of the combined OC in 1960. Clinicians should also consider the noncontraceptive benefits of this remarkable and life-changing technology that allows all reproductive age women to improve their lives, including those with chronic illnesses and disabilities.

Thrombophilic conditions in the adolescent: the gynecologic impact

As Virchow's triad suggests, a fine balance exists between the vascular wall, intravascular contents, and dynamic blood flow, such that a shift in this balance predisposes to thrombosis. Although thromboembolic events (TEs) are relatively infrequent in adolescents, the morbidity and mortality associated with TEs can be significant. Over the past 15 years, TEs and inherited and acquired thrombophilic conditions underlying them have become increasingly recognized in teens at risk, with combined hormonal contraception constituting one of the most significant of these risk factors. Therefore, managing gynecologic problems in teens who have thrombophilic conditions can be challenging. It is important to have a clear understanding about safe options available to help address adolescent gynecologic concerns in this setting and to manage situations collaboratively with a hematologist.

[Hormone therapy, fertility and pregnancy in antiphospholipid syndrome]

Antiphospholipid syndrome (APS) carries a risk of thrombosis and infertility. Consequently the use of any type of hormone therapy and pregnancy in APS requires special considerations. The present article provides a broad review of all these issues. The use of contraception, hormone replacement therapy and selective estrogen receptor modulators in APS are described. In vitro fertilization/embryo transfer and ovarian induction in these patients are reviewed. Lastly, the possible fetal and maternal complications that can occur during pregnancy are described and, based on the literature, recommendations for the management of pregnancy in women with APS are provided.

Contraception in women at high risk or with established cardiovascular disease

Oral contraceptives are one of the most effective and widely used reversible contraceptive methods. Over 90 million women worldwide, including over 44 million in developing countries, are now using oral contraceptives. Despite their advantages, there is concern about the links between combined oral contraceptives and the risk of cardiovascular disease. The risk attributable to oral contraceptive use in women < 35 years of age is small, even if they smoke, but there are substantially increased risks in older women who both smoke and use oral contraceptives. Differences between oral contraceptive types in the relative risk of venous thromboembolism contribute little to the total cardiovascular mortality associated with oral contraceptive use, even though the total number of cardiovascular events is increased. It is important to consider the user's age and smoking status when determining oral contraceptive-attributable risks. Hormonal oral contraceptives have changed and now contain lower doses of estrogen and progestagen.

Gynecologic care of medically complicated adolescents

Gynecologic care of adolescents presents a challenge under the best of circumstances, but when the patient has significant medical processes that interact with the process of puberty, the care of these patients may become extremely difficult. A review of the more common medical illnesses of adolescents and the interaction on the events of puberty and normal menstrual function is presented with emphasis on contraception and future fertility. Although many of the contraceptive options present a possible increased risk to these patients, it must be kept in mind that these adolescent patients will develop emotionally and become sexually active at some point in their lives, and the potential risk of the resultant pregnancy must be weighed carefully. The various options of management for gynecologic problems are discussed.

Family planning requirements in the adult congenital heart disease clinic

OBJECTIVE

To determine whether women with congenital heart disease were receiving appropriate advice on contraception.

SETTING

Adult congenital heart disease clinic in a tertiary cardiac referral centre.

DESIGN

Questionnaire administered to 35 consecutive female patients attending the adult congenital clinic. The cardiologist assessed what the risk would be if each patient used an oestrogen containing contraceptive pill (OCP).

RESULTS

Of the 33 patients admitted to the study 6 patients thought their heart condition precluded them from taking an OCP when in fact it did not and 3 incorrectly said that an OCP would be suitable for them. Three women with relatively minor lesions had been incorrectly denied the OCP and 2 further patients were using inappropriate methods. There had been 6 unwanted pregnancies in the total group.

CONCLUSIONS

Many women with congenital heart disease do not know the most appropriate method of contraception for them or have received incorrect advice. It is often patients with less severe lesions who receive the most inappropriate advice. It is clear that the family planning needs of this population are currently poorly catered for. Each unit must ensure that the information necessary in making informed decisions on contraception is available to the doctor advising on family planning.

Contraception. A clinical review for the internist

Effective use of contraception allows couples to control their fertility and, in certain instances, is associated with important noncontraceptive benefits. Surgical sterilization offers safe, effective, and permanent contraception for women and men. Low-dose OCPs offer safe, effective contraception for most women able and willing to take pills consistently. In addition, their use confers a variety of important noncontraceptive benefits. The availability of long-acting progestin injectable and implantable methods has made highly effective and convenient birth control available for women who are not good pill takers as well as for those for whom contraceptive doses of estrogen are contraindicated. Barrier methods are readily available and provide protection against STDs; unfortunately, erratic use is all too often associated with inadequate contraceptive efficacy. IUDs offer convenient, highly effective contraception for appropriate candidates.

Oral contraceptives: an update

Despite continual improvement in oral contraceptive formulations, many women still have unwarranted concerns about their safety and remain ignorant of their nonreproductive health benefits. The need for a reliable method of contraception is the greatest among adolescents and women older than 35 years--the two groups in the United States with the highest abortion rates.