the College Student with Chronic Disease Why It Shouldnt Happen and Whats Next MP Malee PhDMDMBA May 30 2014 DISCLAIMER I have no actual or potential conflict of interest in relation to this educational activity or presentation ID: 934299
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Slide1
Unintended Pregnancy in the College Student with Chronic Disease: Why It Shouldn’t Happen and What’s Next?
MP Malee,
PhD,MD,MBA
May 30, 2014
Slide2DISCLAIMER I have no actual or potential conflict of interest in relation to this educational activity or presentation.
Slide3What We Will Cover……. 1. Intended and unintended pregnancies and the role of birth control in these statistics 2. Characterize the habits of our healthcare client 3. What acute and chronic issues prompt a visit? 4. Prescription drugs: use/misuse/abuse 5. Correlate of unintended pregnancy: potential for fetal/
neonatal and long-term consequences of maternal
behaviors and medication exposures
6. Common complaints, diagnoses, and treatments
7. Common chronic diseases and management
8. Contraceptive options in chronic disease
9. Summary thoughts
Slide4Intended and Unintended Births in the US: 1982-201037% of births in the US are unintended at the time of conception, essentially unchanged since 1982.The proportion of unintended births declined significantly between 1982 and 2006-2010 among married, non-Hispanic white women.Unintended births are more likely among:unmarried women,
African-American women
women with less education
w
omen with less income
Slide5Percentage of Births that were Intended at Conception by Mother’s Age, Marital Status, and Education, 2006-2012Age: In those 15-19y/o and 20-24y/o, 23% and 50%, respectively, had births that were intended at conceptionMarital Status: 33% of those not married or cohabiting, 49% of those cohabiting, and 77% of those married had births that were intended at conception.
Education
: Intended births at conception varies with education--
college degree (83%),
some college (63%)
, high school diploma (60%), less than high school diploma (59%).
So
unintended
pregnancies are LESS likely in our college population, but they
do
occur.
Non-use of Contraception and Unintended BirthsReasons for non-use of contraception, offered by 19.2% of the over 4 million women who gave birth each year included: -36% ‘thought that they couldn’t get pregnant’…… *NO difference by age, marital status, income, but IS a difference in educational level— 26% with some college education vs
42% with a HS education or less
So education and available resources are
key
, and that’s where we can make a difference!
Slide7So now we know about the stats for intended and unintended births in the majority age group of our cohort, and a bit about their thoughts regarding birth control.What else do we know about our college healthcare clients?
Slide8Who Are Our Healthcare Clients?Characterized in the National College Health Assessment; Spring 2013 (ACHA)Participants:153 schools, majority of which 4+ year public institutions, 123k students (34% response)**59% characterize their health as very good or excellent, and 91% as good, very good or excellent**Importantly,
53%
of respondents reported a dx and/or tx for a health issue in the past 12 months
What do we know about their habits, healthy and otherwise?
Slide9What About Their Habits? Alcohol: any use in the past 30 days- 65%, male (M) = female (F)Cigarettes: any use past 30 days-
17% (M) vs 12% (F)
Marijuana
:
any
use past 30 days-
21% (M) vs 15% (F)
All other drugs combined
(
incl
cigars, cocaine, amphetamines, hallucinogens
,
anabolic steroids, club drugs):
20% (M) vs 9% (F)
R
isk behavior when drinking alcohol
eg
unprotected sex, considered suicide, did something that they later regretted:
54% (M) vs 50% (F)
Use of prescription drug
NOT
prescribed
for them:
16% (M) vs
14% (F)
Slide10What About Their Habits? Sexual behavior: 70% of students reported sexual activity within the last 12 months; 56% of sexually active students used birth control, 62% mostly/always use a protective barrier, and 60%
use
OCPs
16% reported using (or that their partner used) the ‘morning
after
pill’
within the past 12 months, with an unintentional pregnancy rate of
1.8%
Slide11So what complaints prompt a HC visit?
Slide12Proportion of Students Reporting Diagnosis or Treatment for the Following Health Problems within Past 12 Months Allergies--19%Sinus infection--15.6%Back pain--12.5%Strep throat--9.7%Urinary tract infection--9.5%Asthma--8.4%Migraine headache; ADHD – both @ 7.6%Broken bone/fracture/sprain--6.9%Bronchitis--5.8%
Psychiatric condition—5.7%
2013 ACHA NCHA II
Slide13Categories of HC Client Concerns: Mental HealthMental healthcare issues require considerable resources, andaccount for almost 20 percent of total student HC visits!
R
epresented mental health diagnoses include: anxiety, depression, ADHD, eating disorders, adjustment reaction, bipolar/psychosis, and alcohol abuse.
So they seek
continuity
HC for mental health issues
…What other diagnoses prompt continuity
care
?
Slide14Continuity Care in College StudentsInvolves 5-15% of the total college populationDx include eg allergies (20%), asthma (9%),
chronic
illness (
5-12%), underweight (3-6%), obesity (11.9-12.6%)
Many on medications, and some on
several
medications, as seen on the next slide
Slide15Slide16Drug Use and Misuse/AbuseMany of the drugs used/misused/abused by college-aged students are prescription drugs50% of college students are offered a prescription drug for nonmedical purposes by their sophomore year; 12% of students acknowledge misusing a prescription opioid in their lifetimeAccording to the NIDA, women are 55% more likely to be prescribed drugs that can be abused, such as narcotics and tranquilizers, putting them at greater potential risk for misuse/abuse
Slide17Use/Misuse/Abuse What Medications Are Involved? StimulantsStimulants such as eg Ritalin (methylphenidate) and Adderall, (dextroamphetamine), are prescribed for ADHD, narcolepsy, and short-term management of weight lossOnly 30.5% with a Rx for ADHD acknowledged taking the medication
as directed
62%
diverted
the medication to someone without a prescription
Potential of
misuse
for anorexic effects, heightened attention/wakefulness, academic enhancement, hallucinations, euphoria and altered perceptions
Slide18Use/Misuse/Abuse:Stimulants6.7% of women acknowledged using stimulants NOT prescribed for them,Caucasian women are 2-4 times more likely to abuse stimulants of any other race/ethnicity
In another report,
11%
acknowledged using
prescription stimulants in nonmedical settings
in the past year, and
36% have used them at least once in their lifetime!
Withdrawal
symptoms include fatigue, depression, and sleep disturbances
Slide19Use/Misuse/Abuse What Medications Are Involved? OpioidsOpioids (hydrocodone / oxycodone), prescribed for pain relief and act by blocking pain perception; medical risks include respiratory depression/deathCaucasian women are more likely to abuse prescription pain relievers than women of another
races/ethnicities
23% of women aged 18-34y/o reported taking pain relievers
NOT
prescribed for them
Slide20Other Issues with Opioids… Overdose characterized by sedation and may be accompanied by aspiration, respiratory depression, deathOften co-formulated with eg acetaminophen, aspirin, ibuprophen…..so overuse can lead to liver
damage/failure or GI
bleeding
Chronic exposure can lead to
dependence
;
withdrawal is uncomfortable
(and can
be fatal for the fetus if
the client is pregnant)
Slide21Use/Misuse/Abuse: Sedatives and Tranquilizers Sedatives (barbiturates) and tranquilizers (benzodiazepines) including valium and xanax, are often prescribed for anxiety, panic attacks, sleeping disorders2.4% reported
using sedatives not prescribed for them
Caucasian women
reportedly
abuse sedatives and tranquilizers more frequently than other races/ethnicities
Slide22Use/Misuse/Abuse: Sedatives and TranquilizersLong-term use/abuse can result in dependence/addictionAbrupt withdrawal can result in rebound seizures, as well as other acute medical and psychiatric manifestations
Slide23Abuse of Prescription Medications: Potential ConsequencesInclude addiction, episodic hypertension, tachycardia, tachypnea, irregular cardiac rhythm, hyperthermia, heart failure, seizure, hostility, paranoia, overdose, increased risk for STDsA potential also exists for sharing/selling prescribed medications…..
Slide24Is there sharing and selling of prescription drugs?Yes! 35.8% ‘diverted’ a prescribed medication at least once!The most commonly diverted medications were ADHD medications (stimulants and non-stimulants), with a 62%
diversion rate, and
prescription analgesics
(opioids and prescription NSAIDs), with a
35%
diversion rate.
Slide25‘Diverted’ MedicationsOther classes of diverted medications include asthma and allergy medications eg antihistamines, steroids; other psychotropic meds including antidepressants, anxiolytics, anti-psychotics and tranquilizers; other non-psychotropic meds included muscle relaxants, gastric secretion inhibitors,
etc
Sharing
was the
most common method of
diversion
at
34%, with sales at 9%
Slide26So What Do We Have So Far?We have an ‘at risk’ population relative to alcohol abuseWe have an ‘at risk’ population relative to tobacco abuse, all other drugs of abuse, and use of prescription drugs that are and are NOT prescribed for themWe have an ‘at risk’ population relative to sexual activity in the absence of birth control
Slide27Anything Else?We have an ‘at risk’ population relative to medications and drugs of abuse and naiveté regarding the potential maternal and fetal effects in the event of an unplanned pregnancyAnything else? Yes—correlates of unintended pregnancies!
Slide28Correlates of Unintended Pregnancies-Delay in seeking or absence of prenatal care which is associated with an increased risk of adverse outcomes eg low birth weight, neonatal mortality: 19% vs 8.2%-Medical care by Medicaid (as an indicator of resources available to care for the child): 65% vs 35%-
Reduced rates of breastfeeding
, noting that breastfeeding is associated with
decreased
infections/SIDS for offspring, and
reduced
risk of T2 DM in woman….from 39% to 26%!! Breastfeeding is encouraged!
Slide29So although these longer-term consequences are significant, there are additional consequences that are equally and perhaps even more important…….
Slide30Correlates of Unintended Pregnancies:Potential Fetal/Neonatal and Long-Term Consequences of Maternal Behaviors and ExposuresDrugs of Use and Abuse
Slide31Drug of Abuse: Alcohol In all, of the 80 percent of college students who drink alcohol, half "binge drink“ (about four drinks in two hours for women and five in two hours for men), according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA).
Not surprisingly, binge
drinking
appears
to exert a greater effect than the same volume across a longer period of time (eg 4 drinks in one day vs 1 drink a day for 4 days
)
What about alcohol in pregnancy?
Slide32Drug of Abuse: Alcohol and PregnancyAlcohol freely crosses placentaKnown to be teratogenic; can have chronic nonreversible sequelae, or may seem to have no apparent sequelaeNo exact dose:response relationship: maternal age, ethnicity, genetic factors, and pattern of alcohol consumption appear to affect outcome of offspring
Slide33Drug of Abuse: Alcohol Potential Fetal/Neonatal EffectsFetal Alcohol Spectrum Disorder includes:Fetal Alcohol Syndrome
-a commonly identified cause of mental retardation, poor growth, often evident in the fetus, persisting in infancy and childhood; a chronic nonreversible
sequelae
of maternal alcohol use
-prevalence at 1-7/1000 live births, and higher if also include alcohol-related neurodevelopmental disorders
Fetal Alcohol Syndrome Cont’dFAS includes abnormalities in 1) growth, with growth restriction, noted in utero, often with microcephaly, persisting thru infancy and childhood; 2) CNS abnormalities, reflected in impairment of self-regulation, cognition and adaptive functioning; in infancy, manifested as irritability, regulatory problems eg sleep, attention; and 3) facial dysmorphia
In childhood, microcephaly and short stature persist; CNS manifestations include hyperactivity, developmental delay, hypotonia, learning disabilities, MR, poor attention and concentration skills, and deficits in memory and reasoning
Slide35Substance Abuse: Tobacco Smoking during pregnancy is associated with: -abruption -PROM -abnormal placentation
-preterm labor and delivery
-low birthweight
-neonatal mortality rate above unexposed (RR=1.2-1.4)
-neonatal hypertonicity, excitability
-risk SIDS increased two- to four-fold
-risk T2 DM increased four-fold in offspring as young adult
-increased rate of behavioral disorders in offspring
-increased rates of asthma, decreased sperm volume
and count in offspring
Slide36Substance Use/Abuse: OpioidsRecall that opioid meds are often prescribed/shared/sold; ‘opioid’ refers to natural or synthetic substances with morphine-like activityPrenatal exposure to opioids, and on occasion, sedative-hypnotics, places the baby at risk for ‘Neonatal Abstinence Syndrome’ (NAS) ie withdrawal Ss and SsRate of opioid use in US is increasing …1.9 to 5.6 per 1000 births between 2000-2009; not surprisingly, the rate of NAS also increased, from 1.2 to 3.4 cases per 1000 births
Slide37Substance Use/Abuse: OpioidsNAS manifests with high pitched cry/irritability, sleep disturbances, tone alterations, feeding difficulties, GI disturbances; tx supportive, prn medicationLong-term outcome: likely unremarkable, but confounded by other variables such as IUGR and its ramifications, as well as various postnatal factors, eg maternal SES, educational level, etc
Slide38Substance Abuse: CocaineAssociated with increased risk abruption, fetal demise, growth restriction, prematurityNeonatal manifestations include hyperactivity and inability to orient to environmentManifestations are not a function of withdrawal but instead of recent exposure, as can be detected in neonatal urine for up to 7 days after deliveryLong-term effects are variable, often contingent on environmental factors during childhood
Slide39Substance Use/Abuse: MarijuanaNeonates can be hyperexcitable, irritable and jittery, with an increased arousal responseDoes not affect global intelligence, but may impair sustained attention, visual memory, and analysis and integration in exposed adolescents
Slide40Substance Use/Abuse: AmphetaminesUsed to treat narcolepsy, ADHD eg Adderal and Strattera, and in the short term, obesityUsed with caution if there’s a history of heart disease or dysrhythmia; many partner with primary caregiver to monitor pulse, SBP, DBP, as they increase dosageUnclear if prenatal exposure is associated with prematurity, growth restriction, congenital anomalies, and/or affects neurodevelopmental outcomes
Unclear if increased risk ADHD in offspring is related to
in utero
exposure, genetic predisposition or a combination/interaction of both
Slide41Substance Use/Abuse: AntidepressantsIn the college population, antidepressants are taken more regularly and more responsibly….60% stated that they took their medication as prescribed; 20% reported never taking them.Six percent who did not have a Rx for antidepressants reported taking them for coping with the environment.It’s important to refer appropriately, discuss and document options for birth control if sexually active, and the possibility of pregnancy, +/- breastfeeding, in the choice of medication…….
Slide42Substance Use/Abuse: AntidepressantsIF pregnancy diagnosed…Acknowledge the risks of suboptimal dosing given the increased volume of distribution, and of medication discontinuationRisk
of
depression relapse is 43%, greatest
in first vs third
trimester,
and more common (68
%)
in those who d/c’d med before conception or in early
pregnancy; the relapse rate is much less (26%) for those who
maintained their medication.
Slide43Substance Use/Abuse: Antidepressants: Safety IssuesSSRIs and SNRIs are effective in the Tx of depression and anxietyLarge study indicates risk of fetal demise or infant mortality IS NOT INCREASED by SSRIs; risk exists for transient neonatal withdrawalSafety profiles generally reassuring, and if client has good response with medication, changing drugs upon a pregnancy diagnosis is not recommended; referral for further conversation re risks and appropriate fetal f/u IS
appropriate
Psychotherapy remains an important aspect of treatment during and after pregnancy
Slide44Substance Use/Abuse: Antidepressants: Safety Issues in PregnancySSRIs and SNRIs include:fluoxetine (Prozac): reassuring pregnancy safety profile; long
T1/2
discourages first-line choice (accumulation in neonate)
paroxetine
(Paxil
):
may
be
(controversial) associated
with an increased risk of CHD,
particularly VSDs (NOT first-line choice in pregnancy)
sertraline
(
Zoloft): many consider it first-line;
some
association with omphaloceles and
VSDs (switching not rec)
citalopram
(Celexa) and
escitalopram
(Lexapro):
some
data with increased risk VSD, anencephaly,
craniosynostosis
(switching not rec)
Slide45Substance Use/Abuse: Tricyclic Antidepressants (TCAs): Safety IssuesMost studies have shown no association between TCAs and congenital anomaliesExposure may result in transient neonatal withdrawalNo reported long-term effect on motor and behavioral development in exposed offspring
Includes desipramine, nortriptyline, imipramine, amitriptyline, and clomipramine
Slide46Common Complaints, Diagnoses, and Treatments at any Student Health Center(keeping the possibility of undiagnosed pregnancy in mind……)
Slide47Tx of Respiratory InfectionsCommon cold: reassurance re resolution without intervention in 10 daysReview: data lacking re efficacy of most OTC interventionsFavor acetaminophen, cepacol throat lozenges, lidocaine throat spray (sore throat), dextromethorphan (cough)Bronchitis: typically viral; consider C-Xray (r/o pneumonia; shield prn); rec many of same interventions as for common coldSinusitis: ABT tx considered if eg Ss for > 10d, severe Ss and T>39; favor amoxicillin, azithromycinEncourage inactivated flu vaccine!
Slide48Acne TxComprehensive assessment focuses the treatment aimed at: 1) counteracting follicular hyperproliferation; 2) increased sebum production; 3) P. acnes proliferation; and 4) inflammation.Tx can include topical retinoids, benzoyl peroxide, azelaic acid, topical antibiotic, and/or an oral antibiotic**In a reproductive-aged women
,
reliable birth control guides treatment options
. In its absence, topical retinoids (eg tretinoin and adapalene), both Class ‘C’, are often not prescribed;
tazarotene
aka
tazorac
(Class X;
eg
NTDs, cardiac anomalies) is not used, as is the case for oral isotretinoin aka accutane, Class X (
eg
hydrocephaly, microcephaly, cardiac, clefts)
Slide49And now for some additional chronic diseases/issues……..and why an unplanned pregnancy can be problematic
Slide50DiabetesStudents should be aware of the necessity of BC and the importance of planning a pregnancy in the presence of T1 DM or poorly controlled T2 DMMost recommend that the HgbA1c be in the 5-6% range prior to attempting pregnancy to minimize the otherwise increased risk of miscarriage and congenital anomaliesAnomalies can include cardiac abnormalities as well as renal agenesis, spina bifida and caudal regressionFor T1DMs, medication review is important, as diabetic vasculopathy may result in HTN, and the anti-hypertensive agents--ACE inhibitors and angiotensin receptor blockers--are teratogenic (oligohydramnios, microcephaly, cardiac)
Slide51ObesityRecommendation for weight gain in pregnancy is based on BMI (BMI > 29.9 kg/m2 =‘obese’; rec gain=15-25#)Obesity is associated with an increased risk of: -gestational diabetes -pregnancy-related hypertension, -congenital malformations (clefts, CHD, GI abnormalities eg gastroschisis,
anorectal atresia, hydrocephalus)
-sleep apnea
-fetal growth abnormalities
-fetal demise
Slide52Inflammatory Bowel DiseaseStudents should be aware of the necessity of BC and the importance of planning a pregnancy in the presence of IBDActive disease at the time of conception is associated with 70% risk of flare/disease worsening in pregnancyMedication exposure -consider short courses metronidazole -sulfasalazine can be continued -glucocorticoids should be avoided in the first tri if
possible (placental 18-hydroxylase), and thereafter
used in lowest possible
dosage
(incr
risk HTN, GDM, PPROM, IUGR,
Addisonion crisis)
Slide53Inflammatory Bowel DiseaseMedication exposure cont’d -Azathioprine, mercaptopurine and cyclosporin can be used in pregnancy, preferably at lowest possible dosage; not associated with congenital abnormalities
-*Methotrexate is
contraindicated
(skeletal abnormalities);
discontinue at 3 mos before conception (fat stores)
-Infliximab (Remicade), and other anti-tumor necrosis
factor
agents, can
be used until the beginning of the
third trimester;
since it crosses the placenta,
there
is concern that it might place the newborn
at
increased risk of infection and perhaps affect
efficacy
of vaccinations
Slide54Seizure DisordersStudents should be aware of the necessity of BC and the importance of planning a pregnancy in the presence of seizure disordersNoncompliance with recommended medications is as high as 50%Hormonal contraception at risk for failure due to potential effect of anti-epilepsy drugs (AEDs) on activation of P450 cytochrome system Discourage 3 or more alcoholic drinks as associated with increased risk of seizures*Folate supplementation (400ug) is routinely appropriate given potential effect of some AEDs on folate stores. If planning
pregnancy, ACOG recs 4g/day to decrease risk NTDs
Slide55Seizure DisordersRisk of fetal malformations sec to medications is 4-6% vs the population estimate of 2-3%Avoid polytherapy, if possible, as associated with 6-9% risk malformationAvoid valproate if possible if BC use is unreliable as linked with increased incidence anomalies, especially NTDs, as well as 90% with abnormal facial features (minor dysmorphisms) and
poorer neurodevelopmental outcome in
offspring (eg IQ with dose-related decrease); recently reported <5% increased risk autism spectrum disorder in offspring of valproate-exposed pregnancy
Dilantin is associated with clefts, CHD and GU abnormalities
Phenobarbital is associated with CHD, orofacial malformations, and GU malformations
Slide56Seizure DisordersCarbamazepine (tegretol) is strongly associated with NTDs and GU abnormalitiesLamictal is associated with a 2-3% rate of major malformation with first trimester exposure, but as high as 11% when paired with valproateTopamax is associated with an increased risk of oral clefts, at 16x the background rateKeppra is low risk for anomalies at less than 1% when monotherapy
***
Emphasize and document
importance of pregnancy planning
in this population
and effective BC until that time
Slide57SUMMARY THUS FAR….We have a population at risk for use/abuse of prescription drugs and use of recreational drugs, as well as a population with appropriate use of prescribed medications for assigned diagnoses.We can agree that planning pregnancy is always a good thing, but certainly necessary in many who are medicated for active and/or chronic diagnoses
Slide58Diagnoses Associated with Increased Risk for Adverse Health Event as a Result of Unintended Pregnancy (WHO, 2009)DiabetesEpilepsyHypertensionHIV/AIDSSickle cell diseaseSLEThrombogenic mutationsTB
Slide59What about contraception?
In a student
with chronic disease,
contraception options present a challenge
Slide60ContraceptionEncourage contraception, document the discussion, and provide a referral as appropriateA discussion re potential options for contraception includes family history (?VTE, APLA?), habits (? tobacco), current diagnoses and current medications
Review available methods relative to their
effectiveness and convenience
Slide61ContraceptionReview possible side effects; eg breakthrough bleeding/amenorrhea with OCPs, DMPA; rash/itching at site of transdermal patchProblems with OCP adherence? May prompt a suggestion for extended cycle, continuous use pill, or an alternate form of BCInclude conversation re condoms to prevent STDs, associated with infertility, ectopic pregnancy and chronic pelvic pain, as well as availability
of
emergency contraception
Slide62Contraception OptionsVaginal ring: changed every 3 weeksDMPA (depo provera): injection q 3 monthsContraceptive implants last up to 3 years, and recommended by ACOG for adolescentsIUDs: copper IUDs, progesterone-releasing IUDs, and unmedicated (inert) IUDs also recommended by ACOG for
adolescents; as an aside, copper IUDs also an effective method of post-coital contraception if inserted within 5 days of unprotected intercourse
Continuation rates as high as 80% for IUDs and as low as 30% for vaginal ring
Slide63LARC Long-Acting Reversible ContraceptionCopper IUD: ‘T’-shaped; approved for up to 10 yr use, with failure rate comparable to tubal ligation; common adverse effects are abnormal bleeding and pain
Levonorgestrel
intrauterine system
: ‘T’-shaped; in addition to effects on sperm migration/viability and the change in transport of or damage to ovum, it also suppresses endometrial development and affects cervical mucus. Approved for 5
yrs
, low failure rate; typically doesn’t inhibit ovulation but diminishes menses; some experience hormone-related effects such as HA, breast tenderness
--Complications include expulsion (5%), failure, and
perforation
(1/1000)
--No increased risk PID or infertility
Slide64LARC Cont’dContraceptive implants: placed subdermally; core material of the rod-like implant contains etonogestrel and allows for controlled release over 3 years; suppresses ovulation (HPO axis), thickens cervical mucus and alters endometrial liningMost effective form of reversible contraception, with a typical use pregnancy rate of 0.05%Changes in menstrual bleeding pattern common; other c/o include GI, HAs, breast pain, weight gainComplications insertion/removal uncommon (1-2%)Fertility returns rapidly post removal
Slide65LARC Cont’d-Who’s Eligible?ACOG considers nulliparous women and adolescents candidates for LARC BC methods, including IUDsEvidence suggests they’re more effective and have higher rates of satisfaction vs OCPsEvidence suggests no increased risk PID or infertilityInsertion ok at any time of cycle if pregnancy test negative; ok immediately post abortion or miscarriage in the absence of septic abortionCoincidental condom use appropriate prn as STI protection
Slide66Contraception and Chronic DiseaseHormonal contraception is an issue for those with valvular disease (unless treated with an anticoagulant), HTN ( incr risk MI and CVA) and APLA, and also some with eg SLE (+/- APLA, thrombocytopenia)Hormonal contraceptives can be an issue for those taking anti-seizure medication, except for valproate, as clearance is increased, and anti-seizure medication effectiveness likely decreasedDepo-provera has a continuation rate in adolescents of 47%, and is associated with about 6 pregnancies per 100 women per year; can be considered for those with APLA, HTN, tobacco abuse
Slide67Contraception and Chronic Disease: DMNo specific form of BC is contraindicated in DMWHO and CDC recommend hormonal contraception (lowest effective dose) for those with DM, in the absence of tobacco abuse, HTN, vasculopathy, and <35y/oOCPs with estrogen dose <35ug have no adverse effects on CH2O metabolism, plasma glucose, insulin sensitivityOther estrogen/progesterone preparations eg patch, ring, not well studied in DM
DMPA and progesterone-only pills also ok
Copper IUDs and progesterone-releasing IUD similarly ok for DM
Slide68Contraception andChronic Disease: Seizure DisorderFour-fold increase in OCP failure in this population sec to induction of hepatic enzymes by commonly prescribed anti-seizure medicationsSome data indicate that OCPs can be considered if prescribe increased dosage of anti-seizure med, together with extended cycle OCP regimens with shorter pill-free intervalsAED meds do not affect hormone levels in those using hormone-releasing IUDs (Mirena) and/or depo-provera; these methods are considered as effective as OCPs for this population*Since the efficacy of the ‘morning after’ pill may be similarly affected by AEDs, two doses (one q 12hr) of levonorgestrel 1.5mg is often recommended
Slide69ConclusionsCircling back to the title of this presentation ie Unintended Pregnancy in the Uninformed College Student with Chronic Disease: Why It Shouldn’t Happen and What’s Next?, I would like to emphasize the following points…..Seize opportunities for education at each HC visit
Acknowledge possibility of and
document
a discussion of high risk behaviors with all
clients, including abuse of
EtOH
, tobacco, and recreational drugs, unprotected
sex, abuse/sale/sharing of prescription medications and potential consequences
Slide70ConclusionsPartner with your continuity clients with chronic disease diagnoses—medical and psychiatric. Encourage medication compliance and reliable birth control. Refer to Women’s Health as appropriate, and document topics covered during visits.Capitalize on the expertise of other providers, within and perhaps outside of the college health community, for advice and resources
Slide71THANK YOU!