Family Planning RUSM Ob-Gyn Clinical Core - PowerPoint Presentation

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Family Planning

RUSM Ob-Gyn Clinical Core Case Presentation

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Intended Learning OutcomesA student should be able to:

Describe the mechanism of action and effectiveness of contraceptive methodsCounsel the patient regarding the benefits, risks and use for each contraceptive method including

emergency contraceptionDescribe barriers to effective contraceptive use and to reduction of unintended pregnancy

Describe

the methods of male and female surgical sterilization

Explain

the risks and benefits of female surgical sterilization procedures

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A 17 year old G0 presents to clinic desiring information about contraceptive methods.

She reports that she is sexually active with her boyfriend, using condoms occasionally, when she “needs them.” She has never used any other methods. She has had 2 lifetime partners. She became sexually active at age 15 and had sex with her first partner 3-4 times but didn’t use contraception.

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She has been sexually active with her current partner for the last year. She came today because she last had unprotected intercourse 3 days ago and is worried she might get pregnant. She has decided it’s time for a more reliable method of contraception.

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She has never had a

pelvic exam. She has history of well controlled seizure disorder and had appendicitis at age 11. She is taking Valproic Acid. She smokes one-half pack of cigarettes per day, drinks alcohol socially, and uses occasional marijuana. Her blood pressure is 100/60 and pulse is 68.

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What pertinent historical information should you obtain from any patient prior to presenting recommendations

for appropriate contraception?

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Sexual historyOnset of sexual activityNumber of partners since onsetHistory of STDsMedical history – contraindications to estrogen-containing hormonal contraceptives

Migraines with aura DVT

Uncontrolled Hypertension

Smoking age > 35

Menstrual history

LMP (pregnancy)

Irregular

menses

Future fertility plans

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What physical exam and studies are required prior to prescribing hormonal contraceptives?

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Pap

and pelvic exam have typically been “bundled services,” i.e., these exams are required to prescribe contraceptives. There is no rationale for this bundling. In general, Pap smears should be initiated at the age of 21. So, this patient would not require one at this time.STI

screening for a sexually active teenager should include chlamydia and gonorrhea which may be tested from a urine sample. Screening for other STIs should be done based on individual risk assessment.

A

blood pressure should be obtained in patients who desire estrogen-containing contraceptives to rule out

hypertension. Hypertension

is rare in this age group, but blood pressure is easy to obtain, non-sensitive and

low cost

.

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Please Review

ACOG PB Number 73 June 2006 Use of Hormonal Contraception in Women with Coexisting Medical Conditions

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Which contraceptive agents are most suitable for this patient?

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Combination hormonal methods: Pills, patch, ring

AdvantagesVery effectiveNon-contraceptive benefits include cycle control, decreased risk anemia, ovarian cysts

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Combination hormonal methods: Pills, patch, ring

Disadvantages“Nuisance” side effects – bloating, H/A, breast tenderness, nauseaNo STD protectionNeed to remember daily, weekly, month

Seizure medications may decrease effectivenessSmall risk of significant complication: DVT, PE, CVA, MI

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Condoms

AdvantagesSTD protectionOnly use when neededDisadvantages

Need to use every timeLess effective

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Depo-provera

Advantages4 shots per yearHighly effectiveDisadvantagesIrregular bleeding

Weight gainNo STD protection

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Etonogestrel subdermal implantAdvantagesSingle subdermal insertion of implant lasts for 3 yearsHighly

effectivehots per yearHighly effective

Disadvantages

Irregular bleeding

Weight gain

No STD protection

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Plan B

AdvantagesBacks up regular birth controlUseful for accidents – condom breaking, discontinued methods

DisadvantagesLess effective

May be difficult to obtain

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Cooper IUD

AdvantagesLong-term contraception with single act motivation

Highly effectiveHigh continuation

May be used for post-coital contraception

Disadvantages

No STD protection

Possible

increased bleeding and/or cramps

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Levonorgestrel IUD

AdvantagesLong-term contraception with single act motivation

Highly effectiveHigh continuation May be used for post-coital contraception

Disadvantages

Some experience hormone-related side effects

Possible irregular bleeding

No STI protection

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Fliqz Video: 12. IUD Insertion.

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When/how to start the contraceptive method?

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Consider contraception an “emergency”

Best if patient leaves with a methodAdvance prescriptions of Plan B to all patients (except those with an IUD)Best if method begins that day if negative pregnancy testCombination methods – Quick start: First pill on day of visit regardless of cycle, preferably in clinicDepo‐provera – Same day shot

Subdermal implant-­‐ same day insertionIUD – Same day insertion

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Depo‐provera – Same day shot

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IUD – Same day insertion

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Combination methods – Quick start: First pill on day of visit regardless of cycle, preferably in clinic

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Subdermal implant-­‐ same day insertion

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As a means of determining your comprehension of the key concepts presented, please answer the APGO uWISE questions in Unit 3 Gynecology, Chapter 33.

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Competencies Addressed

Patient CareMedical Knowledge Practice-Based Learning and ImprovementInterpersonal and Communication SkillsProfessionalism

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References

ACOG Practice Bulletin 121, Long Acting Contraception, July 2011, reaffirmed. 2013.APGO Medical Student Educational Objectives, 10

th edition, (2014), Educational Topic

33.

APGO Clinical Teaching Cases, Educational Topic 33.

Beckman CRB, et al.

Obstetrics and Gynecology

. 7th ed. Chapter 26 & 27, Philadelphia: Lippincott, Williams & Wilkins, 2014.

Zieman

M, Hatcher RA et al. A Pocket Guide to Managing Contraception . Tiger, Georgia: Bridging the Gap Foundation

, 2007

.

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Female Sterilization

RUSM Ob-Gyn Clinical Core

Case Presentation

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Intended Learning OutcomesA student should be able to:

Describe the mechanism of action and effectiveness of contraceptive methodsCounsel the patient regarding the benefits, risks and use for each contraceptive method including

emergency contraceptionDescribe barriers to effective contraceptive use and to reduction of unintended pregnancy

Describe

the methods of male and female surgical sterilization

Explain

the risks and benefits of female surgical sterilization procedures

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The patient is a 37-year-old G3P2 who presents with dysfunctional uterine bleeding—heavy irregular menses for the last 8 months. She has been using progestin-only oral contraceptive pills for contraception. She had previously been taking combined oral contraceptives but was switched to progestin-only pills 1 year ago because her physician told her that her cardiovascular risk was increased because she smokes a pack a day of cigarettes.

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She presents to discuss contraceptive options and is interested in sterilization.

Her past medical history is unremarkable except for mild hypertension treated with Maxide, 25 mg PO daily. She has been in a mutually monogamous relationship for 13 years.

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Physical Examination

General: well nourished and well developed, Ht: 5 feet 4 inches, Wt: 128 pounds, BP: 130/84 HEENT: WNL, no thyromegaly or adenopathyBreasts: No masses

adenopathy or skin changesHeart: normal S1

and S

2

Lungs: clear to auscultation

Abdomen: Soft, no masses, non-tender, no scars

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Pelvic:

External genitalia: normal, Vagina: pink and moist; mild active bleeding per os, no cervical lesion noted, Uterus: small, anteverted, non-tender, no adnexal masses

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The laboratory work done shows:

CBC : Hematocrit = 32% Hemoglobin = 10 mg/dl

WBC = 9.0

x 10

3

/

mm

3

HCG = less

than 2mIU/ml

Cervical cultures – Gonorrhea and

Chlamydia

cultures negative

Endometrial biopsy – proliferative

phase

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Please describe the major methods of female sterilization.

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Methods of Female Sterilization

IntervalLaparoscopicElectrocoagulation (Mono and Bi-Polar)Falope RingHulka Clip

Filshie Tubal Ligation System HysteroscopyEssure Adiana

Post Partum/

L

&

D

Pomeroy

Parkland

Irving

Uchida

Filshie

Tubal Ligation System

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Female Sterilization Overview

Sterilization is the most widely used means of permanent contraception in the US - >700,000 annually#1 method of birth control for women ages 35 to 44Younger women (ages 20-29) are more likely to undergo postpartum sterilization proceduresApproximately 50% of the tubal ligations performed annually are postpartum

Most postpartum procedures are performed within 24 hoursOlder women (ages 35-49) are more likely to undergo interval procedures

Data quoted: Grimes, DA. Update on female sterilization: Failure rates, counseling issues, and post sterilization regret. The Contraception Report. 1996. 7(3): 4-11

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Prior to 1960, sterilization of females was performed primarily as a result of medical indications

Increased interest in family planning coupled with safer and more effective methods allowed sterilization to become a viable method of contraception during the 1960s

Widespread acceptance of laparoscopy led to the development of several methodsElectrocautery (mono-polar and bi-polar)

Clips (Hulka and Filshie)

Bands (Yoon Band, Falope Ring)

Data Quoted From: Hulka J and

Stepian

A. Laparoscopic sterilization. In: Gordon AG, Hulka JF, Walker DM, and

Campana

A, eds. Practical Training and Research in Gynecologic Endoscopy. 2003.

Sklar

AJ. Tubal Sterilization.

eMedicine

. November 15, 2002. Available at http:www.emedicine.com/med/topic/3313.htm.

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Tubal Anatomy

Ampulla

Isthmus

Fimbria

Infundibulum

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Procedure

Timing

Technique

Minilaparotomy

Post Partum

Post Abortion

Interval

Mechanical Devices (Clips, Rings)

Tubal Ligation or Excision

Laparoscopy

Interval Only

Electrocoagulation (Unipolar, Bipolar)

Mechanical Devices (Clips, Rings)

L

aparotomy

In conjunction with other surgery (Cesarean section,

salpingectomy

, ovarian

cystectomy

, etc.)

Mechanical Devices (Clips, Rings)

Tubal Ligation or Excision

1

Since 2002,

hysteroscopic

methods are available and can be performed

interval-only (Essure and Adiana).

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Laparoscopic

Monopolar Coagulation

Complications

Bowel Burn

Bleeding

Longer portion of tube is damaged

Failures and ectopic pregnancy

Transection

is frequent

1

Peterson LS Contraceptive use in the United States: 1982 -90. Advance Data: From Vital Health Statistics February 1995; 260 1-8

Failure Rate: 7.5/1000 (.07-.75%)

1

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Laparoscopic

Bipolar Coagulation

Benefits

Most common method of laparoscopic sterilization

Burn several locations along the tube

Complications

Formation of

uteroperitoneal

fistulas

High rate of ectopic pregnancy

Potential for bowel burns

Reversals are potentially more difficult due to the extent of tube damage

1 Peterson HB, et al. The risk of pregnancy after tubal sterilization: Findings from the U.S. Collaborative Review of Sterilization. Am J obstet. Gynecol. 1996; 174 (4):1161-1170

Failure Rate: 24.8/1000

1

(.2-2.5%)

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3 separate applications of bipolar

cauteryEach with complete fulguration.

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Bipolar fulguration at three separate sites on the isthmus portion of the tube.

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Laparoscopic

Falope Ring (Yoon band)

Mechanical occlusion invented in 1974

Tubal occlusion accomplished by placing a silicone band around the

tube

Complications

Increased patient discomfort during recovery – large area of necrosis

1

Peterson HB. Et al. The risk of Pregnancy after tubal sterilization: Findings from the U.S. Collaborative Review of Sterilization. Am Journal of Obstetrics and Gynecology. 1996; 174(4): 1161-1170

Failure Rate: 17.7/1000

1

(1.8%)

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Falope Ring/Yoon Band

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Laparoscopic

Hulka Clip

Tubal occlusion is accomplished by placing a spring clip (plastic and gold plate) across the fallopian tube

Hulka clip has limited tubal capacity

Potential

patient allergy due to gold plate

1

Pregnancy After Tubal Sterilization with Bi-Polar

Electrocoagulation

. Obstetrics and GYN. August 1999 Volume 94. Herbert B

Petterson

et al for the CREST Working Group

Failure rates 36.5/1000 (3.7%) (Ectopic 8.5/1000)

1

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Laparoscopic Application of a Hulka Clip

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Hulka Clip

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Laparoscopic and

Minilapararotomy Filshie® Tubal Ligation System

FDA approved in 1996 (post CREST study)Tubal occlusion accomplished by placing a titanium hinge clip lined with silicone rubber across the fallopian tube

Large tubal capacity

Magnetically inert (okay for MRI)

Minimal post operative pain

Designed for use interval and post partum (post vaginal birth and at the time of C-section)

Clip migration rare but possible

1 A Penfield, MD. The Filshie Clip for Female Sterilization: A Review of World Experience. American Journal of Obstetrics and Gynecology, March 2000

2 Failure Rates from Family Health International, used in the initial FDA PMA Submission for the Filshie Clip

Failure rate of 2.7/1,000 (.27%)

1,2

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Filshie

®

Clip – Laparoscopy

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Slide55

Filshie

® Clip – Laparoscopy

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What are the failure rates of these methods?

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Studies and Findings

10,685 WOMEN STERILIZED (1978-1986)MEDIAN AGE: 30 years old

FOLLOW-UP: 8-14 years

METHODS OF STERILIZATION:

Yoon band 31.2 %

Bipolar 21.2 %

Postpartum 15.3 %

Hulka clip 14.9 %

Unipolar

13.4 %

The U.S. Collaborative Review of Sterilization (CREST )

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The U.S. Collaborative Review of Sterilization (CREST )

RESULTS: Failure Rates34 Luteal

phase pregnancies143/10,685 True failures (1.34%)15% Spontaneous abortion

18% Induced abortion

29% Deliveries

3% Ongoing pregnancy at time of study

33% Ectopic pregnancy

2% Status unknown

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Are there any methods that do not require an abdominal incision?

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Methods of Female Sterilization

HysteroscopicEssureAdiana

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Hysteroscopic (Hospital and Office-based

procedur Essure®

Approved in 2002

Micro-insert placed into each tube, PET fibers stimulate in-growth over several weeks

86% Success Rate for 1

st

time placements of micro-inserts

3 months of alternative contraception until HSG procedure confirms occlusion

Not suitable for patients with known allergies to contrast media or hypersensitivity to nickel

Irreversible

May

limit a patients ability to have

in vitro

fertilization, should patient change her mind

May

limit the ability to perform endometrial ablation in the future

ACOG does not recommend concomitant endometrial ablation

FDA. Essure System: Summary of Safety and Effectiveness. November 4, 2002 available at

http://www.fda.gov/cdrh/pdf2/p020014b.pdf

1

UpToDate – Hysteroscopic Sterilization; Jan 2010

Failure rate .26%

1

(5 year rate)

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Hysteroscopic (Hospital and Office-based procedure)

Adiana®

Approved in 2009Catheter delivers low RF energy for one minute then a 3.5 mm non-absorbable silicone

elastomer

matrix is placed in each tubal lumen

3 months of alternative contraception until HSG procedure confirms occlusion

Photograph from Adiana website

1

Adiana

Transcervical

Sterilization System PMA P070022 Draft Panel Discussion Questions, p.2, December 14, 2007.

Failure rate 1.8%

1

(2 year rate)

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What methods are employed in the immediate postpartum period?

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Methods of Female Sterilization

PostpartumPomeroyParklandIrvingUchidaFilshie® Tubal Ligation System

Slide65

Pomeroy Technique

Incision

– suprapubic and

subumbilical

(PP)

Isthmic

portion is

ligated

twice with 0 or 2-0 plain catgut suture

Segment is then excised

Inspect for

hemostasis

and the presence of the tubal

lumen

1

Pregnancy After Tubal Sterilization with Bi-Polar Electrocoagulation. Obstetrics and GYN. August 1999 Volume 94. Herbert B Petterson et al for the CREST Working Group

Tied

Cut

Final result

Failure Rate: 7.5/1000

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Pomeroy Technique

Benefits

Easy technique

Highly effective

Relatively inexpensive (excluding lab costs for pathology)

Complications

Infection and bleeding

Potential ectopic pregnancy

1

Pregnancy After Tubal Sterilization with Bi-Polar Electrocoagulation. Obstetrics and GYN. August 1999 Volume 94. Herbert B Petterson et al for the CREST Working Group

Slide67

Parkland Technique

Isthmic portion of tube is segmented and

ligated at two pointsAn

avascular

area in the

mesosalpinx

is opened

0 or 2-0 plain catgut passed through the opening

Proximal and distal

ligated

and segment excised

Failure rate not reported

1

Slide68

Parkland Technique (continued)

Benefits

Designed to reduces natural tube re-attachment

Good success rates

Few complications

Inexpensive to perform (if no pathology)

Complications

Ectopic pregnancies, infection, bleeding

Time required to perform procedure properly

Failure rate not reported

1

Slide69

Irving Technique

Was

developed for sterilization at C/S

Bury the proximal tubal stump within the

myometrium

Original description – distal tube buried in the broad

ligament

1. Sterilization. The University of Kentucky Department of OB-GYN Women’s Health Curriculum.

Failure rate: 1/1000

1

1 Up to Date – Sept 2010, Stovall T. et al. Surgical Sterilization of Women

Slide70

Irving Technique

Benefits

Used in conjunction with cesarean delivery

Complications

Moderate level of difficulty to perform

Pomeroy and Parkland are quicker

1. Sterilization. The University of Kentucky Department of OB-GYN Women’s Health Curriculum.

Failure rate: 1/1000

1

1 Up to Date – Sept 2010, Stovall T. et al. Surgical Sterilization of Women

Slide71

Most

complex methodInject saline into the subserosal layer 2 cm distal to the

cornuaIncise

serosa

to free a 2 to 3 cm segment

Ligate

proximal and distal end of freed tube

Proximal tube “dunked,” distal is “exteriorized” and

serosa

is then closed

Benefits

Can be performed immediately postpartum

Complications

Moderate level of difficulty to perform

Pomeroy and Parkland are quicker

1

Sklar

AJ. Tubal Sterilization.

eMedicine

. November 15 2002. Available at

http://www.emedicine.com/med/topic3313.htm

Failure rate: more than 20,000 cases performed by Uchida personally without a failure

1

Uchida Technique

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Discussion with patient must take place and cover the following details:

It must be a voluntary decisionDiscuss the methods and other optionsSterilization is permanent Must be 21 years of age or olderProbability of failure

Discussion about methods of contraception for prevention of STDsSpecial consideration for women with mental disabilities

Sterilization and the Process of Informed

Consent

Information taken from the Dept. of Health and Human Services Form: http://www.hhs.gov/forms/HHS-687.pdf

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Summary of Female Sterilization

Tubal occlusion is an effective method of female sterilization regardless of method chosenFailures will occur in some percentage female sterilization procedures regardless of method utilized.Intrauterine PregnancyEctopic Pregnancy