A 25-year-old woman, gravida 2 para 2, comes to the office for a postpartum visit and to discuss contraception. Two weeks ago, the patient had a vaginal delivery at 36 weeks gestation. She is breastfeeding exclusively with no issues. Her lochia has decreased, and she has no pelvic pain. The patient would like to start reliable contraception as soon as possible because she conceived while breastfeeding after her first pregnancy. She takes a daily iron supplement for iron deficiency anemia due to heavy menstrual bleeding. The patient has no other chronic medical conditions and takes no medications. Vital signs are normal. Pelvic examination is deferred. Which of the following is the best contraceptive option for this patient?

Question

A 25-year-old woman, gravida 2 para 2, comes to the office for a postpartum visit and to discuss contraception.  Two weeks ago, the patient had a vaginal delivery at 36 weeks gestation.  She is breastfeeding exclusively with no issues.  Her lochia has decreased, and she has no pelvic pain.  The patient would like to start reliable contraception as soon as possible because she conceived while breastfeeding after her first pregnancy.  She takes a daily iron supplement for iron deficiency anemia due to heavy menstrual bleeding.  The patient has no other chronic medical conditions and takes no medications.  Vital signs are normal.  Pelvic examination is deferred.  Which of the following is the best contraceptive option for this patient?

Quizplus · Accepted Answer

11ec25c8_d990_4462_bc81_e1d25ce253d6_MD0003_00 The choice of postpartum contraception is based on time from delivery, breastfeeding status, patient-specific risk factors, and desire for future fertility. In patients who are <1 month postpartum, estrogen-containing contraceptives are avoided because they increase the risk of thromboembolism (due to estrogen-induced hypercoagulability) and can negatively affect breastfeeding (Choice A). Nonhormonal (eg, copper-containing intrauterine device [IUD]) and progestin-only contraception methods are preferred in patients <1 month postpartum and breastfeeding. However, in this patient with heavy menstrual bleeding complicated by anemia, the copper-containing IUD may increase menstrual bleeding and worsen her preexisting anemia (Choice B). In contrast, progestin-only contraception methods help to decrease menstrual bleeding while also providing contraception. In this patient who desires reliable contraception to avoid another short-interval pregnancy, the best contraceptive option is the subdermal progestin-releasing implant, a long-acting, reversible contraceptive that has high efficacy (>99%) for pregnancy prevention. It does not increase thromboembolic risk or affect breastfeeding and can be inserted immediately postpartum and kept in place for up to 3 years. In addition, it decreases menstrual bleeding in 50% of patients and causes amenorrhea in 20%. (Choice C) Condoms and the diaphragm are barrier methods of contraception that do not affect thromboembolic risk or breastfeeding. However, they have poor contraceptive efficacy (82%). (Choice D) Endometrial ablation can treat heavy menstrual bleeding; however, it is not indicated for contraception and is contraindicated in patients who desire future fertility. Although pregnancy is less likely after this procedure, it remains possible and is associated with obstetric complications (eg, placenta accreta). (Choice E) Progestin-only oral contraceptives do not affect breastfeeding or thromboembolic risk. However, they are less effective (91%) for pregnancy prevention than the subdermal progestin-releasing implant due to high rates of user error and short medication half-life (which requires that the pill be taken at the same time daily to be effective). Educational objective: In breastfeeding postpartum patients, progestin-only contraception methods (eg, subdermal progestin-releasing implant) are preferred and may be initiated immediately because they do not increase thromboembolism risk or affect breastfeeding. References: U.S. medical eligibility criteria for contraceptive use, 2016. (http://www.ncbi.nlm.nih.gov/pubmed/27467196) ACOG practice bulletin no. 206: use of hormonal contraception in women with coexisting medical conditions. (http://www.ncbi.nlm.nih.gov/pubmed/30681544)

A 25-Year-Old Woman, Gravida 2 Para 2, Comes to the Office