A 41-year-old woman, gravida 1 para 1, comes to the office to discuss possible contraceptive options. She was recently diagnosed with hypertension and started on an ACE inhibitor. While discussing the medication, the patient was counseled on the risk of ACE inhibitors in pregnancy and the need for reliable contraception. She has not been on contraception for the past year because she was breastfeeding up until a month ago. Her husband does not want any more children, but the patient is unsure about future pregnancy. She has no other chronic medical conditions and takes no other daily medications. Her menses are monthly with 4 days of light bleeding and mild cramping on the first day. She does not use tobacco, alcohol, or illicit drugs. Blood pressure is 122/78 mm Hg and pulse is 70/min. BMI is 19 kg/m². On pelvic examination, the cervix is multiparous and has no visible lesions. The uterus is mobile and nontender. Which of the following is the most appropriate contraceptive option for this patient?

Question

A 41-year-old woman, gravida 1 para 1, comes to the office to discuss possible contraceptive options.  She was recently diagnosed with hypertension and started on an ACE inhibitor.  While discussing the medication, the patient was counseled on the risk of ACE inhibitors in pregnancy and the need for reliable contraception.  She has not been on contraception for the past year because she was breastfeeding up until a month ago.  Her husband does not want any more children, but the patient is unsure about future pregnancy.  She has no other chronic medical conditions and takes no other daily medications.  Her menses are monthly with 4 days of light bleeding and mild cramping on the first day.  She does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 122/78 mm Hg and pulse is 70/min.  BMI is 19 kg/m².  On pelvic examination, the cervix is multiparous and has no visible lesions.  The uterus is mobile and nontender.  Which of the following is the most appropriate contraceptive option for this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d262_584d_bc81_df5da91abd17_MD0003_00 Contraceptive counseling should be patient-centered and take into consideration patient-specific factors (eg, medical history), risk/benefit profiles of various contraception methods, and the patient's future fertility desires. In this patient with medication-controlled hypertension, the best option is the copper-containing intrauterine device (IUD) for several reasons, including: No effect on hypertension: This is in contrast to estrogen-containing contraceptives, which can elevate blood pressure and increase the risk of stroke or acute myocardial infarction. High efficacy (>99%) for pregnancy prevention: The copper-containing IUD's effectiveness is due to high patient compliance (ie, ease and duration of use, with reinsertion every 10 years) and its multiple mechanisms of action (ie, impairment of sperm function, fertilization, and implantation). Contraceptive efficacy is particularly important for patients taking teratogenic medications (eg, ACE inhibitors). No effect on future fertility: The copper-containing IUD can be removed at any time the patient desires pregnancy, with immediate return of fertility. Although the copper-containing IUD does not help (and may worsen) menstrual bleeding, patients such as this one with light bleeding and mild cramping are ideal candidates because they typically experience minimal adverse effects. (Choices A and E) Bilateral tubal ligation and vasectomy are forms of permanent sterilization and, therefore, inappropriate for patients who are undecided about future pregnancy. (Choices B and D) Combined estrogen-progestin oral contraceptives and the estrogen-progestin vaginal ring can worsen preexisting hypertension due to estrogen-induced angiotensinogen synthesis. Therefore, estrogen-containing contraceptives are an absolute contraindication in patients with severe hypertension and a relative contraindication in patients with mild or medication-controlled hypertension, such as this patient. vaginal ring Educational objective: Long-acting, reversible contraceptives (eg, copper-containing intrauterine devices) are highly effective for pregnancy prevention and can be used in patients with contraindications to estrogen-containing contraceptives (eg, hypertension). 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 41-Year-Old Woman, Gravida 1 Para 1, Comes to the Office