HOW THE RISK FOR VTE AFFECTS THE CHOICE OF CONTRACEPTIVE
The hematologic changes of normal pregnancy shift coagulability and fibrinolytic systems toward a state of hypercoagulability. This physiologic process reduces the risk for puerperal hemorrhage; however, it also predisposes women to VTE during pregnancy and into the postpartum period. Studies assessing the risk for VTE in postpartum women indicate that it increases by a factor of 22 to 84 during the first six weeks, compared with the risk in nonpregnant, nonpostpartum women of reproductive age.7 This heightened risk is most pronounced immediately after delivery, declining rapidly over the first 21 days after delivery and returning to a near-baseline level by 42 days postpartum.
By the time of the recommended three-week postpartum visit, the period of highest VTE risk has passed. For women who are no longer breastfeeding, the benefits of all hormonal contraceptive methods, including those that contain estrogen, outweigh their risks, according to a newly released update to recommendations from the CDC (see Table 1).6 Although combined oral contraceptives are known to increase the risk for VTE by a factor of 3 to 7, data suggest that healthy women who do not have additional risk factors for VTE (eg, thrombophilia, obesity, smoking, or age 35 or older) can use them safely.6
The updated recommendations discourage use of estrogen-containing contraceptives before 21 days postpartum because they present an unacceptable level of risk (regardless of breastfeeding status). But they allow the use of combined hormonal contraceptives in otherwise healthy, breastfeeding women after 30 days postpartum. For women who have additional risk factors for VTE, the risks of combined hormonal contraceptives outweigh the benefits until six weeks postpartum, regardless of breastfeeding status.6
In contrast, progestin-only and nonhormonal contraceptive methods can be safely initiated by both breastfeeding and nonbreastfeeding women before 21 days postpartum, which means that women can begin using them before discharge from the hospital.
WHEN TO CONSIDER LARC OR STERILIZATION
Long-acting reversible contraceptives (LARC) are an important postpartum contraceptive option because they offer highly effective protection against pregnancy that can begin as soon as the placenta is delivered. LARC methods include contraceptive implants and intrauterine devices (IUDs).
According to the CDC’s medical eligibility criteria for contraceptive use, implants can be placed immediately after delivery of the placenta without restriction.8
The copper IUD can be placed within 10 minutes after delivery of the placenta without restriction. If this window is missed, the benefits of inserting the IUD still outweigh the risks. Because four weeks postpartum is another time when the copper IUD can be inserted without restriction, the three-week visit is a reasonable time to screen and schedule a patient for insertion.
The benefits of insertion of the levonorgestrel-releasing intrauterine system (LNG-IUS) are also believed to outweigh the risks before four weeks postpartum. Like the copper IUD, the LNG-IUS can be inserted without restriction at four weeks postpartum or later.
There is no need for a pelvic exam at the three-week postpartum visit among women who undergo immediate postplacental insertion of the copper IUD or LNG-IUS. In fact, women can delay the exam until involution is complete.
Sterilization is best after complete involution
Interval tubal sterilization by laparoscopic, bilateral tubal fulguration or hysteroscopic microinsert placement is one of the most effective ways to prevent pregnancy. Both methods are best performed after the completion of involution and the return of normal coagulation; scheduling can take place at the three-week postpartum visit.
Given the benefit of depot medroxyprogesterone acetate (DMPA) in endometrial suppression before hysteroscopic sterilization, it is reasonable to consider administering DMPA at the three-week postpartum visit in anticipation of surgery after involution is complete.
THE BOTTOM LINE
Since most contraceptive methods can be safely initiated at or shortly after a three-weeks’ postpartum visit, there is no longer any reason to time the routine postpartum visit to coincide with the completion of involution. For healthy women who have had an uneventful delivery, the routine postpartum visit should occur at three weeks.
REFERENCES
1. Speroff L, Mishell DR. The postpartum visit: it’s time for a change in order to optimally initiate contraception. Contraception. 2008;78(2): 90–98.
2. Connolly A, Thorp J, Pahel L. Effects of pregnancy and childbirth on postpartum sexual function: a longitudinal prospective study. Int Urogynecol J Pelvic Floor Dysfunct. 2005; 16(4):263–267.
3. McDowell MA, Wang C-Y, Kennedy-Stephenson J. Breastfeeding in the United States: Findings from the National Health and Nutrition Examination Surveys 1999–2006. NCHS Data Briefs. 2008;5:1–8.
4. Jackson E, Glasier A. Return of ovulation and menses in postpartum, nonlactating women: a systematic review. Obstet Gynecol. 2011;117(3):657–662.