Contraception and Managing Special Cases: focus on

hypertension

Morgan HardigreeUAB School of Nursing

NWH 962Spring 2015

Objectives

• To outline the components of a contraceptive counseling visit

• To define populations at risk for complications with hormonal contraception

• To understand the U.S Medical Eligibility Criteria for Contraceptive Use

• To understand the effects of HTN and heart disease on contraceptive use

Case Study

• 24 yo AA female presents to clinic today for a contraception counseling visit. Patient is a G1P1001. Last pregnancy ended March 2014 at 34 weeks patient had gestational diabetes and preeclampsia. Currently not using any form of birth control. LMP 01/20/2015 states that it was normal. Periods normally last 5 days and occur once a month ,no dysmenorrhea. Last act of sex was 2 weeks ago with no protection. Patient has medical history of HTN and CHF. Patient takes lasix 40 mg and Lisinopril 40 mg daily. Patient sees cardiology every 3-6 months and no complications noted by MD. Wt. 354 Ht. 66 inches. BMI 57. BP 126/72 P 75 R 16. Last PAP was during pregnancy last year. She plans on having gastric bypass within the next month. Patient desires depo for birth control.

• What is important to examine or do at this visit for this patient? Any labs? Is depo a good choice for this patient? If not why and what are her options?

Contraception Use

• Contraception use has increase over the last 30 years.

• 38% of women do not use any form of contraception.

– Pill 17%

– Female sterilization 16.5%

– Male condom 10.2%

– Male sterilization 6.2%

– Intrauterine device (IUD) 3.5%

– Withdrawal 3.2%

– Depo-Provera 2.3%

– (Jones, J., Mosher, W., Daniels, K. ,2012)

The Contraceptive CHOICE Project (Xu, Eisenberg, Madden, Secura, and Peipert, 2014).

• 1010 of these women desired combined hormonal contraception (CHC)

•408 African American•508 Caucasian •48% Hispanic ethnicity

•3399 desired long-acting reversible contraception (LARC) methods

Contraception Use

Population at risk

• 50% of all pregnancies in the United States are unplanned (Moodley, 2011).

• Pregnancy can increase adverse effect of many predisposing health conditions.

• Heart disease is on the rise for women of childbearing age (Ford and Capewell, 2007).

• 6-8% of all pregnancies in the United States are complicated by hypertension (ACOG, 2001).

• Breast cancer

• Diabetes

• Endometrial or ovarian cancer

• Epilepsy

• Hypertension

• HIV/AIDS

• Severe cirrhosis

• Sickle cell disease

• Ischemic heart disease

• Stroke

• Tuberculosis

• Malignant gestational trophoblasticdisease

• Complicated valvular heart disease

• Peripartum cardiomyopathy

• Schistosomiasis with fibrosis of the liver

• Solid organ transplantation within the past 2 years

• Systemic lupus erythematosus

• Thrombogenic mutations

• History of bariatric surgery within the past 2 years

• Malignant liver tumors

Conditions associated with increased risk foradverse health events as a result of unintended pregnancy

(CDC, 2010)

HTN in Pregnancy

• Increase risk for maternal and fetal mortality and morbidity (Bateman et al., 2012).

• Maternal outcomes: – stroke– renal failure– pulmonary edema– death

• Fetal outcomes: – preterm birth– intrauterine growth restriction

Clinical presentation

• Women present for contraception for a number of reasons.

– To prevent pregnancy

– To help with PMS symptoms

– To help regulate irregular menses

– To stop having periods

– To improve acne

Why do women choose a particular type of birth control?

• cost

• convenience

• potential side effects

• effectiveness

• non-contraceptive benefits

Do women think about the effects of contraception on their current health

conditions?

Contraception Counseling Visit: Subjective information

• Comprehensive past medical health history is most important– Previous venous thromboembolism, HTN or other

cardiac conditions, migraines (specific type), gallbladder disease, and current medication use

• Family history

• Tobacco, drug, and alcohol use

• Past pregnancies and next planned pregnancy

• GYN and sexual history

Contraception Counseling Visit: Objective information

• Breast exams, pelvic exams, cervical cancer screenings, or sexually transmitted disease testing is not required before initiating or renewing hormonal contraception (CDC, 2010; ACOG, 2001).

• Rule out Pregnancy

• Assessment of blood pressure and cardiovascular disease (CDC, 2010)– Document height, weight, body mass index, and blood

pressure.

Quick start method for Contraceptive pills or

injection

(CDC, 2013)

Retrieved from: http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/PDF/248124_Box1_App_B_D_Final_TAG508.pdf

Contraception Counseling Visit: Assessment

• Common ICD-9 codes used: • V25.0 General counseling and advice on contraceptive management • V25.01 General counseling on prescription of oral contraceptives• V25.02 General counseling on initiation of other contraceptive measures• V25.03 Encounter for emergency contraceptive counseling and

prescription• V25.04 Counseling and instruction in natural family planning to avoid

pregnancy• V25.09 Other general counseling and advice on contraceptive

management• V25.4 Surveillance of previously prescribed contraceptive methods • V25.40 Contraceptive surveillance unspecified• V25.41 Surveillance of contraceptive pill• V25.49 Surveillance of other contraceptive method

Contraception Counseling Visit: Plan

• It is the healthcare provider responsibility to guide and educate the patient based on their health and risk factors.

• Things to consider when guiding and educating patient on contraceptive methods (Zieman, 2014):– efficacy– Convenience– duration of use (reversibility)– next planned pregnancy– effect on uterine bleeding– side effects– Cost– Accessibility– sexually transmitted disease risk and protection– non-contraceptive benefits– And most importantly medical contraindications

Contraception Counseling Visit: Plan

• Informed of all benefits and risk of their desired contraceptive method.

• Recommended follow up: – to discuss side effects or other problems with

their contraception

– to assess any changes in their health status

– to assess for satisfaction with their current method as needed

– (CDC, 2010)

Retrieved from: http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/PDF/248124_Box1_App_B_D_Final_TAG508.pdf

(CDC, 2010)

Download the CDC’s U.S. Medical Eligibility Criteria for

Contraceptive Use, 2010 application for iPhone/iPad from

the iTunes App Store.

Retrieved from: http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htm

Retrieved from: https://www.fptraining.org/

Effects of contraception on blood pressure and cardiovascular risk

•CHC•Estrogen increases angiotensinogen levels •Fluid retention due to the enhanced aldosteroneeffects cause fluid retention and increase in blood pressure.• It is common for a women’s blood pressure to raise 3 to 5 mmHg when taking CHC. •Studies have shown that out of 10,000 CHC users 41.5 patients with experience elevated blood pressure •(Hatcher, 2011).

•Depo-provera (DMPA)•The US Medical Eligibility Criteria for Contraceptive Use (2010) states, “Concern exists about hypo-estrogenic effects and reduced HDL levels, particularly among users of DMPA (p. 36).” •DMPA prevents conception by inhibiting the gonadotropin release from the pituitary gland and as an end result decreases the circulation of estrogen in the body. •Premenopausal women need estrogen to inhibit fatty deposit in the inner lining of arteries. •In high risk patients (multiple cardiovascular risk factors) a decrease in the circulation of estrogen can dysfunction of the lining of blood , increasing the effects of arthrosclerosis, and can lead to future cardiac events. •(Sorensen et al., 2002).

Effects of contraception on blood pressure and cardiovascular risk

Current Recommendations

• BP 140/90

– the risk of taking CHC outweighs the advantages

• BP >160/>100

– there are unacceptable health risk for CHC

– theoretical or proven risk of DMPA outweighs the advantages

• (CDC, 2010)

Current Recommendations• Other CV risk

– Tobacco use: CHC is contraindicated for women over 35 who smoke

– Obesity: advantages outweigh the risk– History of high blood pressure during pregnancy: no

known contradictions– Hyperlipidemias- advantages outweigh the risk– Multiple risk factors for arterial cardiovascular disease

(older age, smoking, diabetes, and HTN): unacceptable heath risk

– (CDC, 2010).

For patients with cardiovascular risk and hypertension progestin only pills (POP) or LARCs have no restrictions for use

Case Study

• What is important to examine or do at this visit for this patient? BP, HT, WT, BMI, CV exam (due to history of CHF)

• Any labs? Pregnancy test• Is depo a good choice for this patient? No

category 3 on CDC medical criteria chart• If not why and what are her options? IUD-

nexplanon may be a consideration but with weight loss surgery I would be concerned about drastic wt loss and loose skin

References

ACOG. (2012). Well-Woman Visit. The American College of Obstetricians and Gynecologist, 534, 1-4. Retrieved from http://www.acog.org/-/media/Committee-Opinions/Committee-on-Gynecologic-Practice/co534.pdf?dmc=1&ts=20141120T1537476979.

Bateman, B., Shaw, K., Kuklina, E., Callaghan, W., Seely, E., & Hernandez-Diaz, S. (2012). Hypertension in women of reproductive age in the United States: NHANES 1999-2008.PLoS ONE, 7(4) 1-7. Doi:10.1371/journal.pone.0036171

CDC. (2013). U.S. selected practice recommendations for contraceptive use, 2013. Morbidity and Mortality Weekly Report 63(5), 1-64. Retrieved from http://www.cdc.gov/mmwr/pdf/rr/rr6205.pdf.

References

CDC. (2010). U.S. medical eligibility criteria for contraceptive use, 2010. Morbidity and Mortality Weekly Report, 59, 1-86. Retrieved from http://www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf.

Ford E.S., Capewell S. (2007). Coronary heart disease mortality among young adults in the U.S. from 1980 through 2002: concealed leveling of mortality rates. Journal of the American College of Cardiology, 50, 2128–2132. Doi:10.1016/j.jacc.2007.05.056.

Hatcher, R. (2011). Contraceptive technology. New York, N.Y: Ardent Media.

References

Jones, J., Mosher, W., Daniels, K. (2012). Current contraceptive use in the United States, 2006-2010, and changes in patterns of use since 1995. National Health Statistics Reports, 60, 1-25. Retrieved from http://www.cdc.gov/nchs/data/nhsr/nhsr060.pdf.

Moodley, J. (2011). Potentially increasing rates of hypertension in women of childbearing age and during pregnancy-be prepared. Cardiovascular Journal of Africa, 22 (5), 330-324. DOI: 10.5830/CVJA-2010-074

Sorensen, M., Collins, P., Ong, P., Webb, C., Hayward, C., Asbury, E.,… Pennell, D. (2002). Long-term use of contraceptive depot medroxyprogesteroneacetate in young women impairs arterial endothelial function assessed by cardiovascular magnetic resonance. Circulation, 106, 1646-1651. DOI: 10.1161/01.CIR.0000030940.73167.4E.

References

Xu, H., Eisenberg, D., Madden, T., Secura, G., & Peipert, J. (2014). Medical contraindications in women seeking combined hormonal contraception. American Journal of Obstetrics & Gynecology, 210(3):210.e1-5. Doi: 10.1016/j.ajog.2013.11.023.

Zieman, M.(2014). Overview of contraception. Waltham, MA: UpToDate. Retrieved from http://www-uptodate-com.ezproxy3.lhl.uab.edu/contents/overview-of-contraception?source=search_result&search=contraception&selectedTitle=1%7E150.