UOG

School of Midwifery
Department of Clinical Midwifery
Maternity and Reproductive Health Nursing
By: Kindu Y.
Email:kinduyinges2010@gmail.com

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 Early pregnancy Bleeding
Kindu Y, Lecturer

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 Abortion
• Abortion is the process of termination or expulsion of pregnancy before 28 th completed
weeks of gestation or <1000gm weight.
• WHO: defines abortion if gestational age is < 20 weeks or weight < 500gm
• It is the most common complication of pregnancy
• Ethiopian context is 28 wk or 1000 gm

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 Is the commonest gynecological & obstetric disorder.
• About 15% of clinically recognized pregnancies end in abortion.
• 60% of chemically evident pregnancies end in spontaneous abortion.
• Most abortions (80%) occur before 12 weeks of pregnancy
 Unsafe abortion is a leading cause of maternal mortality:
13% - worldwide
17% - east Africa

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 Risk factors related to abortion mortality

• Age
• General state of health
• Gestational age
• Method of termination
• Technical competence
• Availability and accessibility of facilities

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 Etiology
A. First trimester abortion :
1. Fetal chromosomal abnormalities - particularly Trisomy(47,xy) Polyploidy (e.g.
Triploidy(69,xyy)), & monosomy(45,x).

is the commonest cause of abortion

 50– 70 % of the first trimester abortions are due to chromosomal abnormalities

 the incidence of these abnormalities increased with the increase in the maternal age

 Polyploidy, usually in the form of triploidy, is found in approximately 20% of all

miscarriages.
 Polyploid conceptions typically result in empty sacs or blighted ova but occasionally can
lead to partial hydatidiform moles.

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Anembryonic pregnancy - Blighted ovum added
The vast majority of preclinical and early clinical pregnancy losses are the result
of de novo fetal aneuploidy This is also thought to be the cause of anembryonic
pregnancy losses, whereas pregnancy losses occurring after 10 weeks of fetal
development are much less likely to derive from fetal aneuploidy

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2. Parental balanced translocation
3. Infections: genital tract infection , systemic infection with pyrexia &
ToRCH syndrome
4. Endocrine disorders : Diabetes, thyroid disorders , PCOS & Corpus
luteum insufficiency
5. Uterine disorders: Uterine anomalies , sub mucus fibroid & Asher man's
syndrome

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6. Thrombophilia: Congenital deficiency of protein C & S, & anti-thrombin III
7. Immunological disorders : Anticardiolipin syndrome and SLE

8. Cigarette smoking , anesthetic agents & chemical agents .

9. Psychological disorders

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 Etiology…
 First trimester Associations
 Increasing maternal age
 Obesity
 Caffeine
 Alcohol
 Drug misuse
 Fever

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B. Second trimester abortion:

1. Multiple pregnancy

2. Cervical incompetence (congenital & acquired )

3. Uterine anomalies and sub mucous fibroid

4. Genital tract infection and PROM

5. Systemic infections: HIV, Malaria, syphilis, Rubella

6. Maternal health: Diabetes, Renal disease, HTN

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Unexplained Abortion
 The etiology of spontaneous abortion of chromosomally and structurally
normal embryos/fetuses in apparently healthy women is unclear.

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 Classification of abortion
A. Clinically

1. Threatened abortion

2. Inevitable abortion

3. Incomplete abortion

4. Complete abortion

5. Missed abortion

6. Septic abortion

7. Recurrent abortion

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B. Gestational Age:
1. Fist trimester
2. Second trimester
C. Method
1. Spontaneous
2. Induced

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 Differential diagnosis
• Ectopic pregnancy
• Molar pregnancy
• AUB other than Pregnancy
• Local causes
• Urinary tract, GI tract bleeding

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 Threatened abortion
1.  History  Mild vaginal bleeding.
 No or mild abdominal pain 
2. Examination  Good general condition.
 The cervix is closed
 The uterus is usually to correct size for date
3. U/S which is essential for the diagnosis Showed the presence of fetal heart
activity.

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 Threatened abortion(Mgt.)

1. Reassurance If fetal heart activity is present, > 90% of cases will be

progressed satisfactorily
2. Advice: Decrease physical activity (bed rest is of no therapeutic value),
avoid intercourse.
3. Hormones i.e. Progesterone & hCG Which are used in the first trimester to
support pregnancy, (but they are of no proven value)
4. Anti- D: ?? An adequate dose of anti-D should be given to all Rh –ve,non-
immunised patients, whose husbands are Rh +ve
5. ANC as high risk patients
Because those patients are liable to late pregnancy complications such as
APH and preterm labor .

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 Inevitable and Incomplete abortions
1. History
Heavy vaginal bleeding.

 with no passage of products conception (inevitable)

 with the passage of products of conception (incomplete abortion)
Severe lower abdominal pain which follows the bleeding (both)

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 Inevitable and Incomplete
2. Examinations
 Poor general condition.
 The cervix is dilating and products of conception may be passing through the
os
 The uterus may be the correct size for date (inevitable abortion) or small for
date (incomplete abortion)
3. U/S  Fetal heart activity may or may not present in inevitable abortion or retained
products of conception in incomplete abortion

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 Inevitable and incomplete(mgt.)
1. CBC , blood grouping , Blood
2. Resuscitation  large IV line, fluids & blood
transfusion
3. Expectant management(25% to 76%)
4. Medical management with 800 μg of misoprostol
5. placed vaginally can be up to 84% effective in achieving
6. complete abortion
7. For incomplete abortion, the misoprostol dose can be
8. reduced to 600 μg orally or 400 μg sublingually, with
9. efficacy greater than 90%
10. Evacuation & curettage.
11. Post-abortion management.

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 Complete abortion
1. History
 Heavy vaginal bleeding which has been stopped.
 lower abdominal pain which follows the bleeding which has been stopped.
2. Examination
 The cervix is closed
3. U/S
 showed empty uterine cavity

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 Complete abortion(Management)
1. Confirm it is complete
2. Post-abortion care

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 Missed abortion
•  A missed abortion refers to in-utero death of the embryo or fetus prior to the
20th/28th week of gestation, with retention of the pregnancy for a prolonged
period of time.

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 Missed abortion
1. Most of missed abortions are diagnosed accidentally during routine U/S in early
pregnancy .
In some cases there may be a history of :
 Episodes of mild vaginal bleeding
 Regression of early symptoms of pregnancy .

 Absent fetal movements after 20 weeks gestation.

2. Examination
 The uterus may be small for date

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 Missed abortion
3. U/S (which is essential for diagnosis ) diagnosed if two ultrasound ( T/V or
T/A) at least 7days apart showed an embryo of > 7 weeks gestation ( CRL >
6mm in diameter and gestational sac > 20 mm in diameter ) with no evidence
of heart activity .

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 Missed abortion (Management)
1. CBC , blood grouping , units of blood
2. Platelets count, PT, PTT – to exclude the risk of DIC
NB : DIC does not occur before 5 weeks of missed abortion or IUFD and if occurred
will be of mild grade

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 Anembryonic pregnancy(Blighted ovum)
 It is due to an early death and resorption of the embryo with the persistence of the
placental tissue.
 It is diagnosed if two ultrasound ( T/V or T/A) at least 7 days apart showed after 7
weeks of gestation i.e. gestational sac > 20mm , an empty gestational sac with no
fetal echoes seen .
 It is treated in a similar way to missed abortion .

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 Septic abortion
Definition :
Commonly it is an incomplete abortion which complicated by infection of the uterine
contents .
It can be any clinical variety: Induced, Spontaneous, Incomplete. Inevitable,
Complete, missed abortions.
Features : Poor general condition
Include the features of incomplete abortion i.e. severe vaginal bleeding with passage of
product of conception, with or without history of evacuation.
Features of pelvic infection i.e. pyrexia , tachycardia , general malaise , lower
abdominal pain , pelvic tenderness & purulent vaginal discharge .

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 Septic abortion
Bacteriology : Mixed infection
  The commonest organisms are :
1. Gram -ve : E.coli , strepto & staphylococcus
2. Anaerobics : Bacteroides
 Rarely Cl. tetani , which is potentially lethal if not treated adequately .
Types :
 Mild  the infection is confined to decidua : 80%
 Moderate the infection extended to myometrium 15%
 Severe the infection extended to pelvis + Endotoxic shock + DIC 5%

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 Septic abortion
Management :
1. Investigations :
 CBC , blood grouping , 2 units of blood .
 Cervical swabs (not vaginal) for culture and sensitivity
 Coagulation profile , serum electrolytes & blood culture if pyrexia > 38.5°C
2. Antibiotics : Cephalosporin I.V + Metronidazole I.V
3. Surgical evacuation of uterus  usually 6 - 12 hrs after antibiotic
therapy ( until a reasonable tissue levels of antibiotics have been
achieved )
4. Post-abortion management.

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 Complications of abortion
1. Hemorrhage

2. Complication related to surgical evacuation ie E&C and D&C.

– Uterine perforation- which may lead to rupture uterus in the subsequent pregnancy.

– Cervical tear & excessive cervical dilatation – which may lead to cervical
incompetence.

– Infection – which may lead to infertility & Asher man's syndrome.

– Excessive curettage – which may lead to Adenomyosis

3.  Rh- iso immunization  if the anti –D is not given or if the dose is inadequate .

4. Psychological trauma

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 Post - abortion management
In cases of incomplete, inevitable, complete, missed & septic abortions
1. Support: from the husband, family& obstetric
staff
2. Anti D – to all Rh –ve, nonimmunized patients, whose husbands are
Rh+ve
3. Counseling & explanation:
A.Contraception (Hormonal, IUCD, Barrier) Should start immediately after
abortion if the patient choose to wait , because ovulation can occur 14 days after
abortion and so pregnancy can occur before the expected next period .

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 Post - abortion management
B.When can try again:
 Best to wait for 3 months before trying again . This time allow to regulate
cycles and to know the LMP, to give folic acid, and to allow the patient to be in the
best shape (physically and emotionally) for the next pregnancy
C.Why has it happened
Majority of cases there is no obvious cause

In the first trimester abortion , the most common cause is fetal
chromosomal abnormality

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 Post - abortion management
D. Can it happen again
 As the commonest cause is the fetal chromosomal abnormality which is not a
recurrent cause , so the chance of successful pregnancy next time in the absence of
obvious cause is very high even after 2 or 3 abortions
E. Not to feel guilty  as it is extremely unlikely that anything the patient did can
cause abortion
No evidence that intercourse in early pregnancy is

harmful
No evidence that bed rest will prevent it .

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 PAC: Five elements
1. Emergency treatment of incomplete abortion and its complications
2. Counseling- about procedure, post procedure cxn prevention, when to seek care etc
3. FP services
4. Linkage with other RH services
5. Community-service provider partnership (community awareness creation)

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 Recurrent abortion
Definition :
Is defined as 3 or more consecutive spontaneous abortions
It may presented clinically as any of other types of abortions .
 Types :
Primary : All pregnancies have ended in loss
Secondary : One pregnancy or more has proceeded to viability(>24 weeks gestation)
with all others ending in loss
Incidence :
occurs in about 1% of women of reproductive age

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 Recurrent abortion

Causes

Idiopathic recurrent abortion, in about 50%, in which no cause can be found .

The known causes include the followings :

1. Chromosomal disorders:

 Fetal chromosomal abnormalities & structural abnormalities

 Parental balanced translocation

 2. Anatomical disorders:

Cervical incompetence: →congenital and acquired

Uterine causes: → sub mucous fibroids, uterine anomalies & Asher man's syndrome  

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 Recurrent abortion
Causes

3. Medical disorder:s

 Endocrine disorders : diabetes , thyroid disorders , PCOS & corpus

luteum insufficiency .

 Immunological disorders : Anticardiolipin syndrome & SLE.

 Thrombophilia: congenital deficiency of Protein C&S and antithrombin

III, & presence of factor V leiden.

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 Recurrent abortion
 Infections

 ToRCH - CMV may be a cause of recurrent abortion, but ToRCH are not

causes of recurrent abortion.

 Genital tract infection e.g. Bacterial vaginosis

 Rh – Isoimmunization

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 Recurrent abortion
Diagnosis :
1. History :
 Previous abortions : gestational age and place of abortions & fetal abnormalities.
 Medical history : DM , thyroid disorders, PCOS, autoimmune diseases &
thrombophilia.
2. Examination :
 General : weight , thyroid & hair distribution
 Pelvic: cervix ( length & dilatation ) and uterine size.

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 Recurrent abortion
3. investigations :
A. Investigations for medical disorders:
Blood grouping & indirect Coomb’s test in Rh –ve women
Endocrinal screening: Blood sugar , TFT & LH /FSH ratio
Immunological screening: Anti anticardiolipine antibodies & lupus
anticoagulant.
Thrombophilia screening: Protein C & S, antithrombin III levels,
factor V leiden, APTT and PT.
Infection screening
High vaginal & cervical swabs

ToRCH profile ( which scientifically is not necessary )

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 Recurrent abortion
B. Investigations for anatomical disorders:

TV/US: fibroids, cervical incompetence & PCOS.

Hystroscopy or HSG, fibroids, cervical incompetence, uterine

anomalies & Asherman's syndrome

C. Investigations for chromosomal disorders:

• Parental karyotyping: Parental balanced translocation. Ultimately the use

of parental karyotyping as a screening modality to evaluate the structural
chromosomal etiologies of recurrent pregnancy loss may become insufficient

Fetal karyotyping: Fetal chromosomal anomalies.

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 Recurrent abortion
Management:
In idiopathic recurrent abortion.

With support and good antenatal care , the chance of successful spontaneous pregnancy
is about 60-70%
 Support : from husband, family & obstetric staff.
 Advice : stop smoking & alcohol intake, decrease physical activity

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 Drug therapy

• Progesterone & hCG: start from the luteal phase & up to 12 weeks.
• Low dose aspirin ( 75 mg/day ) start from the diagnosis of pregnancy & up to 37
weeks
• LMWH (20-40 mg/day) start from the diagnosis of fetal heart activity & up to 37ws

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 Recurrent abortion
Management:
In idiopathic recurrent abortion.
With support and good antenatal care , the chance of successful spontaneous pregnancy is
about 60-70%
Support : from husband, family & obstetric staff.
Advice : stop smoking & alcohol intake, decrease physical activity
Drug therapy
• Progesterone & hCG: start from the luteal phase & up to 12 weeks.

• Low dose aspirin ( 75 mg/day ) start from the diagnosis of pregnancy & up to 37 weeks

• LMWH (20-40 mg/day) start from the diagnosis of fetal heart activity & up to 37ws

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Management:
In the presence of a cause: treatment is directed to control the cause
 Endocrine disorders

• Control DM and thyroid disorders before pregnancy

• Ovulation induction drugs , ovarian drilling or IVF in PCOS.
• Progesterone or hCG in corpus luteum insufficiency .
 In anti-cardiolipin syndrome:
Low dose aspirin ( 75 mg/day ) & predinsolone ( 20-30 mg / day), starting when
pregnancy is diagnosed till 37 weeks.
• These drugs are not teratogenic.

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Management:
In thrombophilia:
• Low dose aspirin ( 75 mg/day) starting when pregnancy is diagnosed and low
molecular weight heparin ie LMWH ( 20-40 mg/day) starting when fetal heart
activity diagnosed & to continue both till 37 weeks .
In uterine disorders
• Cervical cerclage in cervical incompetence, best time at the 14 weeks of pregnancy.

• Myomectomy in submucus fibroid, excision of uterine septum in septate &

adhesiolysis in Asherman's syndrome.

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Management:
 In infection:: treatment of the genital tract infection.
 In Rh Isoimmunization: Repeated intrauterine transfusion for the fetus
 In parental balanced translocation

• Explain the risk of fetal chromosomal disorders (~ 30%)

• Encourage to try again or adoption.

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 Cervical Insufficiency
• Also known as incompetent cervix
• characterized classically by painless cervical dilatation in the second trimester.
• It can be followed by prolapse and ballooning of membranes into the vagina, and
ultimately, expulsion of an immature fetus.

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Risk Factors
• the cause of incompetence is obscure
• previous cervical trauma such as dilatation and curettage, conization,
cauterization, or amputation has been implicated

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Evaluation and Treatment
Sonography is performed to confirm a living fetus with no major anomalies.
o Cervical secretions are tested for gonorrhea and chlamydia infection.
o These and other obvious cervical infections are treated.
o For at least a week before and after surgery, sexual intercourse is prohibited.
o Classic cervical incompetence is treated surgically with cerclage, which
reinforces a weak cervix by a purse-string suture.
o Contraindications to cerclage usually include bleeding, uterine contractions,
or ruptured membranes.

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• A rescue cerclage is performed emergently after the cervix is found to be
dilated, effaced, or both.
• The timing of surgery depends on clinical circumstances.
• In women who are diagnosed with cervical insufficiency based on their
previous obstetrical outcomes, elective cerclage is usually done between 12
and 14 weeks’ gestation.
• If the diagnosis is made in high-risk women using transvaginal sonography to
document cervical shortening < 25 mm, then cerclage is done at that time.

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 For the remainder who undergo emergent rescue cerclage, there is debate as to
how late this should be performed( ?23 weeks )

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 Cerclage Procedures
• Of the two vaginal cerclage operations, most use the simpler procedure
developed by McDonald (1963)
• The more complicated operation is a modification of the procedure described
by Shirodkar (1955)
• When either technique is performed prophylactically, women with a classic
history of cervical incompetence have excellent outcomes

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• It is important to place the suture as high as possible and into the dense
cervical stroma.
• There is some evidence that two cerclage sutures are not more effective than
one
• For either vaginal or abdominal cerclage, there is insufficient evidence to
recommend perioperative antibiotic prophylaxis

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 Question

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 6

Ectopic Pregnancy
Kindu Y, Lecturer

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Definition:
 Ectopic pregnancy is one in which the blastocyst implants anywhere other
than the endometrial lining of the uterine cavity
 Ectopic pregnancy accounted for 10 % of all pregnancy-related deaths
 Incidence
 1% to 2%
 More than 95 % ectopic pregnancy are tubal

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 After an ectopic pregnancy, there is a 7- to 13-fold increase in the risk of a
subsequent ectopic pregnancy.
 The chance that a subsequent pregnancy will be intrauterine is 50% to 80%,
and the chance that the pregnancy will be tubal is 10% to 25%; the
remaining patients will be infertile.
 Blighted ova occur more commonly in tubal conceptions than in intrauterine
conceptions, although there is no increase in the incidence of chromosomal
abnormalities in ectopic pregnancies
BO =Ectopic > IUP

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 Sites and frequency of ectopic pxy

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• Ectopic pregnancy is increasing in the world.
 The proposed reasons are
1. Greater prevalence of sexually transmitted diseases
2. Diagnostic tools with improved sensitivity
3. Tubal factor infertility, including restoration of tubal patency or documented tubal
pathology
4. Women with delayed childbearing and their accompanied use of assisted reproductive
technologies, which carry increased risks of ectopic pregnancy
5. Increased intrauterine device (IUD) use and tubal sterilization

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 Risk Factors

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 Cigarette smoking :
o In the periconceptional period increases the risk of ectopic pregnancy in a dose-
dependent manner
o This may be the result of impaired immunity in smokers, thus predisposing them to
pelvic inflammatory disease, or to impairment in tubal motility
 In vitro fertilization:  
o May be due to impaired tubal motility from hormonal stimulation
o Increased the incidence of "Atypical" implantation: Cornual, abdominal, cervical &
ovarian

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 Age > 40 years

 Myoelectrical activity is responsible for propulsive activity in the fallopian tube.

 Aging results in progressive loss of myoelectrical activity along the fallopian tube,
which may explain the increased incidence of tubal pregnancy in perimenopausal
women .

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Contraceptives
 Hormonal control of the muscular activity in the fallopian tube may explain
the increased incidence of tubal pregnancy associated with failures of the
morning after pill, minipill, progesterone-containing intrauterine devices
(IUDs), and ovulation induction.
 Levonorgestrel-containing intrauterine system has a 5-year cumulative
pregnancy rate of 0.5 per 100 users of which half are ectopic.
 Tubal sterilization can be followed by an ectopic pregnancy.

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 Pathophysiology of Ectopic pregnancy

Histopathology
o Lack of a submucosal layer within the fallopian tube wall provides easy
access for the fertilized ovum to burrow through the epithelium and allow
implantation within the muscular wall.
o As the rapidly proliferating trophoblast erodes the subjacent muscularis layer,
maternal blood pours into the spaces within the trophoblast or the adjacent
tissue.
o The lack of resistance allows early penetration by trophoblasts
o The anatomic location of a tubal pregnancy may predict the extent of
damage.

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 Clinical Manifestations

Symptoms
 Triads- occur in 50% of patients
oAmenorrhea
ovaginal bleeding
oAbdominal pain on the affected side
 Other pregnancy discomforts such as breast tenderness, nausea, and urinary frequency may
accompany more ominous findings.
 Shoulder pain worsened by inspiration, which is caused by phrenic nerve irritation from sub
diaphragmatic blood, or
 Vertigo and syncope from hemorrhagic hypovolemia.
 Many women with a small unruptured ectopic pregnancy have unremarkable clinical
findings.

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Physical examination
 Vital Signs normal or deranged
 With ruptured tubal ectopic
o Pale

o Acutely sick

o Signs of fluid collection

o Signs of acute abdomen.

o Cervical motion tenderness

o Adnexal mass

o Bulging cul-de-sac

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Acute Vs chronic ectopic pregnancy
 There may be a difference between an "acute" and a "chronic" ectopic
pregnancy with regard to the risk of tubal rupture.
 Acute ectopic pregnancies are those with a high serum β -HCG level at
presentation and rapid growth.
 These carry the highest risk of tubal rupture compared with chronic
ectopic pregnancies, which demonstrate static serum β -HCG levels.
 Theoretically, an acute ectopic pregnancy has healthy growing trophoblastic
cells that do not result in early bleeding, and women thus present for care
later.

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o This is compared with the chronic form, which has abnormal trophoblastic
cells, which die early, have lower serum β -HCG levels, and present with
early pregnancy bleeding that leads to earlier diagnosis.
o Timing of tubal rupture is partially dependent on pregnancy location.
o As a rule, tubes rupture earlier if implantation is in the isthmic or ampullary
portion.
o Later rupture is seen if the ovum implants within the interstitial portion.
o Rupture is usually spontaneous, but can also be caused by trauma such as
that associated with bimanual pelvic examination or coitus

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 Diagnosis
• Clinical: high index of suspicion
• Laboratory tests:
Hct

Blood group & Rh

Urine HCG

Serum beta HCG

Serum progesterone

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 Dx of ectopic pxy
• Ultrasound
• Culdocentesis
• Endometrial Sampling
• Diagnostic laparoscopy : Gold standard for diagnosis of ectopic pregnancy
• Discriminatory zone

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 Differential diagnosis
• Abortion
• GTD
• PID
• TOA
• Corpus luteum cyst
• Cystitis
• Renal colic
• Adnexal cyst torsion
• Degenerating myoma
• Appendicitis
• Mesenteric lymphadenitis

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Serum β-HCG Measurements
o β-HCG detected as early as 8 days after the LH surge.
o In normal pregnancies, serum β -HCG levels rise in a log-linear fashion until
60 or 80 days after the last menses, at which time values plateau at about
100,000 IU/L.
o With a robust uterine pregnancy, serum β -HCG levels should increase
between 53 and 66 percent every 48 hours.
o Inappropriately rising serum β -HCG levels only indicate a dying pregnancy,
not its location.

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Serum progesterone
o Done when serum β-HCG determinations & sonographic findings are
inconclusive
o There is minimal variation in serum progesterone concentration between 5
and 10 weeks' gestation, thus a single value is sufficient.
o They found that results were most accurate when approached from the
viewpoint of healthy versus dying pregnancy.

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o With serum progesterone levels of <5 ng/mL, a dying pregnancy was
detected with near perfect specificity and with a sensitivity of 60 percent.
o Conversely, values of >20 ng/mL had a sensitivity of 95 percent with
specificity around 40 percent to identify a healthy pregnancy.
o Ultimately, serum progesterone can only be used to buttress(support) a
clinical impression, but cannot differentiate between an ectopic and
uterine pregnancy.

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Sonography
• Using TVS, a gestational sac is visible between 4.5 and 5 weeks, the yolk sac appears
between 5 and 6 weeks, and a fetal pole with cardiac activity is first detected at 5.5 to 6
weeks
• When the last menstrual period is unknown, serumβ–HCG testing is used to define
expected sonographic findings.

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• Each institution must define a β -HCG discriminatory value, that is, the lower limit at
which an examiner can reliably visualize pregnancy.
• At most institutions, a concentration between 1,500 and 2,000 IU/L represents this
value.
• Accurate diagnosis by sonography is three times more likely if the initial β-HCG level
is above this value.
• Free peritoneal fluid suggests intra-abdominal bleeding

06/27/2021 Kindu Y. 78
 The absence of intra uterine pregnancy on TVU with β-HCG levels above the
discriminatory value signifies an abnormal pregnancy either
 Ectopic

 Incomplete abortion, or
 Resolving completed abortion
 Conversely, sonographic findings obtained when β-HCG values lie below the
discriminatory value are not diagnostic in nearly two-thirds of cases. Repeat in 48 hr

06/27/2021 Kindu Y. 79
Ultrasound identifies
 An intra cavitary fluid collection caused by sloughing of the decidua can create a
pseudogestational sac, or pseudosac.
 This one-layer sac is typically situated in the midline of the uterine cavity, whereas a
normal gestational sac is eccentrically located.
 Visualization of an extra uterine yolk sac or embryo confirms a tubal pregnancy,
although such findings are present in only 15 - 30 % of cases
 Fluid collection (hemoperitonium )
 Adnexal mass

06/27/2021 Kindu Y. 80
Culdocentesis
o With a 16- to 18-gauge spinal needle, the cul-de-sac may be entered through the
posterior vaginal fornix
o Normal-appearing peritoneal fluid is designated as a negative test.
o If fragments of an old clot or non clotting blood are found in the aspirate when placed
into a dry clean test tube, then hemoperitoneum is diagnosed. Test is positive

06/27/2021 Kindu Y. 81
 If the aspirated blood clots after it is withdrawn, this may signify active intraperitoneal
bleeding or puncture of an adjacent vessel.
 If fluid cannot be aspirated, the test can only be interpreted as unsatisfactory.
 purulent fluid suggests a number of infection-related causes such as salpingitis or
appendicitis.
 non gynecologic findings, fat necrosis from pancreatitis and feculent material from a
perforated or ruptured colon or an inadvertent puncture of the rectosigmoid colon.

06/27/2021 Kindu Y. 82
Endometrial Sampling
 There are a number of endometrial changes associated with ectopic
pregnancy that include decidual reactions found in 42% of samples,
secretory endometrium in 22 %, and proliferative endometrium in 12 %.

06/27/2021 Kindu Y. 83
 Management of Ectopic Pxy
1. Medical: Oral, parenteral or direct Injection into Ectopic Pregnancy
 Methotrexate
 Prostaglandins
 Mifepristone
 Potassium chloride

 Hyperosmolar glucose
2. Surgical
3. Expectant management
4. Anti D for Rh negative women

06/27/2021 Kindu Y. 84
o Medical therapy is preferred by most, if feasible.
o The best candidate for medical therapy is a woman who is asymptomatic,
motivated, & has resources to be compliant with treatment surveillance.
o Absolute contraindications for medical therapy include
• Ruptured ectopic pregnancy

• Hemodynamic instability

• Inability to remain compliant with post therapeutic monitoring

• Intrauterine pregnancy

• Breast feeding, and

• Clinically important hepatic/renal dysfunction

06/27/2021 Kindu Y. 85
Predictors of success in medical therapy include:
1. Initial serumβ-HCG level:
 Single best prognostic indicator of treatment success in women given single-dose
methotrexate
 Serum β-HCG level <5,000 IU/L success rates of 92 %
2. Ectopic pregnancy size (<3.5cm)
3. Absent fetal cardiac activity: if cardiac activity is seen in the ectopic
pregnancy , success is low.

06/27/2021 Kindu Y. 86
Methotrexate
o This is a folic acid antagonist that competitively inhibits the binding of
dihydrofolic acid to dihydrofolate reductase, which in turn reduces the
amount of the active intracellular metabolite, folinic acid.
o This leads to diminished nucleotide precursors and limited DNA
synthesis.
o The most common side effects are stomatitis, conjunctivitis, and transient
liver dysfunction, although myelosuppression, mucositis, pulmonary
damage, and anaphylactoid reactions
o Although these side effects are seen in as many as a third of women treated,
they are usually self-limited.

06/27/2021 Kindu Y. 87
 In some cases, leucovorin (folinic acid) is given following treatment to blunt
or reverse methotrexate side effects. Such therapy is termed leucovorin
rescue.
 The single-dose and multi-dose methotrexate protocols are associated with
overall resolution rates for ectopic pregnancy of about 90 %.
 Failures included women with tubal rupture, massive intra-abdominal
hemorrhage, need for urgent surgery, and blood transfusions.
 Contraception for 3 to 6 months after successful medical therapy with
methotrexate, as this drug may persist in human tissues for up to 8 months
after a single dose

06/27/2021 Kindu Y. 88
 Medical Treatment Protocol

06/27/2021 Kindu Y. 89
Direct Injection into Ectopic Pregnancy
1. Methotrexate
In efforts to minimize systemic side effects of methotrexate,
Done under sonographic or laparoscopic guidance.
Pharmacokinetic studies with 1 mg/kg of methotrexate injected either into the sac or
intramuscularly showed similar success rates but fewer side effects with intra
gestational injection .
2. Hyperosmolar Glucose
Direct injection of 50 % glucose into the ectopic mass using laparoscopic guidance was 94
% successful in women with an unruptured ectopic whose serumβ -HCG level was <2,500
IU/L.

06/27/2021 Kindu Y. 90
 Surgical Management
Laparotomy or Laparoscopy
 Salpingectomy
 Salpingostomy (conservative surgery)

06/27/2021 Kindu Y. 91
 Expectant mgt
 In select women, some choose close observation in the event that there will
be spontaneous resorption of an ectopic pregnancy.
 Intuitively, it is difficult to accurately predict which woman will have an
uncomplicated course with such management.
 Although an initial serum β-HCG concentration has been shown to best
predict outcome, the range varies widely.
 Preferable to avoid expectant management because of the prolonged
surveillance and associated patient anxiety.
 Abandoned in our country!

06/27/2021 Kindu Y. 92
 Persistent Ectopic
o Incomplete removal of trophoblastic tissue and its continued growth causes
tubal rupture in 3 to 20 % of women who had conservative surgery.
o Perhaps ironically, persistent ectopic pregnancy is more likely with very
early pregnancies. Specifically, surgical management is more difficult
because pregnancies smaller than 2 cm are harder to visualize and
completely remove.

06/27/2021 Kindu Y. 93
 To obviate this, administered a prophylactic dose of 1 mg/m2 methotrexate
postoperatively, which reduced the incidence of persistent ectopic pregnancy as well as
length of surveillance.
 The optimal schedule to identify persistent ectopic pregnancy after surgical therapy
has not been determined.
 Protocols describe serum β-HCG level monitoring from every 3 days to every 2
weeks.
 Currently, standard therapy for persistent ectopic pregnancy is single-dose methotrexate
with 50 mg/m2 BSA.

06/27/2021 Kindu Y. 94
 Ovarian Pregnancy
o Ectopic implantation of the fertilized egg in the ovary is rare.
o Risk factors are similar to those for tubal pregnancies.
o 4 classic Spiegelberg anatomic and histologic criteria which are as follows:

1.The fallopian tubes should be intact and separate from the ovary
2. The gestation should appear in the usual ovarian pelvic location
3.The gestation should be connected to the uterus by the ovarian ligament
4. Ovarian tissue must be present in the histologic specimen of the gestation sac walls

06/27/2021 Kindu Y. 95
 Abdominal pregnancy
• Studdiford's criteria used to diagnose primary abdominal pregnancy are
described as:
• Studdiford criteria to diagnose primary abdominal pregnancy:
1. Normal bilateral fallopian tubes and ovaries;
2. Absence of uteroperitoneal fistula; or
3. Presence of a pregnancy related to the peritoneal surface exclusively

06/27/2021 Kindu Y. 96
 Gestational trophoblastic disease

06/27/2021 Kindu Y. 97
 GTD
• Refers to a spectrum of interrelated but histologically distinct tumors
originating from the placenta
• All forms are characterized by distinct tumor marker
– Beta-HCG
• Pathogenesis is unique b/c it is maternal tumor arising from gestational rather
than maternal tissue

06/27/2021 Kindu Y. 98
Modified WHO classification of GTD

06/27/2021 Kindu Y. 99
 GTD
• Gestational trophoblastic neoplasia (GTN) refers to the subset of gestational
trophoblastic disease that develops malignant sequelae.
• These tumors require formal staging and typically respond favorably to
chemotherapy.
• Most commonly, GTN develops after a molar pregnancy, but may follow any
gestation.
• The prognosis for most cases of GTN is excellent, and patients are routinely
cured even in the presence of widespread metastases.

06/27/2021 Kindu Y. 100

 Risk factors
• Two main risks are
– Extreme maternal age(esp. more than 35 yrs old)- complete mole

– History of previous GTD(10 fold)

– Recurrence-1-2%

– 16-28% of recurrence after two molar pregnancies

• Other risks
– Current smoking(more than 15 per day)

– Vitamin A deficiency

– Older paternal age

06/27/2021 Kindu Y. 101

 Hydatidiform Mole
• abnormal pregnancies characterized histologically by aberrant (markedly
different from the accept) changes
• within the placenta.
• Non invasive and localized accounts for 80% of GTD cases
• Two types
– Complete
– partial

06/27/2021 Kindu Y. 102

 Features of Complete and Partial Hydatidiform Moles

06/27/2021 Kindu Y. 103

 Complete mole
• Lacks fetus
• Karyotype
– 46XX or 46XY in complete
• Leads to excess uterine growth than expected GA
– 2ry to tumor itself and/or intrauterine hemorrhage with retained clot
• Marked increase in HCG lead to complications
• Ovarian enlargement 2ry to theca lutein cyst

• Hyperemesis Gravidarum

• Early development of preeclampsia

• Hyperthyroidism(often subclinical)

06/27/2021 Kindu Y. 104

 Complete mole

A 46,XX complete mole may be formed if a 23,X-bearing hap­loid sperm penetrates a 23,)(-
containing haploid egg whose genes have become "inactive: Paternal chromosomes then duplicate
to create a 46)0( diploid chro­mosomal complement solely of paternal origin. Alternatively, this
same type of Inactivated egg can be fertilized Independently by two sperm, either 23)(- or 23,Y-
bearlng, to create a 46.XX or 46)(Y chromosomal complement again of paternal origin only.

06/27/2021 Kindu Y. 105

 Complete Mole
• Considerable homology b/n beta HCG and TSH

– So HCG has weak thyroid stimulationg activity

• 1 mcu of hCG is equivlent to 0.0013 mcu of TSH
• Theca lutein cysts
– A form of ovarian hyperstimulation 2ry to high level of HCG

– Resolve few weeks to months after Rx of GTD

06/27/2021 Kindu Y. 106

Photograph of a complete hydatidiform mole specimen. Note the grape-like fluid
filled clusters of chorionic villi

06/27/2021 Kindu Y. 107

 Partial mole
• Are the only type of GTD associated with presence of fetus and AF and fetal
cardiac activity may be detected
– But high rate of IUFD 2o to triploidy
• Karyotype
– Triploid(69XXX,69XXY

– So, often misdiagnosed as incomplete or missed abortion and correct diagnosis made by
pathology
• Unlike complete mole the following are Infrequent
– excess uterine growth, ovarian enlargement, preeclampsia, hyperemesis or
hyperthyroidism
– b/c HCG levels are generally lower than in complete mole

06/27/2021 Kindu Y. 108

 Partial mole

Partial moles may be formed if two sperm, either 23)(- or 23,Y-bearing, both fertilize a 23)(-

containing haploid egg, whose genes have not been inactivated. The resulting fertilized egg is

triploid. Alternatively, a similar haploid egg may be fertilized by an unreduced diploid 46,XY sperm.

06/27/2021 Kindu Y. 109

 Evaluation of GTD
• Possibility considered in any premenopausal woman with abnormal vaginal bleeding
• Evaluation include
– Serum HCG

– U/S
– Histopathology

– Ploidy Determination

– Immunostaining

06/27/2021 Kindu Y. 110

Serum hCG
• Always elevated in GTD than IUP of same GA
• 40% of complete moles are associated with HCG level more than 100,000 miu/ml

– Normal non pregnant level= less than 5 miu/ml

– Peak normal pregnancy level= less than 100,000 miu/ml

06/27/2021 Kindu Y. 111

 Histopathology
• In early pregnancy, it may be histologically difficult to distinguish among
complete moles, partial moles, and hydropic abortuses.
• Hydropic abortuses are pregnancies formed by the traditional union of one
haploid egg and one haploid sperm but are pregnancies that have failed.
• Their placentas may display hydropic degeneration, which can mimic some
villous features of hydatidiform moles.
• Unfortunately, there is no single criterion that distinguishes these three.
• But, in general, complete moles characteristically have two prominent
features:
(1) trophoblastic proliferation and
(2) hydropic villi.

06/27/2021 Kindu Y. 112

• There are striking differences, however, from these classic findings in
gestations younger than 10 weeks.
• In these early gestations, hydropic villi may not be apparent, and molar stroma
may still be vascular
• Partial moles are reliably diagnosed when three or four major diagnostic
criteria are demonstrated:
(1) two populations of villi,
(2) enlarged, irregular, dysmorphic villi (with trophoblast
inclusions),
(3) enlarged, cavitated villi (≥3-4 mm), and
(4) syncytiotrophoblast hyperplasia/atypia

06/27/2021 Kindu Y. 113

 Management Of Hydatidiform Mole
• Removing the tumor with or with out the uterus

– Suction curretage
– Hysterectomy –in those who completed family size
• Post molar follow up

06/27/2021 Kindu Y. 114

• Suction curettage ( EVA Vs MVA) is the preferred approach because:
– less likely to result in uterine perforation or intrauterine adhesions than sharp
curettage
– evacuates the uterus more completely than medical methods
• Patients who have no desire for future fertility
– may opt for hysterectomy
• eliminates the risk of local invasion, but does not prevent metastasis.

06/27/2021 Kindu Y. 115

• A suction catheter of 12 mm is usually sufficient to evacuate a complete molar
pregnancy since there is no fetus.
• The suction curette is not advanced to the fundus
– instead, it is placed just inside the internal os
• Vacuum pressures of 50 to 60 cm Hg are then applied and the hydropic
placental tissue is drawn into the curette.
• Intravenous oxytocin is administered, and for uterus over 14-weeks size,
fundal massage to stimulate myometrial contraction
• Rh immune globulin may be withheld if the diagnosis of complete mole is
certain.

06/27/2021 Kindu Y. 116

 Postmolar followup
• Monitoring- regression of the tumor should be followed by serial serum B-hCG level
• Contraception- should be given during the whole course of the follow up period
• Following molar evacuation, patients must be monitored for development of
postmolar gestational trophoblastic neoplasia
• 15% of patients with complete mole develop GTN
• In contrast, following partial molar pregnancy, the risk of GTN is 4% to
6%percent.

06/27/2021 Kindu Y. 117

• Risk factors for persistent GTN 

–  Factors that have consistently been shown to be predictors of development of GTN

after a complete mole are:
– 1) hCG level over 100,000

– 2) presence of large (>6 cm in diameter) theca lutein cysts

– 3) significant uterine enlargement
• which are all signs of marked trophoblastic proliferation

06/27/2021 Kindu Y. 118

– In order to rule out development of a postmolar tumor, patients are monitored every
1 to 2 weeks hCG levels until three consecutive normal values are obtained.
– Approximately 50 percent of patients achieve normal hCG levels 6 to 14 weeks after
molar evacuation
– patients with complete and partial molar pregnancy were followed with monthly
hCG levels for a total of six months after achieving three consecutive normal values

06/27/2021 Kindu Y. 119

• A single blood sample demonstrating an undetectable level of β-hCG
following molar evacuation is sufficient to exclude the possibility of
progression to GTN in most patients.
• Some women, especially those with a partial mole, may be safely discharged
from routine surveillance once an undetectable value is achieved

06/27/2021 Kindu Y. 120

 Persistent gestational trophoblastic disease

• Plateaus

– decrease less than 10% for at least 4 values over 3 wks

• Rises

– increase more than 10% for 3 values over 2 consecutive wks eg. day 1,7,14

• Persistently detected for more than 6 months after molar evacuation

• Histologic evidence of choriocarcinoma

06/27/2021 Kindu Y. 121

Contraception
• It is important to emphasize the use of reliable contraception during the entire
follow-up period.
• Eliminates the potential confusion that arises in the interpretation of a rising
hCG levels in a patient who has not been using a reliable contraceptive
method.
• Oral contraceptives were the preferred method of contraception in this
setting.

06/27/2021 Kindu Y. 122

Malignant GTD
• Can develop after molar or non molar pregnancy
• After molar pregnancy
– Symptoms

• Vaginal bleeding is most common

– 15% will have localized disease and another 4% will have metastatic disease after
evacuation
• Localized ones are mostly invasive mole and few are choriocarcinoma

• Metastatic are virtually always 2ry to choriocarcinoma

06/27/2021 Kindu Y. 123

 FIGO criteria for GTN

06/27/2021 Kindu Y. 124

 FIGO anatomic staging

FIGO Staging of Gestational Trophoblastic Neoplasia

Stage 1: Disease confined to the uterus

Stage 2: GTN extend outside the uterus but limited to the genital
structures(adnexa, vagina, broad ligament)

Stage 3: GTN extend to the lungs, with or without known genital tract
involvement

Stage 4: all other metastatic sites

06/27/2021 Kindu Y. 125

 Choriocarcinoma
• Malignant form of GTD
• Occurrence
– 50% arise from complete HFM

– 25% from normal pregnancy

– 25% from spontaneous abortion or ectopic

06/27/2021 Kindu Y. 126

• Irregular vaginal bleeding is the most common symptom
– Typical clinical presentation is late PPH which persist beyond the usual 6-8 wks

– But may develop a year or more after an antecedent pregnancy

– Can be severe hemorrhage if tumor erodes through the myometrium or uterine vessels
• Respiratory symptoms(Cough, chest pain, hemoptysis) or CNS bleeding are
indicative of metastasis

06/27/2021 Kindu Y. 127

• Physical findings

– Enlarged uterus
– Lung is the commonest site of metastasis(80%)

– Vaginal metastasis in 30% of cases

• Very vascular and prone to bleeding

• May become infected

– Liver & brain are also sites of metastasis(10%)

06/27/2021 Kindu Y. 128

• Management is mainly using chemotherapy
• Based on the stage of the disease
• Single agent chemotherapy-methotrexate

• Combined chemotherapy
• Patients still need contraceptive on the period of follow up.

• If well treated choriocarcinoma is one of the malignat tumors having good

response

06/27/2021 Kindu Y. 129

• Chemotherapy for low risk & high risk GTN
• Prophylactic Chemotherapy
• Ectopic Molar Pregnancy
• Coexistent Fetus
• Phantom β-hCG
• Quiescent Gestational Trophoblastic Disease

06/27/2021 Kindu Y. 130

 Any Question

06/27/2021 Kindu Y. 131

 Quiz
Characterize complete and incomplete molar pregnancy

06/27/2021 Kindu Y. 132

 The Puerperium
 The puerperium is the period of time encompassing the first few
weeks following birth.
 The duration:
o considered by most to be between 4 & 6 / 6-8 weeks

06/27/2021 Kindu Y. 133

 Puerperium Contd…
 Characterized by:
 Many Anatomic & Physiological changes
 Some mothers can have life threatening complications

06/27/2021 Kindu Y. 134

 Puerperium Cont’d…
 Some mothers can have life threatening complications like
o Uterine sub-involution
o Late PPH
o Puerperal fever
o Postpartal psychiatric disorders
o PP thyroiditis
o Obstetric neuropathies

06/27/2021 Kindu Y. 135

 Anatomic& Physiologic Changes
 Uterus
 Immediately after placental expulsion, fundus of the contracted uterus lies slightly below the
umbilicus.
 Anterior & posterior walls, each measure 4 to 5 cm thick
 Immediately postpartum, the uterus weighs approximately 1000 g
 Muscle cells shortening begins within 2 days & as a result the uterus begins to
involute.
 Immediate postpartum-1000gm slightly below umbilicus
 1 week- 12wks
 2week- in pelvis
 4th week- to prepregnant size

06/27/2021 Kindu Y. 136

  After Pains
 Pain from intermittent uterine contractions after delivery
 In primiparas, the uterus tends to remain tonically contracted following delivery.
 However, in multiparas, it often contracts vigorously at intervals and gives rise to after
pains, which are similar to but milder than the pain of labor contractions
 Common in multis and worsen with increasing parity
 Precipitated by suckling ( oxytocin)
 Usually decrease in intensity and become mild by third day

06/27/2021 Kindu Y. 137

  Endometrial Regeneration
 Within 2 or 3 days after delivery, the remaining decidua becomes differentiated into two layers.
 The superficial layer becomes necrotic & is sloughed in the lochia.
 The basal layer adjacent to the myometrium remains intact & is the source of new endometrium.
 Endometrial regeneration is rapid, except at the placental site
 Histological endometritis is part of the normal reparative process.
 Endometrial Regeneration starts about a week
 complete reepithialization in ~16 days
 At placental site, ~6th week post partum

06/27/2021 Kindu Y. 138

 Lochia
o Is post partal vaginal discharge resulting from sloughing of decidual tissue.
o Lochia is of variable quantity.
o Lochia can be of the following three types
– Rubra – Red
• blood, shreds of tissue, and decidua
• 1st few days ( 2-3 days)

– Serosa – Pale red

• serous to mucopurulent,
• From 3rd/4th day to~ the 10th day

– Alba- white/yellowish white

• admixture of leukocytes, thicker, mucoid,
• Scanty fluid + WBCs
• From ~10th day to the 4th- 8th week PP

06/27/2021 Kindu Y. 139

 Cervix
• Within 1 week
– Thickening
– Narrowing of the opening (~1cm)
– Formation of the Endo Cervical canal
• Complete healing & reepitheliztion takes 6-12wks
• External Os
– transverse slit as a result of laceration of the external os.
• Lower segment
– diminish to tiny isthmus in few weeks

06/27/2021 Kindu Y. 140

  Vagina
 Gradually diminishes in size but rarely returns to nulliparous
dimensions.
 Rugae begin to reappear by the third week but are not as
prominent as before.
 The hymen is represented by several small tags of tissue, which
scar to form the myrtiform caruncles.
 Vaginal epithelium begins to proliferate by 4 to 6 weeks, usually
coincidental with resumed ovarian estrogen production.
 Lacerations or stretching of the perineum during delivery may
result in relaxation of the vaginal outlet.
 Some damage to the pelvic floor may be inevitable,

06/27/2021 Kindu Y. 141

 CVS
• CO, PR, SV
– decline to non pregnant values by 10 days.
• Systemic vascular resistance steady increase after 02 days to reach
prepregnancy state.
• Heart
– Gradual reversal of structural changes ~1yr

06/27/2021 Kindu Y. 142

 Blood and body fluid
• During and after labor :
– Marked leukocytosis as high as 30,000/micl
• Hct
– no significant change ( if no severe bleeding)
• Coagulation factors
– high fibrinogen level persist for ~01 week

06/27/2021 Kindu Y. 143

 • Postpartum diuresis b/n 2nd & 5th days
• Blood volume
- Back to non Pregnant level in ~01week

06/27/2021 Kindu Y. 144

 Weight Loss
• Immediate Post partum loss of 5 to 6 kg
– uterine evacuation and normal blood loss,
• Further decrease of 2 to 3 kg through diuresis in 1-2weeks.
• Prepregnancy weight at ~ 6 months

06/27/2021 Kindu Y. 145

 Urinary Tract
 Immediately postpartum varying degrees of submucosal hemorrhage & edema is seen in the
bladder.
 Postpartum, the bladder has an increased capacity & a relative insensitivity to intravesical
pressure.
 Leading to over distension, incomplete emptying, and excessive residual.
 The dilated ureters & renal pelves return to their prepregnant state 2 to 8 weeks after delivery.
 Urinary tract infection is of concern because residual urine and bacteriuria in a traumatized
bladder, coupled with a dilated collecting system, are conducive to infection
 Elevated GFR and creatinine clearance
Return to their prepregnant state 2 to 8 weeks after delivery

06/27/2021 Kindu Y. 146

 Colostrum
 After delivery, the breasts begin to secrete colostrum, which is a deep lemon-yellow
liquid.
 It usually expressed by second postpartum day.
 Compared with mature milk, colostrum contains more minerals and amino acids.
 It has more protein, much of which is globulin, but less sugar & fat.
 Secretion persists for approximately 5 days, with gradual conversion to mature milk
during the ensuing 4 weeks.
 Colostrum contains antibodies, & its content of immunoglobulin A (IgA) offers the
newborn protection against enteric pathogens.

06/27/2021 Kindu Y. 147

 Reproductive Hormones
 HCG becomes negative within 11-16 days
 Prolactin level elevation
Non lactating until ~03 weeks
Lactating unti ~06 weeks ( continue to raise with episodes of breast feeding)
• GnRH- suppressed 20 to prolactin
• FSH, LH, E, P- very low in the 1st 1-2 weeks
• Reach the follicular phase level at ~3weeks Post Partum in non
lactating women

06/27/2021 Kindu Y. 148

 Ovulation
Anovulation in early puerperium
– 20 to elevated prolactin level
– Refractory gonads
Ovulation may commence in as early as 27 days
Non lactating woman
- 5-11wks Post Partum (average 7week)
Lactating women
- Generally delayed – often after 6mths
- Depends on frequency and intensity of breast feeding

06/27/2021 Kindu Y. 149

 Abnormal Puerperium
Common puerperal problems include
 PPH
 Hypertensive disorders
 Infections
 Thromboembolism
 Bladder problems
 Perineal discomfort
 Lactation failure
 Psychiatric disorders
 Pelvic pains
 Hemorrhoids
 Constipation
 Back aches

06/27/2021 Kindu Y. 150

 Uterine Subinvolution
• Arrest/retardation of uterine involution
• Cause
- Retained products of conception or
- Infections
• Manifestations
– UX Softer &larger than expected on bimanual exam
– Persistent lochia
– Excessive bleeding
• Treatment
- Methylergonovine 0.2 mg every 3 to 4 hours for 24 to 48 hours, but its
efficacy is questionable.
– Bacterial metritis (Chlamydia trachomatis causes third of cases ) responds to
oral antimicrobial therapy with Azithromycin or doxycycline therapy is
appropriate empirical therapy.

06/27/2021 Kindu Y. 151

 Late PPH
• Bleeding from 24 hrs – 12 weeks post partum
• Clinically worrisome uterine hemorrhage develops within 1 to 2 weeks in perhaps 1 % of women.

Causes
• Abnormal Placental site involution
• Retained placental fragment
- Usually the retained piece undergoes necrosis with deposition of
fibrin & may eventually form placental polyp.
- As the eschar of the polyp detaches from the myometrium, hemorrhage may be brisk (occurs
days 7-14, usually self limiting)
• Bleeding disorders (von Willebrand disease)
• Infection

06/27/2021 Kindu Y. 152

 Management of Late PPH
• Uterotonics
- for a stable patient, with empty uterus by ultrasound
- (oxytocin, methylergonovine, or a PG analog)
• Antimicrobials - if uterine infection is suspected
• Suction or sharp curettage for RPC indicated if
Large clots are seen in the uterine cavity.
Bleeding persists or
Recurs after medical management.

06/27/2021 Kindu Y. 153

 Puerperal Infections
 general term used to describe any bacterial infection of the genital
tract after delivery
 Puerperal Fever
- A temperature of 38.0°C (100.4°F) or higher—in the puerperium.
- Oral To > 38.0°C (100.4°F) on any 2 of the first 10 days after delivery,
exclusive of the first 24hrs

06/27/2021 Kindu Y. 154

 Puerperal Infections Contd…
• Of those febrile in the first 24 hrs of delivery Pelvic infection was
diagnosed subsequently in
– 20% of SVDs
– 70% of Cesarean deliveries

06/27/2021 Kindu Y. 155

 focuses of Puerperal Fever
1. Uterine Infection
– The most common
2. Urinary tract infection,
3. Lower genital tract infection,
4. Wound infections
5. Pulmonary infections,
6. Thrombophlebitis, and
7. Mastitis

06/27/2021 Kindu Y. 156

 Uterine Infection
Has different names
– Endometritis
– Endomyometritis
– Endoparametritis
– Metritis With Pelvic Cellulitis-more inclusive & preferred

06/27/2021 Kindu Y. 157

 Uterine Infection Cont…

• Risk factors of Metritis With  Young age & nulliparity

Pelvic Cellulitis  Induction
• Route of delivery
 Obesity
• CS > vaginal
• Is the single most significant risk  MSAF
factor  Bacterial colonization of
• Prolonged labor
lower GT
• ROM
 - Group B streptococcus
• Intrapartal chorioamnionitis
•
Chlamydia T, Mycoplasma ,
Multiple cervical examinations
•
Ureaplasma u,&
Internal fetal monitoring
• Manual removal of placenta
Gardnerella V.
• Multifetal gestation  Low socioeconomic status

06/27/2021 Kindu Y. 158

 Uterine Infection Cont…
Bacteriology
• common vaginal and cervical flora
• Polymicrobial
• Virulence is promoted by
– Polymicrobial infection  bacterial synergy
– Hematoma and
– Devitalized tissues
• Routine pretreatment genital tract cultures are of little clinical use and
add significant costs
• Routine blood cultures seldom modify care

06/27/2021 Kindu Y. 159

 Uterine Infection Cont…

Bacteria Commonly Responsible for Female Genital Infections

Aerobes

Gram-positive cocci—group A, B, and D streptococci, enterococcus, Staphylococcus aureus, Staphylococcus epidermidis

Gram-negative bacteria—Escherichia coli, Klebsiella,Proteus species

Gram-variable—Gardnerella vaginalis

Others

Mycoplasma and Chlamydia species, Neisseria gonorrhoeae

Anaerobes

Cocci—Peptostreptococcus and Peptococcus species

Others—Clostridium and Fusobacterium species Mobiluncus species

06/27/2021 Kindu Y. 160

 Uterine Infection Cont…
Clinical Features
• Fever – Commonly 38-39CO
– most important criterion for the dx of post partal metritis
• Chills that accompany fever suggest bacteremia
• Lower Abdominal pain
• Uterine tenderness
• Parametrial tenderness
• Offensive lochia
– Group A Strept infection-scanty odorless lochia
• Leukocytosis 15-30,000 – no significance

06/27/2021 Kindu Y. 161

 Uterine Infection Cont…
Treatment
• Mild disease – oral antimicrobials as outpatient
- 90% respond for Ampicillin + Gentamycin
• Moderate- severe disease-
- Admit
- IV antibiotics
- 90% respond in 48- 72 hrs
- Can be discharged after being afebrile at least for 24 hrs
- Further oral antimicrobial therapy is not needed

06/27/2021 Kindu Y. 162

 Prevention of Postpartum Infection of
1. Perioperative Antimicrobial Prophylaxis
• antimicrobial prophylaxis at the time of cesarean delivery has remarkably reduced the rate of
postoperative pelvic and wound infections.
• The observed benefit applies to both elective and nonelective cesarean delivery and also includes a
reduction in abdominal incisional infections
• Single-dose prophylaxis with Ampicillin(2gm Iv stat before skin incision ) or a first-generation
cephalosporin is ideal, and both are as effective as broad-spectrum agents or a multiple-dose
regimen

06/27/2021 Kindu Y. 163

  Persistent fever despite antibiotic treatment of metritis may be 20 to
1. Wound infection, dehiscence, abscess
2. Parametrial phlegmon
3. Pelvic abscess
4. Adnexal infections
5. Peritonitis
uterine incision necrosis and dehiscence ,ruptured ovarian/ parametrial abscess
6. Necrotizing fasciitis
7. Septic pelvic thrombophlebitis

06/27/2021 Kindu Y. 164

  Wound Infections
 When prophylactic antimicrobials are given the incidence of abdominal incisional infections following
cesarean delivery is <2 % .
 Wound infection is a common cause of persistent fever in women treated for metritis.
 Other risk factors for wound infections include obesity, diabetes, corticosteroid therapy,
immunosuppression, anemia, hypertension, and inadequate hemostasis with hematoma formation.
 Incisional abscesses that develop following cesarean delivery usually cause fever or are responsible for
its persistence beginning about the fourth day.
 Wound erythema and drainage are present .
 Treatment includes antimicrobials and surgical drainage, and wound care with careful inspection to
ensure that the fascia is intact.

06/27/2021 Kindu Y. 165

 Wound Dehiscence
• Disruption or dehiscence refers to separation of the fascial layer.
• Serious complication &requires relaparatomy
• There could concurrent fascial infection and tissue necrosis.
• Most disruptions manifested on about the fifth postoperative
day and are accompanied by a serosanguineous discharge

06/27/2021 Kindu Y. 166

 Necrotizing Fasciitis
o This uncommon, severe wound infection is associated with high mortality.
o In obstetrics, necrotizing fasciitis may involve abdominal incisions, or it may complicate episiotomy or other
perineal lacerations.
o There is significant tissue necrosis.
o Three risk factors of these—diabetes, obesity, & hypertension—are relatively common in pregnant women.
o Is polymicrobial infections of normal vaginal flora.
o In some cases, however, infection is caused by a single virulent bacterial species such as group A -hemolytic
streptococcus.
o Treatment
- broad-spectrum antibiotics along with prompt
- wide fascial debridement until healthy bleeding tissue is encountered .

06/27/2021 Kindu Y. 167

 Peritonitis
 It is unusual for peritonitis to develop following cesarean delivery.
 It is almost invariably preceded by metritis & uterine incisional necrosis and dehiscence.
 Other cases may be due to
- Inadvertent bowel injury at cesarean delivery
- Rupture of a parametrial or adnexal abscess.
- Rarely be encountered after vaginal delivery.
 Abdominal rigidity may not be prominent with puerperal peritonitis because of abdominal wall
laxity from pregnancy.
 Treatment: laparatomy.

06/27/2021 Kindu Y. 168

 Adnexal Infections
• An ovarian abscess rarely develops in the puerperium.
• These are presumably caused by bacterial invasion through a
rent in the ovarian capsule.
• The abscess is usually unilateral, and women typically present 1
to 2 weeks after delivery.
• Rupture is common and peritonitis may be severe.

06/27/2021 Kindu Y. 169

 Parametrial Phlegmon
o In some women in whom metritis develops following cesarean delivery, parametrial cellulitis is
intensive and forms an area of induration, or phlegmon, within the leaves of the broad ligament.
o Phlegmons are usually unilateral, & they frequently are limited to the parametrial area at the
base of the broad ligament.
o If the inflammatory reaction is more intense, cellulitis extends along natural lines of cleavage.
o The most common form of extension is laterally along the broad ligament, with a tendency to
extend to the pelvic sidewall.
o Occasionally, posterior extension may involve the rectovaginal septum, producing a firm mass
posterior to the cervix.
o Severe cellulitis of the uterine incision may lead to necrosis and separation. Extrusion of purulent
material commonly leads to peritonitis.

06/27/2021 Kindu Y. 170

 DX
– Palpable mass on bimanual & or rectovaginal exam
– MRI- parametrial edema
RX
– In most women with a phlegmon, clinical improvement follows continued
treatment with a broad-spectrum antimicrobial regimen.
– Typically, fever resolves in 5 to 7 days, but in some cases, it is longer.

06/27/2021 Kindu Y. 171

Left-sided parametrial phlegmon: cellulitis causes induration in the parametrium adjacent to the hysterotomy
incision.

06/27/2021 Kindu Y. 172

• Absorption of the induration may require several days to weeks.
• Surgery is reserved for women in whom uterine incisional
necrosis is suspected.
• In rare cases, uterine debridement and resuturing of the
incision are feasible .
• For most, hysterectomy and surgical debridement are needed
and are predictably difficult.

06/27/2021 Kindu Y. 173

 Septic Pelvic Thrombophlebitis
 This was a common complication in the preantibotic era.
 Puerperal infection may extend along venous routes and cause thrombosis
 Lymphangitis often coexists
 The ovarian become involved because they drain the upper uterus and therefore, the
placental implantation site
 Hematogenous extension of Pelvic infection thrombosis in pelvic veins
 Uterine Veins  ovarian veins ( particularly ROV )  Internal Iliac Vein Common Iliac Vein 
Inferior venacava
 Occurs in 1/3000 deliveries

06/27/2021 Kindu Y. 174

 Clinical manifestation
– Women with septic thrombophlebitis usually have clinical improvement of pelvic infection
with antimicrobial treatment, however, they continue to have fever.
– Although there occasionally is pain in one or both lower quadrants, patients are usually
asymptomatic except for chills
DX-
Clinical
Pelvic CT, MRI,
Rx.
– Continued the antibiotic already started.
– Anticoagulation has no proven efficacy

06/27/2021 Kindu Y. 175

Septic pelvic thrombophlebitis: uterine and parametrial infection
may extend to any pelvic vessel as well as the inferior vena cava. Septic pelvic thrombophlebitis: uterine and
The clot in the right common iliac vein extends from the uterine
and internal iliac veins and into the inferior vena cava. parametrial infection may extend to any pelvic
vessel as well as the inferior vena cava.
The ovarian vein septic thrombosis extends halfway to the vena
cava.

06/27/2021 Kindu Y. 176

 UTI
• Predisposing Factors
– Urinary stasis
– Catheterization,
– Prolonged labor
– Frequent pelvic examination
• In 3-4% post partum women
• Clinical
– Dysuria, frequency, urgency, and low-grade fever;
– Urinary retention, hematuria, pyuria
– Pyelonephritis-fever, chills, malaise,CVAT, Nausea & Vomiting
– UA- WBC, RBC, Bacteria
– E.coli- most common etiology (~75%)

06/27/2021 Kindu Y. 177

 UTI Treatment
• Antimicrobials specific against the isolated etiology
• Lower UTI- PO
– Nitrofurantoin
– Trimethoprim-sulfamethoxazole
– Cephalosporins (cephalexin, cephradine)
– Amoxicillin-Clavullinate
• Pyelonephritis – IV antibiotics
Eg .- Ceftriaxone 1 gm IV BID or
- Ampicilin 2gm IV QID + Gentamycin 1.5mg/Kg TID
• Response in 48 hrs, continue po medication for ~10 days

06/27/2021 Kindu Y. 178

 Milk Fever (congestive Mastitis)
• Breast engorgement + fever
– Low grade fever in the 1st few days pp
– Seldom lasts for > 24hr
– 15% of non breast feeding women
– Less severe& less common in breast feeding women
• RX-
– Ice packs, analgesics ,Tight Pressure (for non BF),
– milk expression after Breast feeding
– Pharmacologic suppression- not recommended
– Exclude other causes

06/27/2021 Kindu Y. 179

 Mastitis
• Mammary gland parenchyma infection
• Rare ~<1%
• Usually after 3rd-4th week post partum
• Invariably unilateral
• Marked engorgement followed by inflammation
– Hard, reddened, painful breast
– Chills, rigor, fever, tachycardia

06/27/2021 Kindu Y. 180

 Mastitis Contd.
• Etiology
– S. aureus, MERSA (Community & hospital acquierd)
– Coagulase negative S. aureus,
– Viridae streptococci
• Source – infant nose and throat
• Bacteria enter the breast through the nipple at the site of a fissure or small abrasion
• Treatment
– Milk expression and Continued BF
• Prevents stasis
– Empirically – Dicloxacilin, Cloxacillin/Erythromycin
– With milk culture & sensitivity
– Rx for 10-14 days

06/27/2021 Kindu Y. 181

 Breast Abscess
• In ~ 10 % of mastitis
Dx
– Palpable fluctuating mass ,
– Ultrasound
– No improvement in 48-72hrs of mastitis treatment
RX
– Incision and drainage, pack
– Ultrasound guided needle aspiration (80-90% success)
– Antibiotics

06/27/2021 Kindu Y. 182

 Galactocele
• Occasionally a milk duct becomes obstructed by inspissated
secretions, and milk may accumulate in one or more mammary
lobes.
• The amount is ordinarily limited, but an excess may form a
fluctuant mass—a galactocele—that may cause pressure
symptoms and have the appearance of an abscess.
• It may resolve spontaneously or require aspiration

06/27/2021 Kindu Y. 183

 Venous Thromboembolism (VTE)
Puerperium is - Hypercoagulable state
– High fibrinogen level, Vascular injury, Immobility
– Increased platelet activity
• Incidence 1 in 500 to 1in 2000 pregnancies
• Pulmonary Embolism in 25% untreated cases
DVT
– Commonly lower extremity veins- often left leg
– Ilio femoral and deep calf veins
– Isolated iliac vein

06/27/2021 Kindu Y. 184

 VTE Contd.
Risk factors
– Cesarean delivery
– Instrumental delivery
– Thrombophilias
• Early ambulation- protective
DX and treatment
Superficial vein thrombosis
– Supportive treatment-analgesia, elastic support, and rest.

06/27/2021 Kindu Y. 185

 Postpartum Thyroiditis
• Autoimmune (In ~10% )
• DM – increased risk
• Hypo/ Hyperthyroid features
• Evaluation- TFT
• RX
– Hypo – Thyroxine supplementation
– Hyper-- β-blockers, PTU
• Sequelae
– Permanent hypothyroidism (5-30% of PPT)

06/27/2021 Kindu Y. 186

 Psychiatric Disorders
1. Postpartum Blues
– Mild and transient mood disturbances-
– Affects 40-80% of post partum women
– Usually in the 1st 10 days
– Self limiting-
– Treatment  Reassurance, support

06/27/2021 Kindu Y. 187

 2. Postpartal Depression
• More protracted depressive mood,
• Usual onset >1month postpartum
• symptoms
• In~12-20% post partum women
DX ( DSM V Peripartal Depression)
– Suicidal /Homicidal ideation- psychiatric emergency
Rx:
• Psycohtherapy, antidepressants
• Recurrence ~25%

06/27/2021 Kindu Y. 188

 3. Post Partal Psychosis
 in 0.1-0.2% of all postpartum women;
• symptoms usual onset b/n 1st and 2nd week
• cannot be distinguished from other psychoses
– anxiety, restlessness,
– Manic paranoid thoughts or delusions.
– Abnormal reaction towards family members.
• Admission to a psychiatric clinic ;.

06/27/2021 Kindu Y. 189

 Obstetric Neuropathies
• Injury to branches of lumbosacral plexus by
– Fetal head
– Inappropriate legging
– Forceps
• Usually after prolonged 2nd stage of labor
– Crampy leg pain ( uni or bilateral)
– Variable degree of Sensory or motor deficit
– Foot drop
• Resolve in 2wks- 18 mths (median duration~~2mths)

06/27/2021 Kindu Y. 190

 Management of the Puerperium
Immediate postpartal care (Hospital Care)
– Vaginal bleeding, uterine contraction,
– Urinary retention
• encourage voiding, catheter
– Perineal discomfort
• look for hematoma
• Ice pack to reduce edema over episiotomy/laceration
– Help with breast feeding
– Encourage early ambulation
• Minimal bladder and bowel complaints, ↓TE risk

06/27/2021 Kindu Y. 191

 • Discharge
– within 24- 48hrs) for uncomplicated SVD
– 2-4 days for uncomplicated CS
Instruction on
– Normal/ physiologic changes
– Danger signs (fever, excessive vaginal bleeding, or leg pain, swelling, or
tenderness. Shortness of breath or chest pain, mood problems.)
– Diet , activity, perineal and breast care,

06/27/2021 Kindu Y. 192

 • Subsequent follow up Care
– 3-6days
• infections, postpartum depression, and problems with infant care and feeding,
coitus, contraceptive
– 6weeks PP
• Recovery, Anemia, contraception, complaints
– 6months
• General health, any morbidity

06/27/2021 Kindu Y. 193

 Postpartal Contraception
• Options
– LAM
– Barrier
– Hormonal
– IUDs
– Sterilization

06/27/2021 Kindu Y. 194

 • LAM
• Progestin only-POP, Implants, Injectable
– After 6weeks PP ACOG, WHO
• IUCD
– Both copper and LNG can be used
– Timing
• Post placental (~10min of placental delivery) increased risk of expulsion
• 4-6weeks postpartum(after complete involution)
• Female sterilization
– 24hrs - 07 days postpartum
– 6weeks postpartum

06/27/2021 Kindu Y. 195

 Thank you !

06/27/2021 Kindu Y. 196

 Family Planning
And Contraception

06/27/2021 kindu y 197

 Session objectives
At the end of this session students are expected to:
 Define family planning
 Describe the origins of FP in Ethiopia
 Identify contraceptive method options
 State why to invest in family planning
 Apply appropriate counseling for contraceptive method choice
 Analyze the demand and unmet need of contraceptive in the country

06/27/2021 kindu y 198

 DEFINITION

Family planning refers to an action taken by an individual couples to

have the desire number of children and spacing

 Is ability of individual or couples to decide when to have the children

 Family Planning is having the number of children you want when

you want them

Contraception refers to all measures, temporary or permanent ,

designed to prevent pregnancy

06/27/2021 kindu y 199

 The Evolution of FP

 Modern birth control movement started in 1912

– Margaret Sanger, New York public health nurse

– She opened the 1st FP clinic in 1916

 FP has received growing attention beginning in the 1960s due to three

reasons:
• Serious of discussion by different people implication of rapid
population growth
• International conferences attended by country leaders

• Invention of two types of contraceptives (Pills and IUD)

06/27/2021 kindu y 200
 History of family planning in Ethiopia

• Family planning in modern sense is recent development in

Ethiopia.
• History of modern family planning is related with establishment of
family guidance association of Ethiopia (FGAE)
• FGAE is non profit making and non government association that
was established in 1966.

06/27/2021 kindu y 201

• FGAE
– FGAE established in 1966
– Initially operating in a room which was in the premises of St. Paul
Hospital
– Became the first organization to FP clinic in Ethiopia (1974)
– Became affiliate member of the International Planned Parenthood
Federation (IPPF) (1975)
– Still recently FGAE was the main provider of community and facility
based FP in Ethiopia
– Contraceptive use and advertisement was illegal
06/27/2021 kindu y 202
Challenges on FGAE:

The government did not give attention for population growth(the

population at that time was considered as small)

 Did not get support of Ethiopian people in general and religious

leaders in particular

06/27/2021 kindu y 203

By 1970,FGAE was recognized by international planned parent hood
federation(IPPF) and got some assistance to expand their service.

During this time wives could get contraceptive only after their
husband signed consent.

By 1975 FGAE was allowed to be registered as NGO and became a

full fledged member of IPPF i.e. start to get more regular assistance.

By this time F/p clinics of FGAE were opened in Asmara and Addis
Ababa.

06/27/2021 kindu y 204

By this year MOH and FGAE agreed to train nurse in family planning.

By this year Ethiopian government accept primary health care

including family planning.

By 1980 department of MCH/FP was established by regional health

bureau.

In 1982 Ethiopian government fully, for the first time, officially
allowed F/p service to be given by FGAE as part of national maternal
and child health program under the supervision of the MOH.

06/27/2021 kindu y 205

 Rationale of Family Planning
1. Demographic rationale

2. Health rationale

3. Human right rationale

06/27/2021 kindu y 206

1. The demographic rationale (1960s and 1970s)

 Concern of rapid population growth on economic productivity,

savings and investment, natural resources, and the environment

2. The health rationale (in the 1980s)

 The consequences of high fertility for maternal, infant, and child

mortality

3. The human rights rationale (in the 1990s)

 women’s rights, principally reproductive rights, and the reproductive

health of women and men. This is associated with ICPD, in 1994.
06/27/2021 kindu y 207
 Demographic rationale

•The predominant rationale for much of the late 1960s and 1970s

•Rapid population growth in 1940s and 1950s, resulting from the gap
between declining mortality and continuing high fertility

•Concerns about rapid population growth and high fertility

•Excessive population growth being a threat to food supplies and natural

resources.

06/27/2021 kindu y 208

FP programs were intended to contribute to:

 lower rates of population growth,

 improved living standards and human welfare, and

 lessened impact on natural resources and the environment by

helping to reduce high rates of fertility.

06/27/2021 kindu y 209

 2. Health rationale

 Became prominent during the 1980s; driven by the consequences of

high fertility for maternal, infant, and child mortality

 High maternal mortality was associated with a high number of

pregnancies, births, and abortions.

06/27/2021 kindu y 210

High rates of maternal, infant and child mortality required
attention (1980s)

1. Avoiding the extremes of maternal age (<15 ), >35 years)

 Older- Mal-presentations, uterine rupture, hemorrhage,
abnormal placentation…
 Young - Pregnancy induced hypertension, obstructed labor…
 F/P prevent from the health risks associated with pregnancy,
delivery and the postpartum period.

06/27/2021 kindu y 211

2. Decreasing risk by decreasing parity

Risk of maternal death is 1.5 to 3 times higher for women with 5 or

more children than for women with 2 or 3 children

3. Preventing high risk pregnancies (previous complications, chronic

diseases, anemia…)

4. Decreasing abortion risks (“every child is a wanted child”)

5. Non contraceptive benefits (Protection against STIs and

reproductive tract cancers)

06/27/2021 kindu y 212

 3. Human right rationale

• FP became the subject of international human rights when

the United Nations issued a statement on population on
Human Rights Day in December 1967.
• The Teheran Conference on Human Rights affirmed the
basic right of couples to decide on the number and spacing
of their children and helped to legitimize family planning.

06/27/2021 kindu y 213

• focus on women’s rights, principally reproductive rights,
and the reproductive health of women and men.

• Found strongest articulation at the ICPD

06/27/2021 kindu y 214

• UN on Human rights day December 1967
– “…that the great majority of parents desire to have the knowledge and
the means to plan their families; that the opportunity to decide the
number of and spacing of their children is a basic human right…”

• Teheran Conference on Human Rights 1968

– Affirmed the basic right of couples to decide on the number and
spacing of their children
• The 1994 ICPD has resulted major shift toward reproductive rights…

06/27/2021 kindu y 215

 Advantages of FP
• For women:
– Avoiding pregnancy at the extremes of maternal age

– Decreasing risk by decreasing parity

e.g. Risk of maternal death is 1.5 to 3x higher for women with 5 or
more children than for women with 2 or 3 children

– Preventing high risk pregnancies

– Decreasing abortion risks

– Non contraceptive benefits (Protection against STIs and

reproductive tract cancers)
06/27/2021 kindu y 216
 Global Maternal Death Burden

• Every day in 2017, approximately 810 women died from

preventable causes related to pregnancy and childbirth.
• Between 2000 and 2017, the maternal mortality ratio (MMR,
number of maternal deaths per 100,000 live births) dropped by
about 38% worldwide.
• 94% of all maternal deaths occur in low and lower middle-income
countries.
• Young adolescents (ages 10-14) face a higher risk of complications

and death as a result of pregnancy than other women.

06/27/2021 kindu y 217
 Causes of maternal death in Ethiopia
Systematic review with meta-analysis in Ethiopia (1990-2000):
1.Hemmorage -29.9%
2.Obstructed labour -22.34%
3.Hypertention -16.9%
4.Purperal sepsis-14.68%
5.Unsafe abortion -8.6%

06/27/2021 kindu y 218

Children:
Infant/child deaths are reduced by:
– Spacing births > 2 years apart
– Delaying births until after age 18
– Limiting family size to < 4 children

• Birth interval < 12 months = 70-80% increase in risk of

death for previous child

• Infants born to women < 18 years old are 24% more likely
to die in first month

06/27/2021 kindu y 219

Adolescents:
– Protection from early and unwanted pregnancy
– Prevention of unsafe abortions
– Protection from STDs (e.g. HIV/AIDS)
– Increased education opportunities
– Increased job possibilities
Men:
• Protection from STDs (e.g. HIV/AIDS)
• Less emotional and economic strain
• Improved quality of life

06/27/2021 kindu y 220

Family:
– Less emotional and economic strain

– More resources available for children

– Increased education opportunities for children

– Increased economic opportunities

– More energy for household activities
– More energy for personal development and community
activities
06/27/2021 kindu y 221
Community:
• Reduced strain on environmental resources (land, food,
water)
• Reduced strain on community resources (healthcare,
educational and social services)
• Greater participation by individuals in community affairs

06/27/2021 kindu y 222

 Family planning Counseling

06/27/2021 kindu y 223

 Learning objectives

Define counseling

State the purpose of counselling

Explain the principles of counselling

Describe the qualities of good counselling

Describe the skills required for counselling

Explain the steps in the counselling process

06/27/2021 kindu y 224

 COUNSELING IN FAMILY PLANNING

Counselling refers to a process of interaction, a two-way

communication between a skilled provider bounded by a code of ethics
and practice, and client/s.

It aims to create awareness of and to facilitate or confirm informed and

voluntary sexual and reproductive health decision making by the client.

It is a process, which helps a client to decide if she/he want to practice

family planning

It helps client to choose a method that is personally and medically

appropriate

06/27/2021 kindu y 225

 CONT…

Counselling helps client to understand how to use correctly

and consistently family planning methods.

It requires empathy, genuineness and the absence of any

moral or personal judgment.

06/27/2021 kindu y 226

 Client’s right

1. Information

2. Access to services

3. Informed choice

4. Safety of services

5. Privacy and confidentiality

6. Dignity, comfort, and expression of opinion

7. Continuity of care

06/27/2021 kindu y 227

 Purpose of Counselling

Give correct and comprehensive information

Help clients to make informed choices and decisions

Help clients with special problems or questions

06/27/2021 kindu y 228

 Principles of counselling

1) Engage in two-way communication with the client.

2) Leave the client the right to decide

3) Keep problems of client confidential

4) Tell the truth

5) Show empathy for the client’s needs

6) Master the subject matter

06/27/2021 kindu y 229

 Elements of good counselling

• Focus on the woman's needs and knowledge

• Actively listen and learn from her

• Engage in interactive discussion

• Utilize skilled ways of asking questions

• Explore situations and beliefs

• Do not be judgmental

• Build trust

06/27/2021 kindu y 230

 Elements of good counselling…

• Explore options together

• Facilitate problem-solving

• Make a plan of action together

• Encourage and reinforce actions

• Evaluate together your plan of action

06/27/2021 kindu y 231

 Counselling is Not !
 Solving a client’s problems

 Telling a client what to do or making decisions for client

 Judging, blaming, or lecturing a client

 Pressuring a client to use a specific method

 Interrogating a client

 Imposing your beliefs

 Lying to or misleading a client

06/27/2021 kindu y 232
 Tips for Successful Counselling

• Show respect for every client, and help each client feel at ease.

• Encourage the client to explain needs, express concerns, and ask

questions.

• Be alert to related needs such as protection from sexually

transmitted infections including HIV, and support for condom use.

• Talk with the client in a private place, where no one else can hear.

• Assure the client of confidentiality— that you will not tell others
about your conversation or the client’s decisions.

06/27/2021 kindu y 233

 Tips for Successful Counselling

• Show respect for every client, and help each client feel at ease.

• Encourage the client to explain needs, express concerns, and ask

questions.

• Be alert to related needs such as protection from sexually

transmitted infections including HIV, and support for condom use.

• Talk with the client in a private place, where no one else can hear.

• Assure the client of confidentiality— that you will not tell others
about your conversation or the client’s decisions.

06/27/2021 kindu y 234

 What is Informed Choice?

All family planning clients have right to informed choice:

• Opportunity to freely choose among options

Based on access to

• Complete, accurate information about

all appropriate, available options

06/27/2021 Kindu Y. 235

Family Planning clients have right to freely choose

Whether to:

• Have children, and how many to have

• Use FP or not

• Be tested for STIs/ HIV

• Use condoms

• Talk with partner about condoms or FP

• Reveal their HIV status

06/27/2021 Kindu Y. 236

 Who are our clients?

• New clients who have no method in mind

• New clients with a method in mind

• Clients returning for resupply (satisfied clients)

• Clients returning with problems or a different need (such as dissatisfied

return clients)

• Most FP clients are either return clients (already using a method) or

new clients who have a method in mind.

06/27/2021 Kindu Y. 237

 Clients by population group

• Men, women

• Married, unmarried

• Adolescents

• Clients with high individual risk for STIs

• Clients living with HIV

06/27/2021 Kindu Y. 238

 Clients by fertility plan
• Delayers

• Spacers

• Limiters

• Want to get pregnant

06/27/2021 Kindu Y. 239

 Clients by timing of last pregnancy
• Postpartum

• Postabortion

• Interval

• Never pregnant

06/27/2021 Kindu Y. 240

 Counseling Steps in Family Planning counselling

REDI approach

R--Rapport building

E--Exploration

D--Decision making, and

I--Implementing the decision.

06/27/2021 Kindu Y. 241

 Counseling Steps in Family Planning…

Step one; Rapport building

Greet client with respect

 Make introductions

 Ensure confidentiality and privacy

Help the client to relax and feel comfortable

 Explain the need to discuss sensitive and personal issues

06/27/2021 Kindu Y. 242

 Cont…

Step two; Exploration

• Explore in depth the client’s reason for the visit

• Explore client’s future RH-related plans, current situation, and past experience

Explore client’s reproductive history and goals, while explaining healthy timing
and spacing of pregnancy (HTSP)

Explore client’s social context, circumstances, and relationships

Explore client’s history of STIs, including HIV

06/27/2021 Kindu Y. 243

 Cont…

• Assess the family planning experience/ knowledge and provide

information and discussion about FP, dual protection and HIV/STI
transmission.

• Focus discussion on the method(s) of interest to client: discuss the

client’s preferred method

• Rule out pregnancy

• Properly response to clients concerns and questions.

06/27/2021 Kindu Y. 244

 Cont…
Step three; Decision making

 Identify the decisions the client needs to confirm or make

Explore relevant options for each decision

Help the client weigh the benefits, disadvantages, and consequences of

each option

Encourage the client to make his or her own decision

06/27/2021 Kindu Y. 245

 Cont…

Step four; Implementing the decision.

Assist the client in making a concrete and specific plan for carrying out the decision(s)

Have the client develop skills to use his or her chosen method and condoms

Identify barriers that the client might face in implementing his or her decision

Develop strategies to overcome the barriers

Make a plan for follow-up and/or provide referrals as needed

06/27/2021 Kindu Y. 246

 Challenging moments in counseling

1. Client becomes silent

2. Client cries

3. Client refuses help

4. Client is uncomfortable with the provider (because of gender

difference, age difference)

5. Provider makes mistake

06/27/2021 Kindu Y. 247

 Managing side effects

• Always acknowledge the clients’ complaints

• Take clients’ complaints seriously

• Gain a full understanding of the complaint: Ask and listen!

• Inform and reassure

• Discuss and/or offer medical management as appropriate

• Determine whether the side effect will go away without treatment or

should be treated

06/27/2021 Kindu Y. 248

 Managing side effects cont’d

• Remind the client that he or she is always welcome to come back with
any concerns or questions

• Remind the client that he or she is always welcome to change methods

• Treat side effects or complications accordingly

• If the client is not satisfied with these options, offer the client the
option of switching to another method

06/27/2021 Kindu Y. 249

Client Assessment and Medical Eligibility for FP Use

06/27/2021 Kindu Y. 250

 Client Assessment
 History

The following information should be sought from clients that request FP services to
ensure safety and effectiveness before providing contraceptives.
• Age

• Parity, last delivery, last abortion, history of ectopic pregnancy

• Breast feeding

• Smoking status

• Sexual behavior: self, partner

06/27/2021 Kindu Y. 251

• STIs and HIV status

• Pelvic infection

• Tuberculosis

• Pelvic surgery

• Hypertension

• Diabetes

• CVS risk factors (smoking, obesity, hypertension, previous thrombo-embolic phenomena,

and high lipids)

• Migraine

• Viral hepatitis

• Gall bladder disease

06/27/2021 Kindu Y. 252
 Medications the client is taking:

• Antiretroviral drugs
• Rifampicin

• Antibiotics
• Antidepressants
• Anticonvulsants
 Family history of cancers, cardiovascular diseases and cerebro-vascular accidents

06/27/2021 Kindu Y. 253

 Physical examination

• Blood pressure measurement – note systolic and diastolic

measurements
• Obesity – height and weight
• Pelvic examination – Pelvic examination is seldom necessary, except
to rule out pregnancy in women who are amenorrheic for more than 6
weeks from last menstrual period and before the use of IUCD and
female sterilization.

06/27/2021 Kindu Y. 254

 Laboratory examinations (only when indicated)

 Hemoglobin test
 Screening for STIs/HIV – wet smear, gram stain, VDRL, HIV test
 Pregnancy test: Be reasonably sure that a woman is not pregnant

06/27/2021 Kindu Y. 255

 The US Medical Eligibility Criteria

• Deals with an evidence-based tool

• used to review who can and cannot safely use a contraceptive method
• Improve both the quality of and the access to family planning services
for clients
• was developed within the context of clients’ informed choices and
medical safety

06/27/2021 Kindu Y. 256

 US MEC
 Groups contraceptive methods in to 6 by their similarity
1) Combination hormonal contraceptives (CHC)
2) Progestin only pill (POP)
3) Depot medroxyprogesterone acetate (DMPA)
4) Implants
5) Levonorgestrel-realizing intrauterine system(LNG-IUS)
6) Copper intrauterine device (Cu-IUD)

06/27/2021 Kindu Y. 257

 US MEC
For a given health condition, each method is categorized 1 through 4
1. No restriction of method use
2. Method advantage overweigh risks
3. Method risks overweigh advantages
4. Method poses unacceptably high health risk

06/27/2021 Kindu Y. 258

 Contraceptive methods

Methods of Contraception

Temporary
Permanent methods( used for
methods( used for
limiting)
spacing)

 Natural methods
 Barrier methods
Female Male ale
 Combination hormonal
contraceptives
 Injectables
tubectomy vasectomy
 Implants
 Intrauterine devices

06/27/2021 Kindu Y. 259

 Pearl Index
Indicates effectiveness of a method or is an index of contraceptive failure

Expressed in terms of failure rate per hundred women-years of exposure- WHY

 The total accidental pregnancies in the numerator includes every conception what
ever outcome it has

 The factor 1200 is the number of months in 100 years

 The total months of exposure in the denominator is obtained by deducing from the
period under review of 10 months for all full term pxy and 4 months for an abortion.

06/27/2021 Kindu Y. 260

 Classification of Contraceptive Methods
Contraceptive methods are classified based on their effectiveness in to four tiers:
1) Top-tier or first-tier methods

 Most effective and easy to use

 Require minimal user motivation or intervention and have a typical-use pregnancy

rate <1/100 women during the first year of use

 Gives the longest duration of contraception

 Require the fewest number of return visits

 unintended pregnancy rate reduction may be better achieved by increasing their use
 Include:
o Male and female sterilization
o Intrauterine contraceptive devices
o Implants

06/27/2021 Kindu Y. 261

2) Second-tier methods

 include hormonal contracep­tives that are available as oral tablets,

intramuscular injections, transdermal patches, or transvaginal rings.

 typi­cal-use pregnancy rate of 4 to 7 per 100

3) Third-tier methods

 Include condoms for men and women,

withdrawal, and fertility awareness methods such as cycle beads

 The typical-use pregnancy rate is 13-24 /100

 Efficacy rises with consistent and correct use

06/27/2021 Kindu Y. 262
4) Fourth tier methods- include spermicidal preparations, which

have a typical-use failure rate of 28 /100

06/27/2021 Kindu Y. 263

 Table 2: contraceptive failure rates
during the first year of method use
in women in the united states

06/27/2021 Kindu Y. 264

 Contra
ceptive
metho
ds
arrang
ed by
effectiv
eness

06/27/2021 Kindu Y. 265

 U.S. Medical Eligibility Criteria for Use of Various Contraceptive Methods While Breastfeeding

Time reflects time from delivery.

06/27/2021 Kindu Y. 266

 Natural Family planning Methods
Is a method without any drugs or hormones in it.
1) Rhythm /calendar method
2) Basal body temperature method
3) Symptothermal method
4) Withdrawal/coitus interruptus method
5) Billings/cervical mucus method
 Basis:
 Avoiding sexual intercourse around the time of ovulation
 The time of ovulation can be judged on calendar and symptom basis

06/27/2021 Kindu Y. 267

 Natural Family planning Methods
1) Rhythm Method:
 Based on Ogino-Knaus theory, ovulation occurs on 14 ± 2 days in a
female with a regular 28 days cycle.
 Avoid sex between 12th and 16th day of cycle
 Fertilization span of the sperm is 48-72 hrs. and is 12-24 hrs. for ova
 Cycle day 8-18- Unsafe period
 25-35% failure rate
 Failure rate will be reduced to 10% if sex is avoided 7-21 days
 Thus, sex is safe only in the first 7 days of the menstrual cycle

06/27/2021 Kindu Y. 268

 Natural Family planning Methods

The rhythm/calendar method

06/27/2021 Kindu Y. 269

 Natural Family planning Methods
For irregular method:

 Safe period is shortest cycle -18 (give the first day of the fertile period ) to longest cycle
-11(gives the last day of the fertile period )

Advantages - low cost and no side effects

Drawbacks

 Difficult to predict safe period for irregular cycles

 Can only suited for educated and responsible couples with high motivation and
cooperation

 Not applicable for postnatal period

 Needs abstinence

 High failure rate – 9/100 WY

06/27/2021 Kindu Y. 270
 Natural Family planning Methods
2) Standard Days Method:

 Has simple rule and is easier than rhythm/calendar method

 Cylclebeads- help to track the estimated high and low fertility points
throughout the menstrual cycle

 Only be used by women whose cycles are always b/n 26 and 32 days

 Days 1-7 of the cycle are considered

 Days 8-19 are considered fertile

 From day 20, infertility is considered resumed

 Failure rate – 2/100 WY

06/27/2021 Kindu Y. 271
 CycleBeads

 During use, the red bead denotes men­ses onset, and the small black band is advanced for each day of the menstrual cycle.

 When the white beads are reached, abstinence is observed until brown beads begin again

06/27/2021 Kindu Y. 272

3) Cervical mucus method/Billing method:

 Based on observation of changes in the characteristics of cervical

mucus

 During ovulation - Watery, clear (resembling raw egg white) ,

smooth slippery, elastic on stretching between fingers (called
Spinnbarkeit), and profuse

 After ovulation- thick, scanty, loses elasticity, breaks on stretching

and called Tack- (progesterone dominance)

 Use tissue paper to wipe inside the vagina to characterize the mucus

06/27/2021 Kindu Y. 273

 Cervical mucus during Ovulation

06/27/2021 Kindu Y. 274

 Intercourse is safe during the dry days immediately after menses and
till the mucus is detected

 Abstain until the 4th day after the peak day

 Need high degree of motivation and knowledge of different

characteristics of the mucus

06/27/2021 Kindu Y. 275

 Billing Method

06/27/2021 Kindu Y. 276

4) Basal Body Temperature method

 Body temperature drops briefly & then rises 0.5 degree celsius following
ovulation due to thermogenic effect of progesterone and remains elevated
in the secretory phase.

 A rise in temperature persisting 3 days indicates that ovulation has

occurred.

 Safe period is from fourth day(1st day being the day of ovulation) to the
last day of the next period

 A chart of daily temperature readings must be kept for the method to be

effective
06/27/2021 Kindu Y. 277
5) Symptothermal method:
 Use of at least to indicators to identify the fertile period.
 The cervical mucus method and the basal body temperature method
are usually use in combination.

6) LAM

06/27/2021 Kindu Y. 278

6) LAM
 Basis
Frequent intense suckling

Prolactin released

Inhibits GnRH secretion

Downregulates LH and FSH release

Disrupts follicular development

Anovulation and amenorrhea

06/27/2021 Kindu Y. 279

Key point
3 prerequisites for LAM to insure effective contraception
1) Excusive breast feeding
2) Baby < 6 months
3) Amenorrheic/menses should not have resumed
 Failure rate – 5/WY

06/27/2021 Kindu Y. 280

Natural family planning methods are not suitable for women:

o With irregular cycles, cycles shorter than 21 days

o Adolescent, lactating, premenopausal

o Had cervical surgery

o With vaginal infection

o Have STD or PID in the last 3 months

o Had recent abortion

o Non cooperative husbands or couples who have casual sex

So What?
06/27/2021 Kindu Y. 281
 Reading Assignment
Withdrawal method
Barrier methods
spermicides

06/27/2021 Kindu Y. 282

 Oral contraceptive pills(COC)
Taken by mouth to prevent pregnancy
Types of oral contraceptive pills :
Combined Oral Contraceptives(COC)

 progestin only pill(POP)

06/27/2021 Kindu Y. 283

 Oral contraceptive pills(COC)
•Pills that contain low doses of two synthetic hormones-a progestin and an
estrogen

• Highly effective in preventing pregnancy

•How do they work?
Inhibit ovulation-main MOA
Thicken cervical mucus
Change endometrial lining(thing )
Alter tubal transport
Effectiveness
–Typical use (as commonly use) 6-8% pregnancy rate
–Perfect use - 0.1% pregnancy rate

06/27/2021 Kindu Y. 284

 Oral contraceptive pills(COC)
•Pills that contain low doses of two synthetic hormones-a progestin and an
estrogen

• Highly effective in preventing pregnancy

•How do they work?
Inhibit ovulation-main MOA
Thicken cervical mucus
Change endometrial lining(thing )
Alter tubal transport
Effectiveness
–Typical use (as commonly use) 6-8% pregnancy rate
–Perfect use - 0.1% pregnancy rate

06/27/2021 Kindu Y. 285

 Oral contraceptive pills(COC)

A. Extended-use COCs. Each of the three sequential cards of pills is taken. Placebo pills (peach) are found In the bottom
card.
B. 21n triphasic COCs. Active pills are taken for 3 weeks and are followed by seven placebo pills (green). With triphasic
pills, the combina­tion of estrogen and progestin varies with color changes, in this case, from white to blue to dark blue.
c. 24/4 monophasic COCs. Monophasic pills contain a constant dose of estrogen and proges­tin throughout the pill pack.
With 24/4 dosing regimens, the num­ber of placebo pills Is decreased to four.

06/27/2021 Kindu Y. 286

 Oral contraceptive pills(COC)

06/27/2021 Kindu Y. 287

 Oral contraceptive pills(COC)

Return of fertility after COCs are stopped: No delay

Protection against STIs: None

Advantages
– Safe, effective and reversible
– Can be used at any age (adolescence to menopause)

Potential health benefits

– Prevent/reduce iron deficiency anemia
– Reduce risk of Pelvic Inflammatory Disease
– Reduced risk of uterine/ovarian cancer

06/27/2021 Kindu Y. 288

 Non-Contraceptive Benefits of COC

06/27/2021 Kindu Y. 289

 Absolute contraindication to COC

06/27/2021 Kindu Y. 290

 Relative contraindication to COC

06/27/2021 Kindu Y. 291

Indications for withdrawal in COC
 Severe headache

 Visual disturbances

 Sudden chest pain

 Preoperatively (6 weeks)

 Severe cramp & pains in legs

 Excessive weight gain

 Severe depression
 Wanting pregnancy

06/27/2021 Kindu Y. 292

 …cont’d
Disadvantages
• Challenge daily compliance
• New packet of pill must be at hand every 28 days
• Do not protect STI
• Reduces milk supply - not recommended less than
6months postpartum

Health risks
• Increased risk of myocardial infarction, stroke, venous
thrombosis
• Equivocal evidence of increased risk of breast and cervical
cancer

06/27/2021 Kindu Y. 293

 Side Effects
• Changes in bleeding patterns

• Headaches

• Dizziness

• Nausea

• Breast tenderness

• Weight change

• Mood changes

• Acne

• Blood pressure increase

06/27/2021 Kindu Y. 294

When to Start

Having menstrual cycles

• within 5 days after the start menses

switching from an IUD, inject able and others give in

that day

fully breast feeding less than 6 months after giving birth:

• Give her COCs and tell her to start taking them 6

months after giving birth

06/27/2021 Kindu Y. 295

Fully breast feeding more than 6 months after giving birth:

• Menses has not returned, not pregnant. She will need a backup

• If her monthly bleeding has returned within 5 days menses

Partially breast feeding less than 6 weeks after giving birth :

• 6 weeks after giving birth if menses not return

• Within 5 days of menstruation if menses return

06/27/2021 Kindu Y. 296

 Not breast feeding less than 4 weeks after
giving birth
• She can take on days 21

More than 4 weeks after giving birth

• bleeding has not returned, not pregnant. She will need

a backup method

• bleeding has returned, she can start COCs as advised

for women having menstrual cycles

06/27/2021 Kindu Y. 297

 No monthly bleeding (not related to
childbirth or breastfeeding):
• any time it is reasonably certain she is not pregnant. She
will need backup method for the first 7 days of taking
pills.

After miscarriage or abortion:

 within 7 days after first or second-trimester miscarriage
 If it is more than 7 days after first- or second trimester
miscarriage, she is not pregnant. She will need a backup
method

06/27/2021 Kindu Y. 298

Effects of COC on organs
1) Hypothalamo-pitutary axis: levels of FSH & LH
remain low as in early proliferative phase
2) Ovary: remains quiescent with occasional ovulation
so that evidence of fibrosis & low level of
endogenous steroids
3) Endometrium (P): stromal edema, decidual reaction
& glandular exhaustion
4) Cervix (E+P): Increased glandular hyperplasia &
down growth of cervical epithelium (Ectopy)
5) Uterus (E): slightly enlarged
6) Vagina (P): cytohormonal study shows early luteal
phase

06/27/2021 Kindu Y. 299

 Effects of COC on organs Contd.
7) Liver: liver functions will be depressed
8) GIT: increased incidence of mesenteric
vein thrombosis & ulcerative colitis
9) Urinary: increased incidence of UTI
because of sexual activity
10)Thyroid gland: estrogen in OCs increases
circulating thyroid-binding globulin
affecting tests of thyroid function

06/27/2021 Kindu Y. 300

 Effect of COC on reproduction

 Ovulation returns in three months after withdrawal in 90% of cases

 No increased incidence of congenital anomalies

 Lactation: reduction in milk production &quality of milk

If given less than 6months postpartum period .

Missed pills :

Missed 1 or 2 pills?

• Take a hormonal pill as soon as possible.

• Little or no risk of pregnancy

06/27/2021 Kindu Y. 301

Missed pills cont..
Missed 3 or more pills in the first or second week?

• Take a hormonal pill as soon as possible.

• Use a backup method for the next 7 days.

• Also, if she had sex in the past 5 days, can

consider ECPs

06/27/2021 Kindu Y. 302

Missed 3 or more pills in the third week?

• Take a hormonal pill as soon as possible.

• Finish all hormonal pills in the pack.

• Throw away the 7 non hormonal pills in a 28-pill pack.

• Start a new pack the next day.

• Use a backup method for the next 7 days.

• Also, if she had sex in the past 5 days, can consider

ECPs

06/27/2021 Kindu Y. 303

Missed any non hormonal pills?

• Discard the missed non hormonal pill(s).

• Keep taking COCs, one each day.

• Start the new pack as usual

06/27/2021 Kindu Y. 304

Progestin-Only Pills (POPs)
 Pills that contain very low doses of a progestin
 Can be used throughout breastfeeding and by women
who cannot use methods with estrogen.

How do they work?

 cervical mucus thickening(4hrs-22hrs)

 decreased tubal motility

 disrupting menstrual cycle(in 60% of cases)

 prevention of endometrial growth

06/27/2021 Kindu Y. 305

POP Contd.
o A distinct disadvantage is that these contraceptives must be
taken at the same or nearly the same time daily.
o If a progestin-only pill is taken even 4 hours late, a back-
up form of contraception must be used for the next 48
hours.
o Also, their effectiveness is decreased by the medications
shown in Table on next slide .
o Women taking any of these medications should not use this
form of contraception.
o Finally, unlike combined oral contraceptives, the mini-pill
does not improve acne and may even worsen it in some
women.

06/27/2021 Kindu Y. 306

 …cont’d
Effectiveness:

Breastfeeding women:

• Typical use (as commonly use) - 1% pregnancy rate

• Perfect use -0.03% pregnancy rate

Not breastfeeding:

• Typical use (as commonly use) – 3%-10% pregnancy rate

• Perfect use -0.09% pregnancy rate

06/27/2021 Kindu Y. 307

 Cont…..

Advantages:

• Side effects of estrogen will be eliminated

• No adverse effect on lactation

• No “on & off” regimen during taking

• Reduces risk of PID & endometrial cancer

• Return of fertility after POPs are stopped: No delay

• Protection against STIs: None

06/27/2021 Kindu Y. 308

 …cont’d
Side Effects
• Changes in bleeding patterns
• Headaches
• Dizziness
• Mood changes
• Breast tenderness
• Abdominal pain
• Nausea

06/27/2021 Kindu Y. 309

Medications That Contraindicate Progestin-Only Oral Contraceptive

Carbamazepine (Tegretol)
Felbamate
Oxcarbazepine
Phenobarbital
Phenytoin (Dilantin)
Primidone (Mysoline)
Rifabutin
Rifampicin (Rifampin)
Topiramate
Vigabatrin
Possibly ethosuximide, griseofulvin, and troglitazone

06/27/2021 Kindu Y. 310

Managing missed pill
If a woman is 3 or more hours late taking a
pill or misses one completely
• Take the most recent pill as soon as possible
• Use backup method for 48hrs
• Take the next pill at regular time

06/27/2021 Kindu Y. 311

Injectables contraceptives
Types
1 . Progesterone only Injectable
The most popular is Medroxy progesterone acetate (DMPA) or
depo Provera which is given for 3 months

Norethinodrone enanthate (NET-EN) which is given in a dose of

200 mg IM every 2 months. It acts in the same way as DMPA &
has the same problem.
2. Combined formulations
• A combination of Estrogen with progesterone
1. Mesigyna
• A combination of norwthidindrone ethanoate (50 mg) with estradil
valerate (5mg) given monthly
• has less bleeding problem
• effective

06/27/2021 Kindu Y. 312

Combined formulations …..
2. Cyclofem- 25 mg medroxy progesterone
acelate + 5mg estradol cypionate

• They come pre-loaded in a 5 syringe & put in a

suspension with the addition of 2.5 ml dextran
• Mixture must be shaken between injection & its
injected deep in to the Gluteal using Z track injected
technique & not massaged.

06/27/2021 Kindu Y. 313

 Common trade Duration of effect Active ingredients Name
names

Depo-Provera, 90 days 150 mg DMPA

Depo-Clinovir, medroxyprogesterone (progesto
others acetate in an aqueous gen-only)
microcrystalline
suspension

Noristerat, 60 days 200 mg NET-EN

Norigest, norethisterone progesto(
Doryxas, and enanthate )gen-only
others in an oily preparation

Mesigyna, 30 days mg norethisterone 50 Mesigyna

Norigynon enanthate and combine(
mg estradiol 5 )d
valerate

314 Kindu Y. 06/27/2021

 DEPO-PROVERA

Is the most common Injectable contraception

• It is an aqueous solution of suspended micro crystals

mechanism of action

• In addition to thickening cervical mucosa &

alternation of endometrial (making the endometrium
hostile to implantation, DMPA effectively block LH
surge & there fore ovulation does not occur.

06/27/2021 Kindu Y. 315

 DEPO-PROVERA
• Efficacy

• Some studies show the efficacy of DMPA is equal to

sterilization 1 out of 400 will becomes pregnant /year (0.3%)

• One of reason for high effectiveness is that its high dose provides
more than 3 months of Protection: - that is a women will have 2
weeks of “ Grace period ” during which she can be late for her
next dose but still be protected.

• Very effective – 0.3 pregnancies per 100 women

06/27/2021 Kindu Y. 316

 DEPO-PROVERA
advantages

 This method is not associated with compliance problem & forget

fullness.

 It’s long-term

 Private, no one can tell that the women is using it

 Safely used in lactating mother as soon as 6 weeks after birth

 No estrogen side effect therefore can be used in patients with heart

disease, sickle-cell anemia, age > 35 & smokers, seizure disorders
& Hypertension

06/27/2021 Kindu Y. 317

 Cont …

Allows some flexibility in return visits  clients

can return 3 months + 2-4 wks safely.

Non contraceptive benefits

 Prevent ectopic pregnancy  prevent uterine fibroids

 Low endometrial cancer  reduce menstrual flow & anemic

It’s Accepted by many clients

Can be used in prevention of heavy menstruation

06/27/2021 Kindu Y. 318

 DEPO-PROVERA

disadvantage
• The return to fertility may be delayed by 18
months 90% become pregnant following DMPA
• Injection itself is disadvantageous (said by some
women)
• Does not protect STI & HIV/AIDS

• Some women complaint about amenorrhea

06/27/2021 Kindu Y. 319

 DEPO-PROVERA
Indications
• Estrogen free contraception is needed

• Breast feeding women (at 6 wks)

• At least 1 year of birth spacing desired

• Sickle cell disease & seizure disorder

• Women at any age requiring highly effective long acting contraception

• Private (secrete) use is desired

• After abortion

06/27/2021 Kindu Y. 320

DEPO-PROVERA
absolute CI

• Pregnancy

• Undiagnosed DUB or unexplained vaginal bleeding

• Malignant disease of the breast

Relative CI
• Liver disease
• Severe cardiovascular disease (MI)
• Severe depression
• Rapid return of fertility desired

06/27/2021 Kindu Y. 321

 DEPO-PROVERA

SIDE EFFECTS

• There is no increased risk of any lethal complication

most common side effects are
• Heavy bleeding –rare

• Amenorrhea- common specially after 9-12 month

use  this 2 are common reasons for discontinuing
DMPA
• If bleeding persists a NSAIDs for a week e.g.
Indomethacin 25 mg po bid for 07 days may be given
06/27/2021 Kindu Y. 322
DEPO-PROVERA

• Break through bleeding

• If 1 & 3times can be managed by providing COCs for 1-2
months. Or 1.25 mg estrogen or 2mg estradiol can be given
for 07 days daily
• If anemia <5% HCT, a women can be switched to other
contraceptive or provide iron supplement

06/27/2021 Kindu Y. 323

 DEPO-PROVERA

Other problems

• Weight gain

• Abdominal pain

• Headache

• Anxiety

• Dizziness

• Frequent urination

• Depression

06/27/2021 Kindu Y. 324

 Emergency Contraceptive pills
EC promotion and use in the country would reduce
incidence of unwanted pregnancies, which otherwise
would have ended in unsafe abortion and its complications

• serve as a back up to other family planning methods

• According to a national survey on abortion conducted by

Ethiopian society of obstetrics and gynecology (ESOG)
abortion related mortality was 1,209 per 100,000 abortions

06/27/2021 Kindu Y. 325

 FP for adolescent
• Unwanted pregnancy is one of the major RH challenges faced by
adolescents in Ethiopia.

• 54% of pregnancies to girls under age 15 are unwanted compared to

37% for those ages 20-24.

 This indicates the need to refocus programs and prioritize

interventions tailored to adolescents under 15 years

06/27/2021 Kindu Y. 326

 Emergency Contraception (EC)

Definition: Emergency Contraception refers to

contraception methods that can be used by women
following unprotected intercourse or if the woman had a
contraceptive accident such as leakage or slippage of
condom to prevent an unwanted pregnancy

• EC should not be used as a regular family planning

method but should be used in an emergency as a back up 

06/27/2021 Kindu Y. 327

 Emergency Contraception (EC)
• post-coital contraception
• Risk of pregnancy following unprotected intercourse
around time of ovulation is 8%
• Indications:
1. Unprotected intercourse
2. Condom rupture
3. Missed pill
4. Sexual assault
5. Unplanned 1st time intercourse

06/27/2021 Kindu Y. 328

 Emergency Contraception (EC)
Options:

1.Combined Oral Contraceptive Pills (COCs): An increased

dose of combined oral contraceptives containing ethinyl
estradiol and levonorgestrel (Yuzupe’s regimen)
• 4 low dose tablets of COC followed by another dose 12 hours later

• 2 “standard dose” COC followed by another equal dose 12 hours later

1. Progesterone Only Pills (POPs): High dose Progesterone

Only Pills containing levonorgestrel(20 POP pills)

2. Intra-utérine Contraceptive Devices (progesterone

06/27/2021 Kindu Y. 329
contaning IUDs) up to 5 days
 Emergency Contraception (EC)
• Treatment with both regimens should not be delayed unnecessarily as efficacy
declines over time.
1. Combined oral contraceptive pills: Contain ethinyl estradiol and levonorgestrel or
comparable formulations.
This regimen is known as the Yuzpe’s method, and it has been used since the 70s. 
• When high dose pills containing 50mcg of ethinyl estradiol
and 0.25mg of levonorgestrel are available, two pills should
be taken as the first dose as soon as convenient, but not later
than 3 days (72 hours) after unprotected intercourse.

• Eg. Neyogynon
• The second two pills should follow 12 hours later.

06/27/2021 Kindu Y. 330

 Emergency Contraception (EC)
• When low dose pills containing 30 mcg ethinyl
estradiol and 0.15 mg of levonorgestrel are available,

• four pills should be taken as the first dose as soon as

convenient but not later than 3 days (72 hours) after
unprotected intercourse

• followed by another four pills 12 hours later

e.g. of this group Microginon, prudence, le-ofemenal etc

06/27/2021 Kindu Y. 331

 Emergency Contraception (EC)

2. Dedicated ECs
• When pills containing 0.75 mg of levonorgestrel are available,
one pill should be taken as the first dose as soon as convenient,
but not later than 3 days (72 hours) after unprotected intercourse
to be followed by another one pill 12 hours later
POPs (mini-pills)
• When pills containing 0.03 mg of levonorgestrel are available,
twenty (20) pills should be taken as the first dose as soon as
convenient but not later than 3 days (72 hours) after unprotected
intercourse to be followed by another 20 pills 12 hours later.

06/27/2021 Kindu Y. 332

 IUD
• Effective within 5 day un protective sex
• Effectiveness→ less than 1% failed
Contraindication
• Pregnancy
• Puerperal sepsis
• PID
• Undiagnosed AUB
• GTD

06/27/2021 Kindu Y. 333

 MOA
The precise mechanism is not known
• Studies have suggested that EC pills can:
• Delay or inhibit ovulation
• Prevent implantation by making the inner lining of the uterus
(endometrium) unsuitable for implantation
• Prevent transport of the sperm and ovum

The mechanism that is active in a particular case depends on the

time of the menstrual cycle when emergency contraceptives are
used

06/27/2021 Kindu Y. 334

Mechanism…
• ECPs do not interrupt or abort an established pregnancy

• They can only help in preventing unwanted pregnancy.

Once implantation (pregnancy) has occurred, ECPs are
not effective.

• ECPs, thus, do not cause any form of abortion or bring

about menstrual bleeding.

06/27/2021 Kindu Y. 335

 Eligible women for ECPs

• Clients who are not eligible for ECPs:

• Client already pregnant

• When an emergency contraceptive option other than ECPs should be

considered (e.g. clients seeking care later than 3 days)
• Upon arrival clients have to be screened to determine eligibility.

• However, ECPs should not be delayed or withheld in order to

carry out screening procedures such as pelvic exam

06/27/2021 Kindu Y. 336

 Indications for the use of ECPs:

• When no contraceptive has been used

• When there is a contraceptive accident or misuse
• Condom rupture, slippage or misuse, and IUCD expulsion
• Two OCPs missed consecutively, and late for DMPA
injection by two weeks or more
• Failure of a spermicidal tablet or film to melt before
intercourse
• Failed coitus interruptus (withdrawal)
• Failure to abstain on a fertile day of the cycle in a woman
who uses the calendar method
• In case of sexual assault

06/27/2021 Kindu Y. 337

 Safety and effectiveness
ECs are considered very safe:
• In more than 20 years no deaths or serious medical
complications have been reported

• The COCs used as EC pills have not been associated with

fetal malformations or congenital defects in the event if EC
fails to prevent pregnancy.
• Available data suggest the ECPs do not increase the
possibility that a pregnancy following use will be ectopic.

06/27/2021 Kindu Y. 338

 Safety and effectiveness…
ECs are fairly effective in preventing pregnancy from unprotected sexual intercourse

• It is estimated that if 100 women have unprotected sexual intercourse

during the second or third week of their menstrual cycle, 8 would
become pregnant

• If the same 100 women use combined oral pills as ECs, instead of 8
women only 2 would become pregnant

• If the same 100 women used progestin-only ECs, instead of 8 women

only 1 would become pregnant

• These suggest ECs could reduce the probability of becoming pregnant

from unprotected sexual intercourse by roughly 75 % in the case of
COCs, and 85 % in the case of POPs

06/27/2021 Kindu Y. 339

 Side effects of ECs and their management

• The following are common side effects of ECPs:

• Nausea: It is the most common in ECPs, but COC user

experience more nausea than POP users. It usually does
not last more than 24 hours

• Management of nausea: Take the pill with food or at

bedtime to reduce nausea. A woman who has previously
experienced nausea while using hormonal methods
including ECPs could need prophylactic anti-emetic.

06/27/2021 Kindu Y. 340

 Side effects of ECs and their management
• Vomiting: Occurs in 20% of women using COCs and 5% of women using POPs as
ECs
• Management of vomiting: If vomiting occurs within 2
hours, the dose should be repeated
-Irregular vaginal bleeding or spotting: Some women may
experience irregular vaginal bleeding or spotting following
ECs
-Management: Inform women that ECPs do not bring menses
immediately a common misconception among ECP users. If
the menstrual period is delayed for more than two weeks
from the expected date, the possibility of pregnancy should
be considered and a pregnancy test should be done.

• If you cannot provide the test, refer to facilities where the

service can be provided.
06/27/2021 Kindu Y. 341
Side effects of ECs and their management
• Other problems: Breast tenderness, headache,
dizziness and fatigue, do not generally last more
than 24 hours

• Management: Aspirin or another non-

prescription pain reliever can be used to reduce
the discomfort of headaches and breast
tenderness

06/27/2021 Kindu Y. 342

Overview of implants
Objectives
At the end of this session students, will be able to:
Describe hormonal contraceptive implants as a
safe and effective LARCM
Discuss the drug interaction effect on it’s
effectiveness
Discuss the characteristics of each implant
contraceptive

06/27/2021 Kindu Y. 343

Implants cont.…
Implants are matchstick sized rods flexible
progestin-filled rods or capsules that are placed just
under the skin of the upper arm

WHO,2003

06/27/2021 Kindu Y. 344

 Types of implants
• Many types of implants:
• Norplant: 6 capsules, labeled for 5 years of use
• Jadelle: 2 rods, lasts 5 years
• 75 mg of levonorgestrel
• Implanon: 1 rod, lasts 3 years
• 68 mg of etonogestrel
• Sino- implant: 2 rods, lasts 4 years

06/27/2021 Kindu Y. 345

 Mechanism of action of implants
• Implants continually release a small amount of
progestin steadily into the blood.

• The primary mechanisms are:

• Increased cervical mucus viscosity (within 48-72 hrs).

• Inhibition of ovulation- in about 50% of menstrual cycles.

• Alters endometrium, making it less conducive for

implantation

06/27/2021 Kindu Y. 346

 Safety and effectiveness of implants
• Are one of the most effective and long-lasting
methods
• <1 preg. per 100 women over the first year (5 per
10,000 women).
• A small risk of pregnancy remains beyond the first year.
• Start to lose effectiveness sooner for heavier women
• No delay in return of fertility after removal
• No protection against sexually transmitted
infections
• Do not increase frequency of ectopic pregnancy.

06/27/2021 Kindu Y. 347

 Drug interaction effect on implants effectiveness
• Contraceptive effectiveness may be reduced
when co- administered with some:-
• Antibiotics,
• Anti-fungals,
• Anticonvulsants, and
• Anti-HIV Protease Inhibitors:
• Other drugs that increase the liver metabolism
of contraceptive steroids.

06/27/2021 Kindu Y. 348

 Category 3 Conditions
Breast feeding≤6wk  Severe cirrhosis
Acute DVT/PE (decompensated)
Current & hx of ischemic heart Hepatoma
disease Hepatocellular adenoma
Stroke Rifampicin , refabutin
+ve antiphosphlipid ab. Anticonvulsant therapy
Migraine with aura Retonavir boosted protease
Past hx breast ca. & no evidence inhibitor
of current disease for 5 years NB - current breast cancer is
Category 4 condition

06/27/2021 Kindu Y. 349

 When to start use implants
• Having menses
within 7days after the start(5days for implanon)
no backup
 if >7days → R/O pregnancy + backup for
7days
• Switching from IUD → insert immediately
• Switching from hormonal contraceptive → if
she was using correctly & consistently start
immediately & no need of backup

06/27/2021 Kindu Y. 350

 Cont…
• Fully or near fully breastfeeding
o < 6months →delay at least until 6wk

o > 6monts & no menses → R/O pregnancy + backup

• Partially breast feeding

o < 6wk →delay until 6wk

o > 6wk & no menses → R/O pregnancy + backup

• Non breastfeeding
o < 4wk → start anytime

o > 4wk & no menses →R/O pregnancy + backup

06/27/2021 Kindu Y. 351

 Cont…
• No monthly bleeding unrelated to
breastfeeding or pregnancy → R/O
pregnancy + backup

• After miscarriage or abortion

if with in 7days no need of backup
>7days → R/O pregnancy + backup

• After ECPs insert within 7days after the start

of menses or anytime after R/O pregnancy

06/27/2021 Kindu Y. 352

 Implants Contd.
o1) Norplant:
o This system provides levonorgestrel in six silastic
containers that are implanted sub dermally.
o six rod for five years with each rod containing 38 mg of
levonorgestrel releasing initially 85ug/day and later
30ug/day over five years.
o Mechanism of action and advantages are similar to
DMPA.
o Efficacy is comparable to COC with failure of 0.1 HWY
• The manufacturer stopped distributing the system in
2002

06/27/2021 Kindu Y. 353

Implant…
2.Implanon
• A single rod etonogestrel-containing, reversible,
implant
• 40 mm in length and 2 mm in diameter
• the most effective methods for preventing
pregnancy for 3 years .
• Less than 1 preg. Per 100 women (1/1,000 women)
• Pre-loaded inserter
• Easier insertion and removal
• Store at 25°C (15°-30°C) and avoid direct sunlight.

06/27/2021 Kindu Y. 354

 Pre insertion Counseling for Implanon
• In a private setting, provide more detailed
information
• How it works,
• Its effectiveness,
• How it is inserted,
• Its characteristics,
• Common side effects, and
• When to return
• Answer any questions that the client may have

06/27/2021 Kindu Y. 355

 Implanon insertion procedures
-Confirm that informed consent is obtained.
• Check to be sure the client is eligible.
• Let her wash the entire arm with soap & water
or iodine .
• Locate the best insertion area (8cm above the
elbow fold).
• Strictly use infection prevention practices.
• Use 1ml of local anesthetic (1% without
epinephrine).

06/27/2021 Kindu Y. 356

 Post insertion client instructions
•  Client Instructions for Wound Care key points:
• Keep the insertion area dry & clean for at least 48
hrs.
• Leave the gauze pressure bandage in place for 48
hours
• Leave the smaller bandage in place for 3-5 days).
• Bruising, swelling, or tenderness may occur for
few days.
• Routine work can be done immediately but
• Avoid bumping the area, carrying heavy loads or
putting unusual pressure to the site.

06/27/2021 Kindu Y. 357

 Post insertion client instructions; contd…
• Return to the health facility in case of:-
• Severe lower abdominal pain (ectopic pregnancy?)
• Heavy bleeding
• If the insertion site becomes red with increased
heat and/or tenderness, or if there is pus at the site,
• Bleeding at insertion site
• Expulsion
• Migraine headache
• For removal at the end of 3 years or anytime she
decides to stop using.

06/27/2021 Kindu Y. 358

 Implanon removal procedures
• Key points:
• An easy removal depends on correct insertion;
• If the rods cannot be palpated a provider
inexperienced in removal should NOT begin the
procedure- refer.
• Inject local anesthesia under the ends of the implant
• Remove the implant if it is palpable .
• If the rod can’t be removed, stop the procedure, ask
to return when fully healed (4-6 wks) and try again
or refer
• If the client wants to continue using Implanon , a
new set can be inserted at the time the current set is
removed.

06/27/2021 Kindu Y. 359

Side effects and complications

Side Effects Complications

• Changes in bleeding • Procedure site
patterns
• lighter and fewer days of problems (early)
bleeding, irregular bleeding, • Bleeding /
infrequent bleeding & no hematoma,
monthly bleeding.
• Headaches, • Expulsion,
• Breast tenderness, • Infection /cellulites /
• Mood changes, abscess
• Nausea, wt gaine
• All of which usually
decrease over time.

06/27/2021 Kindu Y. 360

 Implant cont..
3) Jadelle
2 rods
Effective 5 years to prevent pregnancy
1-yr failure: 0.05% (1 in 20,000); 5-yr failure
1.1%
Effectiveness vary based on wt. for Jadelle
& Norplant(>80kg used for 4yrs)
Effectiveness decreases from year to year
No delay of fertility after removal

06/27/2021 Kindu Y. 361

 Implants cont..
Jadelle….
• Pre insertion counselling
• Insertion procedures The
• Post insertion client instructions same as
Implano
• Jadelle removal procedures n
• Side effects and complication
o Except Jadelle has two rods and used 2ml
of lidocaine for insertion and removal

06/27/2021 Kindu Y. 362

 Implants cont ..
4.sino-implant
• Sino-implant is a two-rod system
• with the same amount (150 mg) of levonegstrol
• same mechanism of action as Jadelle
• but provides 4 years of contraception.
• Sino-implant is manufactured in China
• approved for use by 20 countries in Asia and
Africa, in 2012
• Like other implants placed subdermally on the inner
arm approximately 8 cm from the elbow
• have similar removal steps

06/27/2021 Kindu Y. 363

 INTRA UTERINE CONTRACEPTIVE DEVICE -
IUCD
IUCD is a safe, easy to use, reversible,
effective method of child spacing for couples
who are at low risk for STIs/HIV
Careful screening and counseling are essential
for successful use of an IUCD
IUCD can be used safely by breast-feeding
women
Different IUCD can remain in from 5 -10 yrs
Menstrual period may be heavier & longer,
esp. for the 1st few months

06/27/2021 Kindu Y. 364

 Types of IUCD

 Inert- Lippes loop

 Medicated- contain progesterone
1. Progestasert - Contains 38mg of natural
progesterone & supplies 65µg/d into the uterine
cavity for 1 yr
2. Levonorgestrel (Mirena)- Contains 52mg of
LN, releases 20µg of LNg daily, & serves for 5
yrs
 Copper bearing- are copper coated :- Cu T
380A, Multi- load 250, Multi-load 375, Nova T,
Cu T 200 & 220

06/27/2021 Kindu Y. 365

 Types of IUCD

A. Copper­containing device
B. Levonorgestrel-releasing device.

06/27/2021 Kindu Y. 366

 Cu T380A
Also called ParaGard
Widely available
Used for 10 yrs
Very effective, 0.8 pregnancy/100 women
year
Coated with Cu bracelets = 33+33+314mm²
Polyethylene with barium sulfate for X-
ray

06/27/2021 Kindu Y. 367

 Mechanism of Action
Change in cervical mucus that inhibit sperm transport

Chronic inflammatory changes of the endometrium

and f/tubes

 Have spermicidal effects and inhibit fertilization and

implantation

Thinning and glandular atrophy of the endometrium

which inhibits implantation

06/27/2021 Kindu Y. 368

 Advantages Disadvantages
• Highly effective and very
• Side effects, including
safe
cramping and increased or
• Does not interfere with prolonged bleeding
intercourse
• Rare complications include
• Easy to use
perforation & PID
• Long-acting
• Method failure can lead to
• Easily reversible ectopic pregnancy
• Quick return to fertility
• Insertion and removal
• No systemic effects require trained provider
• No STI/HIV protection

06/27/2021 Kindu Y. 369

 Indications/eligible
Healthy reproductive tract –no infection, cancer, or anomaly
Mutually faithful sexual relationship
Completed child bearing
Wants a long term reversible method
Who has precautions for other methods
Breast feeding women
Immediately postpartum (with in 48hrs delivery)
N.B. An IUD may be provided to young, nulliparous
women after thorough consideration

06/27/2021 Kindu Y. 370

 Contraindications

Pregnancy or suspicions of pregnancy

Uterine abnormalities –myoma, didelphic uterus
Acute PID or Hx of PID in the past 3 months
Endometritis/septic abortion
Pelvic malignancies
Undiagnosed AUB
Untreated acute cervicitis or vaginitis
Wilson’s disease(hepatolenticular degeneration)
Immuno-compromised –Leukemia, AIDS, IV drug users

06/27/2021 Kindu Y. 371

 Contraindications To IUCD use

06/27/2021 Kindu Y. 372

 Contraindications To IUCD use

06/27/2021 Kindu Y. 373

 Timing for IUCD insertion

1.Anytime of menstrual cycle, after ruling out pregnancy

2. Postpartum

- Post placental IUCD:- within 10min of placental

delivery, during C/S

- Within 48hrs of delivery

- As early as 4wks postpartum

3. Immediately after safe abortion

06/27/2021 Kindu Y. 374

 Expulsion rates for interval and postpartum
insertions
Timing of insertion Expulsion rate
Interval (more than 4wks after Low(3% for skilled inserters )
delivery)
Immediate postpartum (within Slightly higher (up to 9.5%)
10 minutes)

Early postpartum (b/n Moderately higher(up to 37%)

10minutes and 48hrs)

Data on expulsion rates for late postpartum insertions (48 hrs to 4weeks )
are limited .but not recommended to IUCD insertion in this period due to
increased risk of uterine perforation .

06/27/2021 Kindu Y. 375

 Timing for IUCD removal
• Anytime the client requests

• Evidence of IUD perforation

• Pregnancy occurs

• Partial expulsion

• PID, AUB with anemia, severe pain

• Client at risk for STIs

• IUD has been used for effective period

• Woman has reached menopause

06/27/2021 Kindu Y. 376

 Follow-up schedule (after insertion)
1. There should be one follow-up visit approximately 3-6wks after
insertion

2. warning signs clients should report

• Late period
• Prolonged or excessive abnormal spotting or
bleeding
• Abdominal pain or pain during intercourse
• Abnormal vaginal discharge, pelvic pain , esp.
with fever
• String missing or string seems shorter or longer
3. Client could check for strings: with clean fingers & after each menses

06/27/2021 Kindu Y. 377

 Side Effects and Complications
o Cramping
o Irregular or heavy bleeding
o Syncope due to vaso-vagal episode during insertion
o Missing strings
o Amenorrhea
o Expulsion
o Pelvic infection
o Suspected uterine perforation
o Ectopic pregnancy if failed

06/27/2021 Kindu Y. 378

 Cont…
Cramping
Is common in the 1st 24-48hrs
If there is mild cramping give NSAID
severe cramping & no cause found, remove IUD
Pregnancy occurred
Rule out ectopic pregnancy
If intrauterine:- miscarriage & infection are quite likely
- 1st trimester pregnancy  remove the IUD if strings
are visible
- In 2nd trimester pregnancy or the strings are not visible,
leave the IUD in situ

06/27/2021 Kindu Y. 379

 Cont…
 Missing strings
 Perform speculum & bimanual exams
-String may be high up in the vagina or cervix
-Probe cervical canal with sterile cotton swab-stick
 If the string is not found, rule out pregnancy
 If there is no pregnancy, do ultrasound or abdominal X-ray to rule
out perforation
 IUD located intrauterine remove it with forceps
 If perforation- laparatomy for Cu IUD, but inert IUD may be left in
situ
 Developed PID
 Remove the IUD and treat for PID

06/27/2021 Kindu Y. 380

 Sterilization

1. Male (vasectomy)

2. Female (tubal-ligation)

06/27/2021 Kindu Y. 381

 Sterilization

 A surgical method where by the reproductive function of an

individual male or female is purposefully & permanently
destroyed

 Vasectomy in male and tubal occlusion in female

 Couple need to be adequately informed before any permanent

procedure

 Inform on individual procedure in terms of benefit, risks, side

effects, failure rate & reversibility

06/27/2021 Kindu Y. 382

 Vasectomy
Segment of vas deferens of both sides are resected and
cut ends are ligated

Advantages:

1. Simple

2. Out patient procedure

3. Few immediate & late complications

4. Failure rate is low (0.15%)

5. Minimal expenditures

06/27/2021 Kindu Y. 383

 Vasectomy…
Drawbacks:
1. Additional contraceptive needed for the first
2-3 months
2. Frigidity/impotence, most often psychological

Candidates:
1. Sexually active, psychological prepared &
completed fertility
2. No eczema or scabies around scrotal region
3. Correct hernia &/or hydrocele before
06/27/2021 vasectomy Kindu Y. 384
 complications
1. Immediate:

 Wound sepsis

 Scrotal hematoma

2.Late:

 Frigidity/impotence

 Sperm granuloma

 Increase in sperm agglutinin in secretions

 Spontaneous recanalization

06/27/2021 Kindu Y. 385

 Female sterilization
• Occlusion of both fallopian tubes in some form

• Most popular method of terminal contraception world wide

• Indications:

1. Family planning purposes

2. Socioeconomic after having the desired number of children

3. Medico-surgical indications (therapeutic)

06/27/2021 Kindu Y. 386

 Female Sterilization: Prevalence

 Most widely used modern method in world, in “less-

developed” regions, and industrial countries, including U.S.

 Worldwide, over 210 million couples use FS (Female

Sterilization)

 FS 12% of modern contraceptive use overall in East Africa;

more than 5% of modern use in West Africa

  

06/27/2021 Kindu Y. 387

 Female sterilization
 Time of operation: puerperium, interval or concurrent with medical
termination

 Ligation could be abdominal, vaginal or laparoscopic

 Different surgical types: e.g. Pomeroy’s technique

06/27/2021 Kindu Y. 388

Myths/misconception
• Does not make women weak

• Does not cause chronic back or abdominal pain

• Does not involve removal of a woman’s uterus

• Does not cause hormonal imbalances

• Does not cause heavier bleeding or irregular bleeding or

otherwise change women’s menstrual cycles

• Does not cause any changes in weight, appetite, or appearance

• Does not change women’s sexual behaviour or sex drive

06/27/2021 Kindu Y. 389

 Tubal ligation-complications…
• Immediate: related to anesthesia & the procedure it self

• Remote:

1. General: occasional obesity & psychological upset

2. Gynecological: congestive syndrome, hypo menorrhea & pelvic pain

 Pelvic pain, menorrhagia along with cystic ovaries constitute

“Post Ligation Syndrome”

 Alteration in libido

 Overall failure rate is 0.7%

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 POSTPARTUM AND POSTABORTION
Family Planning

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Objectives

At the end of this session students will be able to:

 Describe options for post abortion and post partum FP

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Unmet need for PP FP
• Only 3-8% of post partum woman want pregnancy with in 2 years

• Only 40% of post partum woman use FP

• After a live birth, the recommended interval before attempting the

next pregnancy is at least 24 months.

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PP FP counselling

• Timing of counseling could be at any of the following

visits:
• Preconceptional

• During antenatal care

• During the latent phase of labor

• Early in the postparum period

• During late postpartum period

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 Breast-feeding- Contraception
• Breast-feeding (Lactational amenorrhea method/ LAM)can only be considered
as a method of contraception if

• The women is amenorrheic

• Wtihin the first 6 months postpartum and

• Exclusively breast-feeding

• Even in women who are breast-feeding properly

• 12% will ovulate within the first 6 months and

• 2% will get pregnant

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 Unsafe Abortion Contraception

• Globally, approximately 500,000 maternal deaths each year

• Nearly 70,000 are from unsafe abortion

• A way to end unsafe abortion is through contraception

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Post-abortion FP

• Timing of counseling
• When the woman feels well enough
• Before or after treatment for abortion

• Safe methods to prevent pregnancy are available

• Most contraceptive methods can be used
immediately following abortion
• Inform the client that she could become pregnant
again within 10 days if not using contraception

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 Cont…
• Provide or inform how she could obtain
contraceptive services
• After abortion, the recommended minimum
interval to next pregnancy is at least six months
• In order to reduce risks of adverse maternal and perinatal
outcomes

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 Post abortion FP Methods

• Uncomplicated abortion:
• Uterine Size up to 12 Wks: All methods can be
used
• Uterine Size Greater > 12 Wks
• Most methods can be used immediately, IUCD can
also generally be used (Category 2)

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Take home message
 A woman could become pregnant again
within 10 days following abortion
 Safe methods to prevent pregnancy are
available after abortion & delivery
 For PP FP counseling should preferably
be during ANC

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• Abortion with Complications:
• Infection or genital trauma
• Delay female sterilization and IUD insertion

• Severe bleeding:
• Sterilization should be delayed

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 THANK YOU!

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