Contraception in Medically Complex Patients

Introduction

The main goal of contraceptive use in medically ill patients is to decrease the chances of unplanned pregnancies. In addition, adults with obesity, migraines, cardiac conditions, diabetes mellitus, hypertension, hyperlipidemia, or seizures require a highly effective contraceptive method to avoid pregnancies.

Why Is Contraception Required in Medically Complex Patients?

Women with medical conditions can face many unexpected and unplanned pregnancy risks. However, every woman faces a risk of medical conditions like gestational diabetes and hypertension during pregnancy. In addition, women with complex medical conditions can face greater chances of preterm labor, delivery with low birth weights, fewer gestational periods, pre-eclampsia, and birth defects with unplanned pregnancies. So, the use of contraception is essential in medically complex patients. If these patients are planning the pregnancy, it should be planned under a complete doctor consultancy.

How Are Contraceptives Categorized for Medically Complex Patients?

Contraceptive categorization is done to decrease unnecessary barriers to contraceptive access. The WHO (World Health Organization) and USMEC (United States Medical Eligibility Criteria for Contraceptive Use) have presented four categories for contraceptives in medically complex patients.

• Category 1: It is assigned with no restrictions for using contraceptives in associated conditions.

• Category 2: It has the advantages of the contraceptive method used greater than proven risks.

• Category 3: The risks of using contraceptives have been proven more than the advantages. This category is usually not recommended unless no other methods are available.

• Category 4: It is assigned when contraceptive use has a risk in usage and provides unacceptable health risks.

What Are the Medical Conditions That Require Cautious Use of Contraceptives?

• Venous Thromboembolism: When blood clots are formed in the veins, that condition is called a venous embolism. The patient is contraindicated from using CHC (combined hormonal contraception), as estrogens can increase the risk of thromboembolism in women. CHC includes pills, patches, or rings; all are contraindicated for acute deep vein thrombosis and pulmonary embolism. All these come under category 4 of CDC medical eligibility criteria. All patients with a higher risk of recurrence with deep vein thrombosis and pulmonary embolism come under category 4. Those with a lower recurrence rate come under category 3; for the patient with a non-recurrence risk factor, the use of CHC is low in them, and progesterone-only can be used as category 2; and category 1 for copper intrauterine devices.

• Thrombophilia: When the blood gets clotted quickly, the condition is called thrombophilia. The clot is formed by the proteins present in the blood called the thrombins and fibrins. The deficiencies in anticoagulants can cause an increase in the levels of the proteins and thus increases thrombosis. Patients with inherited deficiencies are contraindicated for CHC (combined hormonal contraceptives) as they come under category 4. However, using progestin-only contraceptives is more beneficial as it is category 2. Copper intrauterine devices can come under category one as they are used without restriction.

• Obesity: Obese patients can have a higher risk for venous thromboembolism than in women with ideal weight. Although all contraceptives are used in obese patients, the Progestin-only method, Medroxyprogesterone (DMPA), Norplant, and Levonorgestrel intrauterine device (LNG-IUD) provide better results in obese patients as they contribute less to patient weight gain.

• Bariatric Surgery: It is the surgery performed to enhance fertility for weight loss of obese patients. This patient needs to use contraceptives to avoid pregnancy for two years after the procedure. The USMEC (United States Medical Eligibility Criteria For Contraceptive Use) does not recommend oral contraceptives for these patients. Non-oral contraceptives are one option used in these cases. Some non-oral contraceptives are Etonogestrel releasing subdermal implants and LNG-IUD contraceptives, which are indicated after bariatric surgery.

• Migraine Headaches: Migraine is a severe type of headache. The contraceptive used in migraine patients without aura is usually combined hormonal contraceptives (CHC) or patients with no other conditions or family history related to cardiovascular diseases; Progestin-only is an available method for these patients.

• Cardiac Conditions: Cardiac conditions include ischaemic heart diseases, valvular heart disease, and cardiomyopathy. Progestin-only, combined hormonal contraceptives (CHC), Depo-Provera, intrauterine devices, and Estrogen-based contraception are indicated contraceptives in cardiac patients.

• Hypertension: When the patient's blood pressure rises above 120/90 mm of Hg, the condition is hypertension. The contraceptives used in hypertension are CHC, under category 4; DMPA, under category 3; and non-hormonal contraception.

• Diabetes Mellitus: When the blood glucose levels are elevated, diabetes occurs. CHC, progestogen oral hormonal contraception, long-acting reversible contraception, and barrier methods like condoms are used in diabetes-controlling patients.

• Hyperlipidemia: The condition includes changes in high-density lipoproteins, triglycerides, and low-density lipoproteins. The use of DMPA is considered better for contraception.

• Systemic Lupus Erythematosus (SLE): It is an inflammatory disease caused by immune system attacks. Patients with lupus should take Progestin-only and Estrogen and progestin or barrier methods to control pregnancy as it can cause severe birth defects in children.

• Sickle Cell Anemia: It is a blood disease associated with the abnormal shape of RBCs. The use of progestin contraceptive or Depo is indicated in these cases.

• Cystic Fibrosis: Increasing blood sugar, blood clots, estrogen-containing products, risk of vaginal infections, and gallstones are common symptoms of cystic fibrosis. Patients with cystic fibrosis can have sterilization methods like vasectomy, copper intrauterine devices, hormonal methods like Depo, and barrier methods that can be used to control pregnancy.

• Inflammatory Bowel Disease: The use of oral contraceptives can cause inflammatory bowel diseases. The Progestogen-only method is useful in patients with inflammatory bowel disease.

• Seizures: The use of oral contraceptives can also increase the chances of seizures in patients. Progesterone-only, intrauterine devices, vaginal rings, implants, and contraceptive patches are effective methods of contraception for these patients.

Conclusion

Patients who are medically ill are recommended to have contraceptives, to avoid unplanned pregnancies, as birth defects or other issues like preterm delivery can occur in these cases. The medically ill patients deal with issues like seizures, cardiac conditions, hyperlipidemia, bariatric surgery, hypertension, diabetes, obesity, sickle cell anemia, and inflammatory bowel diseases. All these patients dealing with such diseases should give serious attention to conceiving a child because it can be very dangerous to have an unplanned pregnancy. So, they all need to initially contact their gynecologist to conceive or plan pregnancy.