Long Acting Reversible Contraceptives

Long Acting Reversible Contraceptives

LONG ACTING REVERSIBLE CONTRACEPTIVES ADVANCED: Troubleshooting in difficult insertions and removals Objectives Anticipate difficulties with LARC insertion and removals

List instruments and techniques needed to address these difficulties with step by step strategies Describe non-coercive counseling approach when a patient requests a premature removal Contraceptive users in the US

61 million US women in childbearing years ~43 million of them (70%) are at risk of unintended pregnancy 62% of women of reproductive age currently using some form of contraception

Couples who dont use contraception have ~85% chance of experiencing pregnancy over the course of a year Nearly half (45%) of pregnancies in the US are unintended 27.00%

55.00% 18.00% Unintended pregnancy by consistency of contraception use

5.00% 41.00% 54.00% One year failure rates Effectiveness

Contraceptive Typical-use pregnancy rate Perfect-use pregnancy rate

Ineffective Chance 85% 85%

Less effective Condoms 14% 3%

More effective Pill/patch/Ring 8% 1-3%

Highly effective IUDs 0.8 2% 0.8 2%

Injectable 0.1 0.3% 0.1 0.3% Implant

0.1 0.3% 0.1 0.3% Sterilization (male and female)

0.1 0.3% 0.1 0.3% Contraceptive Methods in the U.S. 25.00% 20.00% % of women

at risk of unintended pregnancy* 15.00% 10.00% 5.00% 0.00% Increase in LARC use

THE MEC US Medical Eligibility Criteria (MEC) CDC recommendations for specific contraceptive methods with certain medical conditions MEC Categories of Safety

Theres an APP for that: - Can be downloaded on iOS and Android operating systems (https://www.cdc.gov/mobile/mobileapp.html) Another helpful APP Contraceptive Point-of-Care App Non-coercive Counseling

10 minute counseling video: https://www.youtube.com/watch?v=OP9klE0JLLU Easy Set Up Challenges with IUD insertions Discomfort/difficulty with speculum placement

Visualizing the cervix Extreme uterine position/uterine distortion Prior c-sections Tight cervical os Vasovagal reaction Perforation Positions of the Uterus

Tips Use as short a speculum as possible Give lidocaine 2-3 cc prior to tenaculum placement Put traction on the tenaculum to straighten out the uterus Very gently advance the sound, letting it follow the

smooth surface of the canal Cannot find cervix Relaxation techniques Position patient move further down on the exam table,

with their hips off the edge Remove redundant labial tissue from sides of speculum Speculum handle close to perineum Lateral wall traction (glove, condom, instrument) Switch speculum size (length and width)

McRoberts maneuver Post C-section uterus Position of cervix can be very challenging as lower uterine segment often scarred to anterior abdominal wall Uterus often seems initially anteverted and then fundus

curves downwards midline to almost retroverted position Sound vs Sound with dilation Graduated os finders More tips Have smelling salts available (for vasovagal reactions)

If perforation is suspected suspend procedure perform ultrasound Monitor vitals x 1 hour Re-try insertion in 2 weeks with ultrasound guidance and more experienced provider Use caution with:

Recently post partum and breastfeeding Uterus is softer, higher risk of perforation Prior c-section Fibroids Challenges: Removal Malpositioned IUD Missing Strings

Embedded IUD Ultrasound To confirm if IUD in place if patient returns with concerns The Low-down on Low-down IUDs: Malposition and IUD Failure IUDs in the Cervix:

- Copper IUD - Odds ratio for pregnancy with intracervical insertion 13.93 (95%CI 4.13 48.96) - Absolute risk increase of 1-2% - LNG IUD - Intracervical versus fundal placement found no difference in

failure between groups Malposition stats and risk factors 10% of IUD are malpositioned Risk factors: Adenomyosis (OR 3.04 (1.08-8.52)) Related to change in contractility of uterus?

NOT associated with post-abortion or 6-9 week postpartum insertion Protective factors: Prior vaginal delivery (OR 0.53 (0.32 0.87)) Private Insurance (OR 0.38 (0.24 0.59))

IUDs move IUDs move up/down uterus after insertion Most commonly, IUDs shift towards fundus after insertion Particularly true in women with lower parity Most malpositioned IUDs will move into proper position within 3 months without any intervention Watchful waiting is a reasonable option

Removal with missing strings Cytobrush Ultrasound to confirm in uterus Thread retriever IUD hook Alligator forceps MVA aspirator with #5 or # 6 cannula

Embedded IUD May only become apparent when removal efforts unsuccessful, feels stuck or strings break off Ultrasound confirmation is the next step Usually needs to be removed hysteroscopically

CONTRACEPTIVE IMPLANT Implant Insertion Proper positioning Proper placement Lidocaine with epi Anticipatory guidance re: bruising

Insensitivity to Lidocaine Removal: Pop Out Technique http://www.screenr.com/MS7N Removal challenges Broken device

Deep insertion If distal end more palpable, can remove from that end. US guidance helpful. Implant and shadow Removal of Deep Implant

Removal of Deep Implant Removal of Deep Implant Resources: Videos Pop out Implant removal technique: http://www.screenr.com/MS7N Liletta insertion video (this link doesnt always work, you may have to google Liletta insertion

video https://www.lilettahcp.com/resources/placement ARHP Copper IUD insertion video https://www.youtube.com/watch?v=FuPFbgSm0QQ ARHP Mirena IUS insertion video https://www.youtube.com/watch?v=hlfV8tKgw6E Implant insertion video: https://www.youtube.com/watch?v=1KPiltHQZ9w (I may substitute out something better for this one, if something better is produced in the next few months) LARC training resources at getLARC.org http://getlarc.org/training/

Resources: Patient Ed Patient education on choosing between IUDs: http://www.reproductiveaccess.org/resource/iud-facts/ Patient education on implants: http://www.reproductiveaccess.org/resource/progestin-implant/ Take home information sheet after progestin IUD is placed: http://www.reproductiveaccess.org/resource/progestin-iud-user-guide/

Take home information sheet after copper IUD is placed: http://www.reproductiveaccess.org/resource/copper-iud-user-guide/ Take home information sheet after implant is placed: http://www.reproductiveaccess.org/resource/progestin-implant-user-guide/ Web site for patients, especially teens, on contraception: https://www.bedsider.org/

Resources for Clinicians How to switch methods and prevent gaps in contraceptive coverage: http://www.reproductiveaccess.org/wp-content/uploads/2014/12/switching_bc.pdf CDC US Medical Eligibility Criteria long version: https://www.cdc.gov/reproductivehealth/contraception/usmec.htm Quick start algorithm:

http://www.reproductiveaccess.org/wp-content/uploads/2014/12/QuickstartAlgorithm.pd f Medical eligibility by the CDC for LARC and other methods: https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-el igibility-criteria_508tagged.pdf

Recently Viewed Presentations

  • Christ-Centered Marriage

    Christ-Centered Marriage

    Christ-Centered Marriage. Putting Christ in the center of our marriage is the key to being successful. Notice what God in the home will do for someone (II Sam. 6:6-12) While the ark rested in the home of Obed-Edom, the Lord...
  •  What is a good length of string?  Depends

    What is a good length of string? Depends

    Examples Action analysis (GOMS modeling) counting keystrokes and mental operations Cognitive walkthroughs Create a Mock-Up or Prototype Need to begin to show the users something Even low fidelity prototypes reveal problems and misunderstandings. Wizard of OZ emulation can be effective.
  • What's wrong with manson - KCCBA

    What's wrong with manson - KCCBA

    NEW YORK'S NEW IDENTIFICATION LAW. Karen A. Newirth. [email protected] 212-364-5349. How certain were you at the time your identification that you identified the real gunman? How good was the view you had of the gunman? How closely were you paying...
  • Vocabulary Words World Literature Week 4 Virulent  Doctors

    Vocabulary Words World Literature Week 4 Virulent Doctors

    Vocabulary Words World Literature Week 4 Virulent Doctors are advising the public to get inoculated against a virulent strain of the bird flu. Virulent Definition: adj.—extremely poisonous, infectious, or damaging to organisms Synonym: infectious, contagious, lethal Antonym: weak Deft The...
  • Cohesion - Weber State University

    Cohesion - Weber State University

    Tahoma MS Pゴシック Arial Gill Sans MT Wingdings 2 Verdana Times New Roman Solstice 1_Solstice 2_Solstice 3_Solstice 4_Solstice 5_Solstice 6_Solstice Cohesion Cohesion Form of Paragraphs Form of Paragraphs Deductive Paragraph Advantages of the Deductive Structure Advantages of the Deductive Structure...
  • Paradigmes et enjeux des arts du XXe siècle 1900-1950

    Paradigmes et enjeux des arts du XXe siècle 1900-1950

    Kandinsky, Klee, Moholy-Nagy. L'importance des liens entre les arts, l'artisanat et l'industrie ; entre l'architecture, le design et l'art. 1 sem Slide 22 Slide 23 Slide 24 Slide 25 Slide 26 Slide 27 Slide 28 Slide 29 Slide 30 Slide...
  • Hawthorn Amateur Football Club - Hawthorn Spartans

    Hawthorn Amateur Football Club - Hawthorn Spartans

    Our Mission "Hawthorn Amateur Football Club prides itself on the management of a successful sporting club, providing a facility in the local Hawthorn Community to further develop sport amongst junior and adult sports minded people, whilst also providing an environment...
  • Project Octopus: Network Topology Discovery

    Project Octopus: Network Topology Discovery

    Rosen Sharma MONET : Cornell Department of Computer Science Goals To discover the topology of an existing network given little or no information. This would allow SurReal -- a network simulation system -- to simulate the network and gather valuable...