NR 508 Week 2 Case Study Discussion
Claudia is a 26-year-old mother of two G2P2, she recently delivered her last child 9 months ago, and has been using
... [Show More] condoms for birth control for the last 7 months. Today she is requesting a more reliable birth control, she is not sure of her current pregnancy plans, however, she does not wish to discuss sterilization. No religious contraindications for treatment. Previous methods include condoms, and oral contraceptive pills.
PMH: positive for mild hypertension with first pregnancy, seasonal allergies.
Surgeries: Right inguinal hernia and tonsillectomy.
Family history: Mother HTN and Father colon CA both living
Social History: Denies tobacco use, wine one to two glasses a week, denies recreational drugs, exercises twice a week.
Drug allergies-Sulfa causes a rash.
Current medications-MVI with Fe, Calcium chews, prn Allegra for allergies.
Height 65 inches, weight 137 pounds, BP 110/75, P 70, R 16. PAP collected today, breast exam WNL, urine pregnancy negative.
Physical exam is normal.
What are your treatment goals for Claudia today?
Strategies to prevent unintended pregnancy include assisting women at risk for unintended pregnancy and their partners with choosing appropriate contraceptive methods and helping them use methods correctly and consistently to prevent pregnancy.
• PE: normal; BMI = 22.8; , BP 110/75, P 70, R 16; Breast exam: WNL; Urine pregnancy negative; PAP result: pending
• She does have family history of HTN with her mother and colon cancer with her father; PMH of positive for mild hypertension with first pregnancy, current BP is within normal limit and she does exercise twice weekly
• Social assessment:
o Claudia, although no mention of a spouse, reported that she used condoms as a birth control method in the past showed her stableness and understanding of preventative measures in family planning.
o She is a busy mother two children, one of whom is 9 months old, so I would discuss methods that are low maintenance and safe for her.
o She is also clearly not ready for sterilization, thus ruled out that option.
What are two possible contraceptive methods for Claudia? Please give brief rationale for each.
CDCP’s Categories for classifying hormonal contraceptives and intrauterine devices
1 = A condition for which there is no restriction for the use of the contraceptive method.
2 = A condition for which the advantages of using the method generally outweigh the theoretical or proven risks.
3 = A condition for which the theoretical or proven risks usually outweigh the advantages of using the method.
4 = A condition that represents an unacceptable health risk if the contraceptive method is used.
According to the CDCP’s chart above, Claudia meets categories 1 and 2, thus she is eligible for most methods usages.
Condition Cu-IUD LNG-IUD Implants DMPA POP CHCs
History of high blood pressure during pregnancy (when current blood pressure is measurable and normal) 1 1 1 1 1 2
My recommendations would be:
1. Claudia reported previous use of oral contraception, I would discuss her previous experiences with that particular product, associated side effects and toleration to the medication. While an IUD or implant may make more sense if you don’t want to get pregnant for at least a year or two, the pill is a bit more flexible. If she is agreeable to resuming oral contraceptives, then we would proceed to choosing the best medication that fits her plam at present (DeLeo et al, 2016).
2. Implantable Contraception is the other method which is low maintenance for a mother of 2 young children. She would not have to remember to take her pills daily, nor worrying about a dislodged IUD. Facts about implantable contraception (Curtis et al, 2016):
• The etonogestrel implant, a single rod with 68 mg of etonogestrel, is available in the United States.
• Fewer than 1 woman out of 100 become pregnant in the first year of use of the etonogestrel implant with typical use.
• The implant is long acting, is reversible, and can be used by women of all ages, including adolescents.
• The implant does not protect against STDs; consistent and correct use of male latex condoms reduces the risk for STDs, including HIV.
• The implant can be inserted at any time if it is reasonably certain that the woman is not pregnant
• If the implant is inserted within the first 5 days since menstrual bleeding started, no additional contraceptive protection is needed.
• If the implant is inserted >5 days since menstrual bleeding started, the woman needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days.
Pick one method and list five (5) patient-centered teaching points for the method you chose today.
During contraceptive counseling and before insertion of the implant, information about common side effects, such as unscheduled spotting or light bleeding and amenorrhea, especially during the first year of use, should be discussed
- What is the implant? (Curtis et al, 2016)
• The implant is a type of hormonal birth control. It is a tiny plastic rod, about the size of a matchstick. The implant contains a progesterone-like hormone called etonogestrel (et-oh-no-JES-trel) that prevents pregnancy. The implant is easily inserted under the skin of your arm by a health care provider.
-How effective is the implant? (Curtis et al, 2016)
o The implant is very effective. Less than 1 out of 100 women with the implant will get pregnant each year. The implant is as effective as sterilization, but your ability to become pregnant quickly returns once the implant is removed.
-How does the implant work? (Curtis et al, 2016)
The implant is easily inserted in about one minute under the skin of your upper arm. Once inserted, the implant slowly releases a hormone into your body. This hormone causes several things to happen that prevent pregnancy:
o Your ovaries stop releasing eggs.
o Thick cervical mucus forms and blocks the opening to your uterus.
o The lining of your uterus thins, which keeps a fertilized egg from attaching to your uterus.
o The implant lasts up to 3 years. After that, the hormone supply runs out and it stops working. If you want to keep using this method, you have to get a new implant. Your health care provider can insert a new implant once the old one is removed. Removal takes about three minutes.
-What are the benefits of using the implant? (Curtis et al, 2016).
• You do not have to think about your birth control every day or every time you have sex.
• The implant works for 3 years.
• If you want to stop using the implant, it can easily and quickly be removed at any time.
• The implant is safe to use while breastfeeding.
• The implant can be a good birth control method for women who cannot use estrogen.
-What are the downsides of using the implant? (Curtis et al, 2016).
o The implant does not protect against sexually transmitted infections.
o The implant may cause irregular bleeding. Some women have heavy and/or longer periods. Others have periods that are lighter and occur less often. Some women stop getting their period all together.
-Where can I get more information? (Curtis et al, 2016).
For more information on the contraceptive implant, talk to your health care provider.
Compare the implant to other birth control options using ARHP’s Method Match at www.arhp.org/MethodMatch.
-Emergency contraception: Reduces the risk of pregnancy by at least 75% if initiated within 72 hours after unprotected intercourse. There are no medical contraindications to its use except that it is ineffective if taken during an established pregnancy (De Leo et al, 2016).
What would your contraceptive choice be if Claudia smoked 10-15 cigarettes per day? Explain your answer.
Condition Cu-IUD LNG-IUD Implants DMPA POP CHCs
Smoking
a. Age <35 years 1 1 1 1 1 2
b. Age ≥35 years
i. <15 cigarettes/day 1 1 1 1 1 3
ii. ≥15 cigarettes/day 1 1 1 1 1 4
(Curtis et al., 2016)
According to the CDCP’s recommendations (Curtis et al., 2016) as shown in table above, I would still recommend contraceptive implantation because the benefits and risks remain the same. However, if Claudia should want to change her birth control method, i.e. CHC which risks outweighs the benefits, then additional counseling would be warranted. If she decides to switch back to oral contraception, then a discussion about the type of birth control pills most fitting for her. Oral contraception without estrogen are much less likely to cause these problems. The risk is higher for women who smoke or have a history of high blood pressure, clotting disorders, or unhealthy cholesterol levels. However, the risks of developing these complications are much lower with either type of pill than with pregnancy (De Leo et al, 2016).
References:
Curtis, K.M., Jatlaoui, T.C., Tepper, N.K., Zapata, L.B., Horton, L.G., Jamieson, D.J., Whiteman, M.K., 2016.
Division of Reproductive Health, National Center for Chronic Disease Prevention and Health
Promotion. MMWR Recomm Rep 2016; pp. 1-40.
De Leo, V., Musacchio, M. C., Cappelli, V., Piomboni, P., & Morgante, G. (2016). Hormonal contraceptives:
pharmacology tailored to women's health. Human Reproduction Update, 22(5), 634-646.
doi:10.1093/humupd/dmw016
Response to Peer:
Hi Coreen,
Your post is insightful and informative to me because I, too, chose implantable contraception for Claudia. There are several reasons why I chose this method, but the primary goal is to prevent her from getting unplanned pregnancy. As a busy mother of two young children, she needs a method that is reliable, long term and easy to manage (Reeves, Zhao, Secura & Peipert, 2016).
The contraceptive implant and the IUD are the most effective reversible contraceptive methods available, with failure rates of less than 1% for both perfect and typical use. These methods have low typical-use failure rates because they don’t require user intervention (Reeves, Zhao, Secura & Peipert, 2016).
Advantages of implants include (Reeves, Zhao, Secura & Peipert, 2016) :
• High effectiveness of up to 99 percent within seven days of implant insertion
• Very inexpensive method of long-term contraception, comparable to intrauterine devices
• Safe in the majority of women
• Efficacy for three years without further intervention
• Easily removed in most cases to allow pregnancy to occur naturally
• Independent of user memory or schedule, and of sexual intercourse, as it provides continuous contraception
• Provides anonymity of use and is convenient to adopt
• Safe for use during lactation
• Relieves menorrhagia and dysmenorrhea in many cases
• Amenorrhea in one of every five women on the implant, which is often perceived to be a benefit
• Reduces the risk of pelvic inflammatory disease due to the thick cervical mucus which prevents microbes from ascending from the vagina into the uterus
• Suitable in conditions which preclude the use of combined hormonal contraception
• Quick return of fertility within 21 days of implant removal
• Some women experience improvement in acne following the use of the implant
• Some protection against endometrial cancers
Disadvantages of the contraceptive implant include (Reeves, Zhao, Secura & Peipert, 2016):
• It offers no protection against sexually transmitted infections (STIs)
• Interaction with anticonvulsants, certain antibiotics, or St. John’s wort may occur
• Immediate protection may not be available in all situations, and another mode of effective contraception must then be used for at least seven days following insertion
I feel that the benefits outweighed the risks in Claudia’s situation. Thank you for your post.
Thuha
Reference:
Reeves, M. F., Zhao, Q., Secura, G. M., & Peipert, J. F. (2016). Risk of unintended pregnancy based on intended
compared to actual contraceptive use. American Journal Of Obstetrics & Gynecology, 215(1), 71.e1-
71.e6. doi:10.1016/j.ajog.2016.01.162
Response to Prof:
Please include the specific chosen drug name, drug class, mechanism of action, dose, route, frequency, drug-drug interactions, and most common side effects. Pertinent Pharmacokinetics and Pharmacodynamics specific for our patient, and how that influenced your decision about management and treatment(s) choice. Explain prevention of toxicity and thoroughly educate patient about the intervention(s) you are providing.
Dr. Medina,
The etonogestrel-releasing implant 68mg (Nexplanon) is a single rod which provides high contraceptive effectiveness for 3 years. It’s implanted discreetly under the skin of the inner, upper arm. It’s also reversible and can be removed by health care provider at any time during the 3-year period (Curtis et al, 2016). I am recommending Nexplanon implantable method because it carries less risks then estrogen-progesterone combination. Claudia is under age 35, already has 2 children, and needs a reliable method of contraception. Implantable Nexplanon shows less than 1% of pregnancy after one year of use. It is also easily reversible should Claudia and her partner decide to have more children at any time in the next 3 years.
Mechanism of Action (Curtis et al, 2016):
• The contraceptive effect of NEXPLANON is achieved by suppression of ovulation, increased viscosity of the cervical mucus, and alterations in the endometrium.
Pharmacodynamics (Curtis et al, 2016):
• Exposure-response relationships of NEXPLANON are unknown.
Pharmacokinetics (Curtis et al, 2016):
• Absorption
• After subdermal insertion of the etonogestrel implant, etonogestrel is released into the circulation and is approximately 100% bioavailable.
• Distribution - the apparent volume of distribution averages about 201 L. Etonogestrel is approximately 32% bound to sex hormone binding globulin (SHBG) and 66% bound to albumin in blood.
• Metabolism - in vitro data shows that etonogestrel is metabolized in liver microsomes by the cytochrome P450 3A4 isoenzyme. The biological activity of etonogestrel metabolites is unknown.
• Excretion - the elimination half-life of etonogestrel is approximately 25 hours. Excretion of etonogestrel and its metabolites, either as free steroid or as conjugates, is mainly in urine and to a lesser extent in feces. After removal of the implant, etonogestrel concentrations decreased below sensitivity of the assay by one week.
Most common side effects:
The most common side effect of NEXPLANON is a change in normal menstrual bleeding pattern. In studies, 1 in 10 women stopped using NEXPLANON because of an unfavorable change in their bleeding pattern (De Leo et al, 2016):
• Longer or shorter bleeding during your period
• No bleeding at all during the time of your period
• Spotting between your periods
• Varied amounts of time between your periods
Tell your health care provider right away if (De Leo et al, 2016):
• You think you may be pregnant
• Your menstrual bleeding is heavy and prolonged
Other frequent adverse effects include (De Leo et al, 2016):
• Mood swings
• Weight gain
• Headache
• Acne
• Mood swings, nervousness, or depressed mood
• Vaginitis
• Breast pain
• Viral infections such as sore throats or flu-like symptoms
• Stomach pain
• Painful periods
• Back pain
• Nausea
• Dizziness
• Pain
• Pain at the site of insertion
Drug interactions:
Changes in Contraceptive Effectiveness Associated With Coadministration Of Other Products (Curtis et al, 2016):
Drugs or herbal products that induce enzymes, including CYP3A4, that metabolize progestins may decrease the plasma concentrations of progestins, and may decrease the effectiveness of NEXPLANON. In women on long-term treatment with hepatic enzyme inducing drugs, it is recommended to remove the implant and to advise a contraceptive method that is unaffected by the interacting drug.
Some of these drugs or herbal products that induce enzymes, including CYP3A4, include (Curtis et al, 2016):
• Barbiturates
• Bosentan
• Carbamazepine
• Felbamate
• Griseofulvin
• Oxcarbazepine
• Phenytoin
• Rifampin
• St. John's wort
• Topiramate
• HIV Antiretrovirals
• Increase In Plasma Concentrations Of Etonogestrel Associated With Coadministered Drugs
• CYP3A4 inhibitors such as itraconazole or ketoconazole may increase plasma concentrations of etonogestrel.
• Changes In Plasma Concentrations Of Coadministered Drugs
o Cyclosporine
o lamotrigine
Prevention of Toxicology:
The contraceptive implantable systems consist of synthetic progestogens and polymer capsules or rods. Toxicological studies of implantable contraceptives therefore need to address both the progestogens and the polymers. Full toxicological information on etonogestrel is not available and much of the data are derived from the prodrug, desogestrel. The data from toxicology, genotoxicity, carcinogenicity and fetal development studies of desogestrel demonstrated overall safety of the drug in these tests (De Leo et al, 2016).
Before insertion of NEXPLANON, the healthcare provider should confirm that (De Leo et al, 2016):
The woman is not pregnant nor has any other contraindication for the use of NEXPLANON
The woman has had a medical history and physical examination, including a gynecologic examination, performed.
The woman understands the benefits and risks of NEXPLANON.
The woman has received a copy of the Patient Labeling included in packaging.
The woman has reviewed and completed a consent form to be maintained with the woman's chart.
The woman does not have allergies to the antiseptic and anesthetic to be used during insertion.
Aside from educating the Claudia about medication and drug related side effects and drug-drug interaction, the following information are also important to educate her:
Possible risks of NEXPLANON (Curtis et al, 2016):
• Problems with insertion and removal
• Location and removal of the implant may be difficult or impossible because the implant is not where it should be.
• Implants have been found in the pulmonary artery (a blood vessel in the lung). If the implant cannot be found in the arm, your health care professional may use x-rays or other imaging methods on the chest. If the implant is located in the chest, surgery may be needed.
• Ectopic pregnancy
• Ovarian cysts
• Breast cancer
• Serious blood clots
o The risk of serious blood clots is increased in women who smoke. If you smoke and want to use NEXPLANON, you should quit. .
When should I call my health care provider?
Contact your health care provider right away if you have (Curtis et al, 2016):
• Pain in your lower leg that does not go away
• Severe chest pain or heaviness in your chest
• Sudden shortness of breath, sharp chest pain, or coughing blood
• Symptoms of a severe allergic reaction, such as swollen face, tongue or throat, trouble breathing or swallowing
• Sudden severe headache unlike your usual headaches
• Weakness or numbness in your arm, leg, or trouble speaking
• Sudden partial or complete blindness
• Yellowing of your skin or whites of your eyes, especially with fever, tiredness, loss of appetite, dark-colored urine, or light-colored bowel movements
• Severe pain, swelling, or tenderness in the lower stomach (abdomen)
• Lump in your breast
• Problems sleeping, lack of energy, tiredness, or you feel very sad
• Heavy menstrual bleeding
• Felt that the implant may have broken or bent while in your arm
References:
Curtis, K.M., Jatlaoui, T.C., Tepper, N.K., Zapata, L.B., Horton, L.G., Jamieson, D.J., Whiteman, M.K. (2016).
Division of Reproductive Health, National Center for Chronic Disease Prevention and Health
Promotion. MMWR Recomm Rep 2016; pp. 1-40.
De Leo, V., Musacchio, M. C., Cappelli, V., Piomboni, P., & Morgante, G. (2016). Hormonal contraceptives:
pharmacology tailored to women's health. Human Reproduction Update, 22(5), 634-646.
doi:10.1093/humupd/dmw016 [Show Less]