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Family Planning (2)

Family Planning (2). 부산백병원 산부인과 조인호. Health Benefits of Oral Contraceptives. Fertility after OC Use OC stop 후 수개월이 지나야 ovulatory cycle 이 되돌아 옴 . 6 개월이 지나도 돌아오지 않으면 pprolactin-producing pituitary tumors 에 대한 evaluation 이 필요 . Sexuality Menstual cycle 에서 볼 때 , ovulation time 에 가장 증가함 .

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Family Planning (2)

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  1. Family Planning (2) 부산백병원 산부인과 조인호

  2. Health Benefits of Oral Contraceptives

  3. Fertility after OC Use • OC stop후 수개월이 지나야 ovulatory cycle이 되돌아 옴. • 6개월이 지나도 돌아오지 않으면 pprolactin-producing pituitary tumors에 대한 evaluation이 필요. • Sexuality • Menstual cycle에서 볼 때, ovulation time에 가장 증가함. • OC복용과 Sexuality의 상관관계는 없음. • Teratogenicity • OC복용과 상관관계 없음.

  4. Interaction of Oral Contraceptives with Other Drugs • OC의 effectiveness를 감소시키는 Drugs • Phenytoin, phenobarbital rifampin • Antifungal agents • Ampicillin, tetracycline • OC의 effectiveness를 증가시키는 Drugs • Vit C, Acetaminophen • Benzodiazepine : OC로 인해 half life증가

  5. Choice of Oral Contraceptives • 1st choice : Low-estrogen OC (20-35ug of EE) or very low-estrogen OC (20ug EE) • Side effect (Common) • Breakthrough bleeding and spotting • Tx : • multiphasic -> monophasic (same estrogen level) • Estrogen 용량 증가 -20ug of EE (daily for 7days)

  6. Side effect • Nausea, breast tenderness, mood changes and weight gain • Management • Lowest-dose highly effective formulation-only 20ug of EE • Breast tenderness - more progestin activity ( 20-30ug EE + levonorgestrel) • Nasea – 20ug EE

  7. Injectable Hormonal Contraceptives • Depomedroxyprgesterone acetate (DMPA) • Suspension of microcrystals of a synthetic progestin • A single 150mg IM dose – 14wks동안 ovulation supression • 3개월마다 한 번씩 –highly effective • 작용: Total amenorrhea를 일으킴 • Disruption후 1년내 50%, 2년내 90%에서 fertility회복함.

  8. DMPA의 Safety • Lower bone density유발 : • 이유: reflecting reduced estrogen level • But, not been associated with increased fractures. • Bone density의 Rapid increase를 block • Adolescents에 less disirable • Lipid변화 • Total Cholesterol, Triglycerides 감소 • HDL 약간 감소, LDL 약간 증가 혹은 변화없음. • But, not associated with MI • Hemorrhage, teratogenesis유발시키지 않음. • Mood change를 일으키지 않음

  9. DMPA의 Benefits • 감소시키는 것들 • Anemia, PID, ectopic pregnancy, endometrial ca. • 연관성이 없는 것들 • Cervical ca. , ovarian ca. • 증가시키는 것 • Breast ca. • 최근에 나온 DMPA제제 • DMPA 25mg + 5mg long acting estrogen, estradiol cypionate -한달에 한번씩

  10. Subdermal Implants • Levonorgestrel implant (Norplant) • 첫 6-12개월동안 80mg/d release • 이후 점점 감소하여 35mg/d로 감소 • 5년간 plasma level을 25ng/mL로 유지 (20ng/ml이상인 경우 효력이 있음) • 기전 : • LH surge block, • cervix의 mucus를 scant, thick하게 만들어 sperm의 penetration방해 • 단점 : 체중이 70kg이상일때 efficacy가 떨어짐.

  11. 3-koto-desogestrel (Implanon) • Norplant보다 effective • 3년간 지속

  12. Subdermal Implants • Bleeding Patterns • Implant는 Endometrial atropy유발시킴. • Complete amenorrhea에 이르기 까지 daily spotting에서 regular monthly bleeding까지 다양함. • Low-dose oral estrogen, low-dose oral levonorgestre or ibuprofen • Lactation과 무관함. • Implant제거 후 즉시 fertility회복함

  13. Metabolic effect • T-Chol, TG : 감소 • HDL : 변화 없거나 약간 감소 • Atherosclerosis 촉진 • Bone density변화 없음 • Side effect • Irregular bleeding, headache, acne, weigh gain or loss, mastalgia, mood change, depression, hyperpigmentation over the implnats, hirsutism, galactorrhea, symptomatic functional cysts

  14. Emergency Contraception • Estrogen • Hige-dose estrogen : coitus후 72시간 이내 • 작용기전 : altered tubal motility, interference with corpus luteum function, alteration of the endometrium • 용법: 5mg of EE daily for 5days

  15. Estrogen and Progestin in Combination • EE 0.2mg + levonorgestrel 2mg (Ovral 2T복용후 12시간내 다시 2T) • Pregnancy rate : 1.2-1.8% • Side effect : Nausea, vomitting

  16. Levonorgestrel Alone • 처음 0.75mg복용 후 12시간후 0.75mg 다시 복용

  17. LNG : levonorgestrel 0.75mg X 2 Yuzpe : ethinyl estradiol 0.100mg + levonorgestrel 0.50mg X 2, 12hrs

  18. Copper Intrauterine Device • 방법 : Coitus후 72hrs내 삽입 • Coitus후 7일 이내 삽입하였을 때 임신되었는다는 보고는 없음 • Danazol (weak androgen) • Pregnancy rate : 2% • Mifepristone (RU486) • 600mg 12hrs이내에 반복 복용

  19. Sterilization • Surgical sterilization is the most common method of fertility control used by couples in the US. • Tubal Sterilization at the time of laparotomy • Postpartum minilaparotomy soon after vaginal divery • Interval minilaparotomy • Laparoscopy

  20. Surgical Technique • Pomeroy or modified Pomeroy technique

  21. Laparoscopy • Trocar insert into the abdominal cavity through lower margin of umbilicus and suprapubic region • General A. but local anesthesia with conscious sedation is needed. • Overnight hospitalization is rarely needed.

  22. Risks of Tubal Sterilization • General anesthesia • Previous pelvic or abdominal surgery • Hx of PID • Obesity • DM • Motality • 9-10 deaths per 100,000 sterilization in US (1979-1980)

  23. Benefits of Tubal Sterilization • Reduced risk for ovarian cancer (persists for as long as 20 years after surgery) • Sterilization failure • 1달 이내 : 대부분이 임신 후 sterilization을 시행한 경우 • 따라서 수술 전날까지도 routine으로 pregnancy test시행할 것

  24. Reversal of Sterilization • Success rate : Mechanical occlusion is better than electrocoagulation • 75%

  25. Vasectomy • Excision of a portion of the vas deferens. • Local anesthesia • Office setting • Dose not decrease sexual performance • Complication • Scrotal hematomas, wound infection, epididymitis

  26. Abortion

  27. Safety Issues • Risk for death from legal abortion • 0.7 per 100,000 (1996, US) • Total maternal mortality : 7-8 /100,000 live births • 16wks이후부터는 risk for death가 이전보다 10배 상승 • 1st trimester abortion – vacuum curettage • Mid trimester : variable methods • General Anesthesia : • Perforation of the uterus, visceral injury, hemorrhage, hysterectomy and death의 위험성이 증가됨

  28. Techniques for Abortion • 5-7wks ; vacuum curettage • 5-6mm flexible plastic cannula and a modified 50mL plastic syringe as vacuum source • After 7wks : larger rigid plastic cannulas (8-12mm in diameter) • General anesthesia is unnecessary • Local anesthesia, IV sedatives and analgesics

  29. Medical Means for Abortion • Mifepristone (RU486) • Progesteron antagonist • Early pregnancy에서 abortion유도 • Misoprostol, prostaglandin과 병합하면 효과높음 • 200mg mifepristone orally +800ug of vaginal misoprostol => 98% complete abortion • 처음 mifepristone투약 후 1-3일 지나도 효과 없으면 다시 병원으로 와서 misoprostol투약, 이경우 절반이상에서 4-5시간안에 expel됨

  30. Methotrexate (MTX) • Widely used to treat ectopic pregnancy • MTX ,50mg/M2 IM + misoprostol 800ug PV • 92% success rate (35days) • MTX+mifeprisone은 MTX + misoprostol과 비교하여 볼때 efficacy는 동일하나 보다 비싸다. • 50mg IM과 50mg oral투여는 효과가 동일.

  31. Second-trimester Abortion • D & E • Labor- induced Methods • Hypertonic solution • Prostaglandin • Oxytocin

  32. Hypertonic solutdion • Amnioinfusion of hypertonic saline • Oldest method • Comlication • Serious Maternal DIC

  33. Prostaglandins • E & F series of Prostaglandins can cause Uterine conraction at any stage of gestation • Prostaglandin E2 and F2α are highly effective • Side effect • Vomiting, diarrhea • Vaginal minopristol(200ug every 2hrs) = PG E2 (20mg every 3hrs)

  34. Misoprostol 200ug / 400ug / 600ug /q 12hr -> abortion rate 70.6% / 82% / 96% (within 48hrs) but, side effect는 용량과 비례 • 임신 후반기에 고용량은 uterine rupture의 위험성이 있으므로 조심할 것 • Ideal dose : misoprostol 400ug /q 6hrs • Body temperature의 상승은 용량과 비례 • Retained placenta : PG abortion에서 흔함 • Instrumental extraction이 half case에서 필요

  35. Oxytocin • Very high dose에서 PG E2와 동일한 효과를 냄 (17-24wks of pregnancy) • 50U in 5% D/W for 3hrs

  36. Complicaton • Incomplete abortion • Retained placenta • 24-36hr까지 expel되지 않으면 D&E가 필요함 • Hemorrhage • Infection

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