Family planning and the prevention of unintended pregnancy. Gestosis and their prevention.

1. Family planning and the prevention of unintended pregnancy. Gestosis and their prevention.

2. Family planning is the planning of when to have children, and the use of birth control and other techniques to implement such plans. Other techniques commonly used include sexuality education, prevention and management of sexually transmitted infections, pre-conception counseling and management, and infertility management. Family planning is sometimes used in the wrong way also as a synonym for the use of birth control, though it often includes more. It is most usually applied to a female-male couple who wish to limit the number of children they have and/or to control the timing of pregnancy (also known as spacing children).

3. Purposes Raising a child requires significant amounts of resources: time, social, financial, and environmental. Planning can help assure that resources are available. Waiting until the mother is at least 18 years old before trying to have children improves maternal and child health. Also, if additional children are desired after a child is born, it is healthier for the mother and the child to wait at least 2 years after the previous birth before attempting to conceive (but not more than 5 years). After a miscarriage or abortion, it is healthier to wait at least 6 months.

4. Modern methods Some families use modern medical advances in family planning. For example in surrogacy treatments a woman agrees to become pregnant and deliver a child for another couple or person. In sperm donations, pregnancies are usually achieved using donated sperm by artificial insemination (either by ICI or IUI) and less commonly by in vitro fertilization (IVF), usually known in this context as ART but insemination may also be achieved by a donor having sexual intercourse with a woman for the sole purpose of initiating conception. This method is known as natural insemination, or NI. There is generally a demand for sperm donors who have no genetic problems in their family, 20/20 eyesight, with excellent visual acuity, a college degree, and sometimes a value on a certain height and age.

5. Birth control With assertions of overpopulation, there have been assertions that birth control is the answer. Birth control is techniques used to prevent unwanted pregnancy. There are a range of contraceptive methods, each with unique advantages and disadvantages. Any of the widely recognized methods of birth control is much more effective than no method. Behavioral methods that include intercourse, such as withdrawal and calendar based methods have little up front cost and are readily available, but are less effective in typical use than most other methods. Long-acting reversible contraceptive methods, such as IUD and implant are highly effective and convenient, requiring little user action. When cost of failure is included, IUDs and vasectomy are much less costly than other methods.

6. United States Title X of the Public Health Service Act, is a US government program dedicated to providing family planning services for those in need. But funding for Title X as a percentage of total public funding to family planning client services has steadily declined from 44% of total expenditures in 1980 to 12% in 2006. Medicaid has increased from 20% to 71% in the same time. In 2006, Medicaid contributed $1.3 billion to public family planning.

7. Pregnancy can be a beautiful thing. But it can also be an inconvenient thing, a financially burdensome thing, a physically dangerous thing, an emotionally and politically charged thing, and a scandalous thing. This is why most women prefer to control their fertility: when pregnancy happens to them, they want it to be at its most beautiful.

8. Unintended pregnancies are those in which conception was not intended by the female sexual partner. Unintended pregnancies are the primary cause of induced abortion, resulting in about 42 million induced abortions per year. Unintended pregnancy is also linked to higher rates of maternal and infant deaths. The use of modern contraceptive methods has greatly reduced the incidence of unintended pregnancy, particularly in more developed countries. However the United States has an unusually high rate of unintended pregnancy, especially among the poor.

9. Causes • Not using contraception. • Using contraception inconsistently or incorrectly. • Contraceptive failure (the method was used correctly, but did not work.) Accounts for relatively small fraction of unintended pregnancies when modern highly effective contraceptives are used.

10. Reasons contraceptives might not have been used or been used incorrectly include: • Coercion. Rape or involuntary sex which sometimes happens in the context of domestic violence. Unintended pregnancies are more likely to be associated with abuse than intended pregnancies. This may also include birth control sabotage - manipulation of someone's use of birth control to undermine efforts to prevent pregnancy. • Lack of knowledge about sex and reproduction. Including erroneous beliefs. • Lack of knowledge or experience with the contraceptive, or lack of motivation to use it correctly. • Lack of planning or ambivalence about whether to have a child.

11. Results of unintended pregnancy include: • Prenatal care initiate later, and less adequate. Adversely affects health of woman and of child and less preparation for parenthood. Delay from unintended pregnancy is in addition to that from other risk factors for delay. Unwanted pregnancies have more delay than mistimed. • Unintended pregnancies preclude chance to resolve sexually transmitted diseases (STD) before pregnancy. Untreated STD in pregnant woman can result in premature delivery, infection in newborn or infant death. • Preclude use of genetic testing to help make decisions about whether to become pregnant.

12. Women with an unintended pregnancy are more likely to suffer depression during or after pregnancy. • Poorer maternal mental health • Increased risk of physical violence during pregnancy • Reduced likelihood of breastfeeding, resulting in less healthy children • Lower mother-child relationship quality (see also Maternal bond) • More likely that mother smokes tobacco (about 30% more likely in the US) or drinks during pregnancy. Which results in poorer health outcomes and additional costs for welfare system. (see also Fetal alcohol syndrome, Fetal alcohol spectrum disorder)

13. Children whose births were unintended are: • Greater likelihood of low birth weight, particularly for unwanted pregnancies. In US eliminating all unwanted pregnancies would reduce rate of low birth weight by 7% for blacks, and 4% for whites, helping to decrease the large disparity in rates for whites vs. blacks. May be through increased risk preterm delivery. • Greater infant mortality. If all sexually active couples in the US had routinely used effective contraception in 1980, there would have been 1 million fewer abortions, 340,000 fewer live births that were unintended at conception, 5,000 fewer infant deaths, and the infant mortality rate would have been 10% lower. • likely to be less mentally and physically healthy during childhood, • at higher risk of child abuse and neglect, • less likely to succeed in school, • more likely to live in poverty, • more likely to need public assistance, • more likely to have delinquent and criminal behavior.

14. Prevention Prevention includes comprehensive sexual education, availability of family planning services, including access to a range of effective birth control methods. Most unintended pregnancies result from not using contraception, many more result from using contraceptives inconsistently or incorrectly. Increasing use of long-acting reversible contraceptives (such as IUD and contraceptive implants) decreases the chance of unintended pregnancy by decreasing the chance of incorrect use. Method failure is relatively rare with modern, highly effective contraceptives, and is much more of an issue when such methods are unavailable, unaffordable, or not used

15. Providing contraceptives and family planning services at low or no cost to the user helps prevent unintended pregnancies. Many of those at risk of unintended pregnancy have little income, so even though contraceptives are highly cost-effective, up front cost can be a barrier. Subsidized family planning services improve the health of the population and saves money for governments and health insurers by reducing medical, education and other costs to society.

16. The United States rate of unintended pregnancies is higher than the world average, and much higher than that in other industrialized nations. Almost half (49%) of U.S. pregnancies are unintended, more than 3 million unintended pregnancies per year. Over 92% of abortions are the result of unintended pregnancy, unintended pregnancies result in about 1.3 million abortions/year. The rate of abortions is high in the United States than in other developed countries because of the higher rate of unintended pregnancies in the US. In 2001, 44% of unintended pregnancies resulted in births, and 42% resulted in induced abortion and the rest in miscarriage. It is estimated that more than half of US women have had an unintended pregnancy by age 45.

17. Teens Of the 800,000 teen pregnancies per year, over 80% were unintended in 2001. One-third of teen pregnancies result in abortion. In 2002, about 9% of women at risk for unintended pregnancy were teenagers, but about 20% of the unintended pregnancies in the United States are to teenagers. A somewhat larger proportion of unintended births are reported as mistimed, rather than unwanted, for teens compared to women in general (79% mistimed for teens vs. 69% among all women in 1998).

18. Types of Birth Control • Reversible Methods of Birth Control • Intrauterine Devices (IUDs) • Copper T IUD-An IUD is a small device that is shaped in the form of a “T.” Your doctor places it inside the uterus to prevent pregnancy. It can stay in your uterus for up to 10 years. This IUD is more than 99% effective at preventing pregnancy. • Levonorgestrel intrauterine system (IUS)-The IUS is a small T-shaped device like the IUD. It is placed inside the uterus by a doctor. It releases a small amount of progestin each day to keep you from getting pregnant. The IUS stays in your uterus for up to 5 years. The IUS is more than 99% effective at preventing pregnancy.

19. Hormonal methods • Oral contraceptives - Also called “the pill,” it contains the hormones estrogen and progestin. A pill is taken at the same time each day. If you are older than 35 years and smoke, have a history of blood clots or breast cancer, your doctor may advise you not to take the pill. The pill is 92–99% effective at preventing pregnancy. • Mini pill - Unlike the pill, the mini-pill only has one hormone, progestin, instead of both estrogen and progestin. It is prescribed by a doctor. It is taken at the same time each day. It is a good option for women who can’t take estrogen. They are 92–99% effective at preventing pregnancy. • This method is prescribed by a doctor! It releases hormones progestin and estrogen into the bloodstream. You put on a new patch once a week for three weeks. During the fourth week, you do not wear a patch, so you can have a menstrual period. The patch is 92–99% effective at preventing pregnancy, but it appears to be less effective in women who weigh more than 198 pounds.

20. Hormonal vaginal contraceptive ring. The ring releases the hormones progestin and estrogen. You place the ring inside your vagina. You wear the ring for three weeks, take it out for the week you have your period, and then put in a new ring. It is 92–99% effective at preventing pregnancy. • Injection or "shot". Women get shots of the hormone progestin in the buttocks or arm every three months from their doctor. It is 97–99% effective at preventing pregnancy. • Implant. The implant is a single, thin rod that is inserted under the skin of a women’s upper arm. The rod contains a progestin that is released into the body over 3 years. It is 99 percent effective at preventing pregnancy.

21. Emergency contraception. • Emergency contraception is NOT a regular method of birth control. Emergency contraception can be used after no birth control was used during sex, or if the birth control method failed, such as if a condom broke. • Women can take emergency contraceptive pills up to 5 days after unprotected sex, but the sooner the pills are taken, the better they will work. There are three different types of emergency contraceptive pills available in the United States. Some emergency contraceptive pills are available over the counter for women 17 years of age or older. If younger than 17 years, emergency contraceptive pills are available by prescription. • Another type of emergency contraception is having your doctor insert the Copper T IUD into your uterus within seven days of unprotected sex. This method is 99% effective at preventing pregnancy.

22. Barrier methods • Male condom. Worn by the man, a male condom keeps sperm from getting into a woman’s body. Latex condoms, the most common type, help prevent pregnancy and HIV and other STDs as do the newer synthetic condoms. “Natural” or “lambskin” condoms also help prevent pregnancy, but may not provide protection against STDs, including HIV. Male condoms are 85–98% effective at preventing pregnancy. Condoms can only be used once, and are most effective when used consistently and correctly. You can buy condoms, KY jelly, or water-based lubricants at a drug store. Do not use oil-based lubricants such as massage oils, baby oil, lotions, or petroleum jelly with latex condoms. They will weaken the condom, causing it to tear or break.

23. Female condom. Worn by the woman, the female condom helps keeps sperm from getting into her body. It is packaged with a lubricant and is available at drug stores. It can be inserted up to eight hours before sexual intercourse. Female condoms are 79–95% effective at preventing pregnancy when used consistently and correctly, and may also help prevent STDs. Diaphragm or cervical cap. Each of these barrier methods are placed inside the vagina to cover the cervix to block sperm. The diaphragm is shaped like a shallow cup. The cervical cap is a thimble-shaped cup. Before sexual intercourse, you insert them with spermicide to block or kill sperm. The diaphragm is 84–94% effective at preventing pregnancy. Visit your doctor for a proper fitting because diaphragms and cervical caps come in different sizes.

24. Spermicides • These products work by killing sperm and come in several forms-foam, gel, cream, film, suppository, or tablet. They are placed in the vagina no more than one hour before intercourse. You leave them in place at least six to eight hours after intercourse. You can use a spermicide in addition to a male condom, diaphragm, or cervical cap. Spermicides alone are about 71–82% effective at preventing pregnancy. They can be purchased in drug stores.

25. Fertility awareness and abstinence • Continuous abstinence - This method means not having vaginal intercourse at any time. It is the only 100% effective way to prevent pregnancy. • Natural family planning or fertility awareness - Understanding your monthly fertility pattern can help you plan to get pregnant or avoid getting pregnant. Your fertility pattern is the number of days in the month when you are fertile (able to get pregnant), days when you are infertile, and days when fertility is unlikely, but possible. If you have a regular menstrual cycle, you have about nine or more fertile days each month. If you do not want to get pregnant, you do not have sex on the days you are fertile, or you use a form of birth control on those days. These methods are 75–99% effective at preventing pregnancy.

26. Permanent Methods of Birth Control • Female Sterilization – Tubal ligation or “tying tubes.” - A woman can have her fallopian tubes tied (or closed) so that sperm and eggs cannot meet for fertilization. The procedure can be done in a hospital or in an outpatient surgical center. You can go home the same day of the surgery and resume your normal activities within a few days. This method is effective immediately. • Transcervical Sterilization - A thin tube is used to thread a tiny device into each fallopian tube. It irritates the fallopian tubes and causes scar tissue to grow and permanently plug the tubes. It can take about three months for the scar tissue to grow, so use another form of birth control during this time. Return to your doctor for a test to see if scar tissue has fully blocked your fallopian tubes.

27. Male Sterilization . Vasectomy - this operation is done to keep a man’s sperm from going to his penis, so his ejaculate never has any sperm in it that can fertilize an egg. This operation is simpler than tying a woman’s tubes. The procedure is done at an outpatient surgical center. The man can go home the same day. Recovery time is less than one week. After the operation, a man visits his doctor for tests to count his sperm and to make sure the sperm count has dropped to zero; this takes about 12 weeks. Another form of birth control should be used until the man’s sperm count has dropped to zero

28. Gestosis Gestosis of pregnant women include a number of pathological conditions that occur during pregnancy, complicating its course. There are early gestosis, usually occurring in the first trimester of pregnancy, and late gestosis, developing in the second half of pregnancy.

29. Early gestosis includes: vomiting in pregnancy (mild form), excessive vomiting and ptializm (salivation). Etiological factor of gestosis, according to many authors, is the failure of mechanisms to adapt to emerged pregnancy. Congenital and acquired deficiency of neuroendocrine regulation of adaptive responses (hypoxia, infection, intoxication, malnutrition in the antenatal period, hereditary factors) contribute to gestosis development, as well as presence of extragenital pathology in a woman (on the part of cardiovascular system - hypertension, hypotension, cardiac defects, endocrine disease - diabetes mellitus, hyper-and hypothyroidism, urinary tract disease - pyelonephritis, glomerulonephritis).

30. Early gestosis (vomiting during pregnancy) include vomiting, which is repeated several times during the day, accompanied by nausea, a decrease in appetite, change in taste and olfactory sensations. In accordance with the severity of the disease they distinguish: • light form; • moderate (moderate); • excessive vomiting (severe).

31. Late gestational toxicosis often occurs in the third trimester of pregnancy and is characterized by multiple organ failure. Late gestosis is manifested by three main symptoms - edema, proteinuria, arterial hypertension, at least - more severe symptoms (convulsions, coma, etc.). In modern obstetrics late gestosis is denoted as OPG-gestosis (under the name of three major symptoms). There are many classifications of late gestosis, but in practical obstetrics they distinguish 4 main clinical forms: • hydrocephalus of pregnant; • nephropathy (mild, moderate, severe); • pre-eclampsia; • eclampsia.

32. Nephropathy of pregnancy is divided into three levels: • mild (hypertension is not higher than 150/100 mm Hg. Art., swelling of feet not higher than shins, proteinuria less than 1 g / l, the fundus has uneven caliber of retinal vessels); • moderate (blood pressure not higher than 175/115 mm Hg. Art., swelling extended to the lower extremities and abdominal wall, proteinuria of 1 g / l to 3 g / l, there is swelling of the retina); • severe degree (blood pressure above 175/115 mm Hg. Art., anasarca, proteinuria more than 3 g / l, the fundus has hemorrhage, marked degenerative changes).

33. Pre-eclampsia - a critical, but a reversible condition, which developed against the background of severe gestosis. In addition to the triad of symptoms of gestosis (OPG), a patient has a headache, nasal congestion, visual disturbances. These signs are regarded as cerebral circulation disorder. Eclampsia - the most severe form of pregnancy problem called gestosis, which is characterized by seizures with loss of consciousness. The duration and number of seizures of eclampsia may be different. During a seizure there develop abnormalities of cerebral blood flow, bleeding in the brain and its membranes. Hemorrhages in internal organs are frequent. Hypoxia and metabolic disease are sharply increasing, there occurs acidosis. Renal function is rapidly deteriorating, oliguria increases. Internal organs often have degenerative changes. Eclampsia is life-threatening for both mother and fetus.

34. The most frequent complication of pregnancy is a threat of interruption and premature birth - one of the main perinatal cause of morbidity and mortality. The main reasons for threat of abortion and miscarriage are: • infectious diseases of mother; • complications related to pregnancy; • traumatic injuries; • iso serological incompatibility of blood between mother and fetus; • developmental anomalies of female genitalia; • neuroendocrine pathology; • various non-communicable diseases of mother; • chromosomal abnormalities.

35. Prevention and treatment of pregnancy induced hypertension Prophylaxis and Early Treatment Because women are usually asymptomatic and seldom notice the signs of incipient pre-eclampsia, its early detection demands careful observation at appropriate intervals, especially in women known to be predisposed to preeclampsia. Major predisposing factors are (1) nulliparity, (2) familial history of pre-eclampsia–eclampsia, (3) multiple fetuses, (4) diabetes, (5) chronic vascular disease, (6) renal disease, (7) hydatidiform mole, and (8) fetal hydrops.

36. Rapid weight gain any time during the latter half of pregnancy, or an upward trend in diastolic blood pressure, even while still in the normal range, is worrisome. Every woman should be examined at least weekly during the last month of pregnancy and every 2 weeks during the previous 2 months. At these visits, weight and blood pressure measurements are made. All women should be advised to report immediately any symptoms or signs of preeclampsia, such as headache, visual disturbances, epigastric distress, and puffiness of hands or face. The reporting of any such symptoms calls for an immediate examination to confirm or exclude preeclampsia.

37. Natriuretic drugs, such as chlorothiazide and its congeners, have been overused severely in the past. Although diuretics have been alleged to prevent preeclampsia, Collins and colleagues (1985) reviewed results of nine studies of more than 7000 women and concluded that perinatal mortality was not improved when diuretics were given. Furthermore, thiazides can induce serious sodium and potassium depletion, hemorrhagic pancreatitis, and severe neonatal thrombocytopenia. The failure of natriuretic drugs to prevent preeclampsia raises serious doubt about the efficacy of rigid dietary sodium restriction.

38. In a study by the Royal College of Obstetricians and Gynecologists (CLASP, 1994), it was concluded that low-dose aspirin was ineffective to prevent preeclampsia. Similarly, the ECPPA Collaborative Group (1996), in a study from 12 Brazilian teaching hospitals, concluded that low-dose aspirin did not decrease the incidence of proteinuric preeclampsia in 1009 women randomized to aspirin or placebo. Low-dose aspirin therapy appears to be safe for the fetus. Although most clinical trials have resulted in no apparent maternal risks, Brown and colleagues (1990) noted a rapid clinical deterioration if therapy was stopped suddenly.

39. Thank you for your attention