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Bipolar disorder in women: Contraception and preconception assessment and counseling Author Victoria Hendrick, MD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Oct 2013. | This topic last updated: Ago 1, 2013. INTRODUCTION Bipolar patients who consider becoming pregnant should receive preconception counseling about the risks to the patient and her child. However, approximately one-half of all pregnancies in the United States are unplanned [1,2]. Thus, prepregnancy counseling is relevant to all female patients of reproductive age, regardless of their plans regarding pregnancy. In addition, contraception should be encouraged for patients who wish to avoid pregnancy. This topic reviews contraception and the preconception assessment and counseling of women with bipolar disorder. Indications for maintenance pharmacotherapy during pregnancy, selecting preconception and prenatal maintenance treatment for bipolar patients, and the teratogenic and postnatal effects of medications used for bipolar disorder are discussed separately. (See "Bipolar disorder in women: Indications for preconception and prenatal maintenance pharmacotherapy" and "Bipolar disorder in women: Preconception and prenatal maintenance pharmacotherapy" and "Bipolar disorder in adults: Teratogenic and postnatal risks of pharmacotherapy".) DEFINITION OF BIPOLAR DISORDER Bipolar disorder is a mood disorder that is characterized by episodes of mania (table 1), hypomania (table 2), and major depression (table 3), as well as mixed episodes (major depression concurrent with mania) [3]. The subtypes of bipolar disorder include bipolar I and bipolar II. Patients with bipolar I disorder experience manic and mixed episodes, and nearly always experience major depressive and hypomanic episodes. Bipolar II disorder is marked by at least one hypomanic episode, at least one major depressive episode, and the absence of manic and mixed episodes. Additional information about the clinical features and diagnosis of bipolar disorder is discussed separately. (See "Bipolar disorder in adults: Clinical features" and "Bipolar disorder in adults: Assessment and diagnosis", section on 'Diagnosis'.) CONTRACEPTION Bipolar patients who want to avoid pregnancy should receive information about contraceptive methods. Many female bipolar patients of childbearing age are treated with medications, but do not use contraception and are not trying to conceive. In a survey of 136 female patients receiving maintenance pharmacotherapy (including drugs that appear to be teratogenic), 41 percent did not use birth control [4]. Female bipolar patients should be encouraged to use long-acting reversible contraceptives, such as intrauterine devices or implants; these require much less attention from the user and are among the most effective methods. In particular, the copper intrauterine device will not interfere with concurrent medications, is nonhormonal, and can be effective for at least 10 years. Contraceptive techniques are discussed separately. (See "Overview of contraception".) It is not known if hormonal contraceptives affect the mood state of bipolar patients [5]. However, randomized trials have demonstrated that the estrogen receptor antagonist tamoxifen efficaciously treats mania [6-9]; this antimanic effect is discussed separately. (See "Bipolar disorder in adults: Pharmacotherapy for acute mania, mixed episodes, and hypomania", section on 'Other medications'.) Drug interactions between antiepileptics and hormonal contraceptives We suggest that bipolar patients treated with carbamazepine avoid hormonal contraception (oral, patch, and vaginal ring) and use a different form of birth control, such as an injectable contraceptive, implant, or intrauterine device (table 4). Carbamazepine may induce hepatic enzymes and increase metabolism of hormonal contraceptives, thus reducing their efficacy (table 4). However, a reasonable alternative is to use high-dose oral hormonal contraceptives and watch for spotting, which may indicate that the contraceptive is failing. Additional information about carbamazepine and hormonal contraception failure is discussed separately. (See "Overview of the management of epilepsy in adults", section on 'Oral contraceptive therapy'.) In addition, we suggest that bipolar patients treated with lamotrigine avoid estrogen containing contraceptives, which may increase lamotrigine clearance and reduce its efficacy for treating bipolar disorder [10]. However, a reasonable alternative includes prescribing higher doses of lamotrigine if an estrogen-based hormonal contraceptive is used. Additional information about drug-drug interactions between lamotrigine and oral contraception is discussed separately. (See "Pharmacology of antiepileptic drugs", section on 'Lamotrigine'.) Hormonal contraceptives can interact with drugs other than anticonvulsants (table 4). PRECONCEPTION ASSESSMENT The clinical assessment of bipolar patients who consider becoming pregnant includes a psychiatric and general medical history, mental status and physical examination, and focused laboratory tests [11-13]. The general preconception evaluation for all patients is discussed separately. (See "Preconception evaluation and counseling", section on 'Components of the preconception evaluation'.) The psychiatric history for bipolar patients should emphasize the following: Age Women should be aware that fertility declines and the risk of fetal chromosomal abnormalities rises with increasing age, especially after the mid-30s. Weight Many female bipolar patients are obese, which increases the risk of pregnancy complications (eg, gestational diabetes, preeclampsia, cesarean delivery, and fetal neural tube defects) [14]. (See "The impact of obesity on female fertility and pregnancy".) Clinicians should encourage patients to conceive at a normal body mass index (BMI), which is calculated from height and weight (calculator 1). Weight loss for overweight patients with dietary therapy, exercise, and other treatments is discussed separately. (See "Overview of therapy for obesity in adults".) Current status of bipolar disorder and course of illness, including current symptoms of a manic (table 1), hypomanic (table 2), major depressive (table 3), or mixed episode (major depression concurrent with mania or hypomania); number of prior mood episodes, particularly during the previous two to five years; and history of psychotic features (delusions and/or hallucinations) and suicidal ideation and behavior. Bipolar patients are encouraged to delay pregnancy until their illness is stable, and a long (eg, 2 years) duration of euthymia prior to conception is preferred. Medications Several medications used to treat bipolar disorder appear to be teratogenic, including valproate and carbamazepine, and to a lesser extent lithium. (See "Bipolar disorder in adults: Teratogenic and postnatal risks of pharmacotherapy".) Supplements Many patients do not realize that herbal supplements are potentially harmful to the fetus Substance abuse Drug, alcohol, and nicotine abuse is widespread among bipolar patients [15]. Women with bipolar disorder should be screened for their use of these substances, educated about the potential impact on the baby, and offered substance abuse treatment; these issues are discussed separately. (See "Overview of illicit drug use in pregnant women" and "Substance use disorders: Principles for recognition and assessment in general medical care" and "Psychosocial treatment of alcohol use disorder" and "Cannabis use disorder: Treatment, prognosis, and long-term medical effects" and "Treatment of opioid abuse and dependence" and "Treatment of cocaine use disorder in adults", section on 'Overview of treatment'.) Psychosocial functioning Psychosocial stressors (eg, domestic violence, marital conflict, inadequate social support, and financial problems) are likely to disrupt the patients stability and should be addressed before pregnancy The general medical history should emphasize the metabolic syndrome and diabetes, which commonly occur in bipolar patients and should be stabilized prior to attempting conception [14]. (See "The metabolic syndrome (insulin resistance syndrome or syndrome X)" and "Overview of medical care in adults with diabetes mellitus".) RISKS ASSOCIATED WITH PREGNANCY Although several risks are associated with pregnancy in bipolar patients, bipolar disorder is not a contraindication for pregnancy [16]. We encourage clinicians to include the spouse when discussing these risks with the patient, as well as other family members who may be called upon to support the patient during and after the pregnancy. Risk of adverse pregnancy and birth outcomes Adverse pregnancy and birth outcomes may occur more often in women with bipolar disorder regardless of treatment status, compared to women without bipolar disorder. A retrospective study of national registries compared outcomes in pregnant bipolar patients who were treated with mood stabilizers (antipsychotics, carbamazepine, lamotrigine, lithium, and/or valproate; N = 320), pregnant bipolar patients who were not treated with mood stabilizers (N = 554), and pregnant women without bipolar disorder who did not receive mood stabilizers (N = 331,263) [17]. The analyses controlled for potential confounders such as maternal age and substance use disorders; the primary findings included the following: Induced or planned caesarean delivery occurred in more treated and untreated bipolar patients than women without bipolar disorder (38 and 31 versus 21 percent) Preterm birth occurred in more treated and untreated bipolar patients than women without bipolar disorder (8 and 8 versus 5 percent) Adverse pregnancy and birth outcomes were comparable for treated and untreated bipolar patients Congenital defects The base rate for congenital defects in the offspring of patients with bipolar disorder appears to be no different than that of the general population, which is 2 to 5 percent [17-21]. However, some medications used to treat bipolar disorder appear to be teratogenic, including valproate and carbamazepine, and to a lesser extent lithium. The increased risk of malformations and adverse postnatal behavioral and developmental effects due to treatment of bipolar disorder during pregnancy is discussed separately, as are the general principles of teratology, genetic and environmental causes of birth defects, and the approach to congenital malformations. (See "Bipolar disorder in adults: Teratogenic and postnatal risks of pharmacotherapy" and "Principles of teratology" and "Genetic and environmental causes of birth defects" and "Approach to congenital malformations".) Risk of maternal mood episodes Clinicians should describe the risk of suffering bipolar mood episodes during pregnancy. As an example, a retrospective study in parous women with bipolar I disorder (N = 980) found that perinatal mood episodes had occurred in 56 percent, and among parous bipolar II patients, 40 percent [22]. Clinicians should also explain that pharmacotherapy may reduce this risk. In Section Editor Paul Keck, MD Deputy Editor David Solomon, MD
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C. The symptoms do not meet criteria for a mixed episode. D. The mood disturbance 1) is sufficiently severe to cause marked impairment in occupational functioning, usual social activities, or relationships with others, 2) necessitates hospitalization to prevent harm to self or others, or 3) has psychotic features. E. The symptoms are not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication, or other treatment) or a general medical condition (eg, hyperthyroidism).
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Text Revision, Fourth Edition (Copyright 2000). American Psychiatric Association.
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C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others. E. The episode 1) is not severe enough to cause marked impairment in social or occupational functioning, 2) does not necessitate hospitalization, and 3) does not have psychotic features. F. The symptoms are not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication, or other treatment) or a general medical condition (eg, hyperthyroidism). Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (eg, medication, ECT, light therapy) should not count toward a diagnosis of bipolar II disorder.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Text Revision, Fourth Edition (Copyright 2000). American Psychiatric Association.
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B. The symptoms do not meet criteria for a Mixed Episode. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to the direct physiological effects of substance or a general medical condition. E. The symptoms are not better accounted for by Bereavement, ie, after the loss of a loved one, the symptoms persist for longer than two months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
Adapted from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision. American Psychiatric Association, Washington, DC 2000.
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Condition
COC/P/R
POP
DMPA
Implants
LNG-IUD
Cu-IUD
Personal characteristics and reproductive history Pregnancy Age Not applicable* Menarche to <40 years = 1 40 years = 2 Not applicable* Menarche to <18 years = 1 18 to 45 years = 1 >45 years = 1 Parity a. Nulliparous b. Parous Postpartum (nonbreastfeeding women) a. <21 days b. 21 to 42 days i. With other risk factors for VTE (such as age 35 years, previous VTE, thrombophilia, immobility, transfusion at delivery, BMI 30, postpartum hemorrhage, postcesarean delivery, preeclampsia, or smoking) ii. Without other risk factors for VTE c. >42 days Postpartum (breastfeeding women ) a. <21 days b. 21 to <30 days i. With other risk factors for VTE (such as age 35 years, previous VTE, thrombophilia, immobility, transfusion at delivery, BMI 30 kg/m 2, postpartum hemorrhage, postcesarean delivery, preeclampsia, or smoking) ii. Without other risk factors for VTE c. 30 to 42 days i. With other risk factors for VTE (such as age 35 years, previous VTE, thrombophilia, immobility, transfusion at delivery, BMI 30, postpartum hemorrhage, postcesarean delivery, preeclampsia, or smoking) ii. Without other risk factors for VTE d. >42 days 2 1 1 1 2 1 1 1 3 1 1 1 3 2 2 2 3 2 2 2 4 2 2 2 1 1 1 1 2 1 1 1 3 1 1 1 4 1 1 1 1 1 1 1 1 1 1 1 2 1 2 1 Not applicable* Menarche to <18 years = 2 18 to 45 years = 1 >45 years = 2 Not applicable* Menarche to <18 years = 1 18 to 45 years = 1 >45 years = 1 4* Menarche to <20 years = 2 20 years = 1 4* Menarche to <20 years = 2 20 years = 1
Postpartum (breastfeeding or nonbreastfeeding women, including postcesarean delivery) a. <10 min after delivery of the placenta b. 10 min after delivery of the placenta to <4 weeks c. 4 weeks d. Puerperal sepsis Postabortion a. First trimester 1* 1* 1* 1* 1* 1* 1 4 1 4 2 2 1 2
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b. Second trimester c. Immediate postseptic abortion Past ectopic pregnancy History of pelvic surgery (see Postpartum, breastfeeding or nonbreastfeeding women, including postcesarean delivery) Smoking a. Age <35 years b. Age 35 years i. <15 Cigarettes/day ii. 15 Cigarettes/day Obesity a. 30 kg/m 2 BMI b. Menarche to <18 years and 30 kg/m 2 BMI History of bariatric surgery a. Restrictive procedures: decrease storage capacity of the stomach (vertical banded gastroplasty, laparoscopic adjustable gastric band, laparoscopic sleeve gastrectomy) b. Malabsorptive procedures: decrease absorption of nutrients and calories by shortening the functional length of the small intestine (Roux-en-Y gastric bypass, biliopancreatic diversion) Cardiovascular disease Multiple risk factors for arterial cardiovascular disease (such as older age, smoking, diabetes, and hypertension) Hypertension a. Adequately controlled hypertension
1* 1* 1 1
1* 1* 2 1
1* 1* 1 1
1* 1* 1 1
2 4 1 1
2 4 1 1
3 4
1 1
1 1
1 1
1 1
1 1
2 2
1 1
1 2
1 1
1 1
1 1
COCs: 3 P/R: 1
3/4*
2*
3*
2*
3*
1*
2*
1*
b. Elevated blood pressure levels (properly taken measurements) i. Systolic 140 to 159 mmHg or diastolic 90 to 99 mmHg ii. Systolic 160 mmHg or diastolic 100 mmHg c. Vascular disease History of high blood pressure during pregnancy (where current blood pressure is measurable and normal) Deep venous thrombosis (DVT)/pulmonary embolism (PE) a. History of DVT/PE, not on anticoagulant therapy i. Higher risk for recurrent DVT/PE (1 risk factors) History of estrogenassociated DVT/PE Pregnancyassociated DVT/PE Idiopathic DVT/PE Known thrombophilia, including antiphospholipid syndrome Active cancer (metastatic, on therapy, or within six months after clinical remission), excluding non-melanoma skin cancer History of recurrent DVT/PE 4 2 2 2 2 1 4 2 3 2 2 1 3 1 2 1 1 1
4 2
2 1
3 1
2 1
2 1
1 1
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ii. Lower risk for recurrent DVT/PE (no risk factors) b. Acute DVT/PE
c. DVT/PE and established on anticoagulant therapy for at least three months i. Higher risk for recurrent DVT/PE (1 risk factors) Known thrombophilia, including antiphospholipid syndrome Active cancer (metastatic, on therapy, or within six months after clinical remission), excluding non-melanoma skin cancer History of recurrent DVT/PE ii. Lower risk for recurrent DVT/PE (no risk factors) d. Family history (firstdegree relatives) e. Major surgery i. With prolonged immobilization ii. Without prolonged immobilization f. Minor surgery without immobilization Known thrombogenic mutations (eg, factor V Leiden; prothrombin mutation; protein S, protein C, and antithrombin deficiencies) Superficial venous thrombosis a. Varicose veins b. Superficial thrombophlebitis Current and history of ischemic heart disease Stroke (history of cerebrovascular accident) Known hyperlipidemias Valvular heart disease a. Uncomplicated b. Complicated (pulmonary hypertension, risk for atrial fibrillation, history of subacute bacterial endocarditis) Peripartum cardiomyopathy a. Normal or mildly impaired cardiac function (New York Heart Association Functional Class I or II: patients with no limitation of activities or patients with slight, mild limitation of activity) i. <6 months ii. 6 months b. Moderately or severely impaired cardiac function (New York Heart Association Functional Class III or IV: patients with marked limitation of activity or patients who should be at complete rest) Rheumatic diseases Systemic lupus erythematosus a. Positive (or unknown) antiphospholipid antibodies b. Severe thrombocytopenia c. Immunosuppressive treatment d. None of the above 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 2 2 3 2 2 2* 3* 2* 4 3 Initiation 3 Continuation 3 3 3 Initiation 1 Continuation 1 4 3 4 1 1 2 1 1 2 1 1 2 2 2 2 2 2 2 2 4 1 1 1 1 1 1 1 1 1 1 1 2 Initiation 4 2 Initiation 4 2/3* 2 2* 1 1 Continuation 3 Continuation 3 3 2* 3 1 1 Initiation 2 Initiation 2 2* 1 1 Continuation 3 Continuation 3 2 2* 1 1* Initiation 2 1 1 Continuation 3 1 1 1 1 4* 1 2* 1 2* 1 2* 1 2* 1 1* 4 2 2 1 2 1 2 1 2 1 1 1 3* 2 2 2 2 2 4* 2 2 2 2 2
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Rheumatoid arthritis a. On immunosuppressive therapy b. Not on immunosuppressive therapy Neurologic conditions Headaches a. Non-migrainous (mild or severe) b. Migraine i. Without aura
- Age <35 yrs - Age 35 yrs 2* 3* 3* 4* 1* 1* 2* 2* 2* 2* 2* 2* 2* 2* 2* 2*
Initiation 2 2 1 1 2/3* 2 1 1 2
Continuation 1 1
Initiation 2
Continuation 1 1
Initiation 1*
Continuation 2*
Initiation 1*
Continuation 1*
Initiation 1*
Continuation 1*
Initiation 1*
Continuation 1*
Initiation 1*
Continuation 1* 1*
2* 2*
2* 2*
1* 1*
4* 1*
4*
2* 1*
3*
2* 1*
3*
2* 1*
3*
2* 1
3*
1* 1
If on treatment, see Drug interactions section below Depressive disorders Depressive disorders 1* 1* 1* 1* 1* 1*
Reproductive tract infections and disorders Vaginal bleeding patterns a. Irregular pattern without heavy bleeding b. Heavy or prolonged bleeding (includes regular and irregular patterns) Unexplained vaginal bleeding (suspicious for serious condition) Before evaluation Endometriosis Benign ovarian tumors (including cysts) Severe dysmenorrhea Gestational trophoblastic disease a. Decreasing or undetectable beta-hCG levels b. Persistently elevated beta-hCG levels or malignant disease Cervical ectropion Cervical intraepithelial neoplasia Cervical cancer (awaiting treatment) Breast disease a. Undiagnosed mass b. Benign breast disease c. Family history of cancer d. Breast cancer i. Current ii. Past and no evidence of current disease for five years Endometrial hyperplasia Endometrial cancer 1 Ovarian cancer Uterine fibroids Anatomical abnormalities a. Distorted uterine cavity (any congenital or acquired uterine abnormality distorting the uterine cavity in a manner that is incompatible with IUD insertion) b. Other abnormalities (including cervical stenosis or cervical lacerations) not distorting the uterine cavity or interfering with IUD insertion Pelvic inflammatory disease (PID) 2 2 4 4 1 1 1 1 1 1 1 1 1 1 1 4 3 4 3 4 3 4 3 4 3 1 1 2* 1 1 2* 1 1 2* 1 1 2* 1 1 2 1 1 1 1 1 1 1 1 1 3 3 1 1 1 1 1 2 2* 1 1 2* 1 1 3* 1 1 3* 1 1 1 1* 2 2* 2 2* 2 2* Initiation 1 1* Continuation 1 2* 1 2*
Initiation
Continuation
Initiation
Continuation
4* 1 1
2*
4* 2 1
2*
1 2
1 1
1 2
1 2 Initiation
1 2 Continuation 2 Initiation 4
1 1 Continuation 2
1 Initiation 4
1 Continuation 2 1 2 Initiation 4
1 Continuation 2 1 2
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a. Past PID (assuming no current risk factors of STIs) i. With subsequent pregnancy ii. Without subsequent pregnancy b. Current PID STIs a. Current purulent cervicitis or chlamydial infection or gonorrhea b. Other STIs (excluding HIV and hepatitis) c. Vaginitis (including Trichomonas vaginalis and bacterial vaginosis) d. Increased risk for STIs HIV/AIDS 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Initiation
Continuation
Initiation
Continuation
1 2 4 Initiation 4
1 2 2* Continuation 2*
1 2 4 Initiation 4
1 2 2* Continuation 2*
1 1
1 1
1 1
1 1
2 2
2 2
2 2
2 2
2/3*
2/3*
Continuation 2 2 2 2
Initiation 2 2 3 2
Continuation 2 2 2* 2
NOTE: If on treatment, drug interactions might exist between hormonal contraceptives, including LNG-IUD, and antiretroviral drugs; refer to the section on drug interactions below as there may be limitations to use of the method. Other infections Schistosomiasis a. Uncomplicated b. Fibrosis of the liver (if severe, see Cirrhosis) Tuberculosis a. Nonpelvic b. Pelvic 1* 1* 1* 1* 1* 1* 1* 1* 1 1 1 1 1 1 1 1
1 1 Continuation 1 3
If on treatment, see Drug interactions section below Malaria Endocrine conditions Diabetes a. History of gestational disease b. Nonvascular disease i. Noninsulindependent ii. Insulin-dependent c. Nephropathy/retinopathy/ neuropathy d. Other vascular disease or diabetes of >20 years' duration Thyroid disorders a. Simple goiter b. Hyperthyroid c. Hypothyroid Gastrointestinal conditions Inflammatory bowel disease (IBD) (ulcerative colitis, Crohn disease) Gallbladder disease a. Symptomatic i. Treated by cholecystectomy ii. Medically treated iii. Current b. Asymptomatic History of cholestasis a. Pregnancy-related b. Past COC-related Viral hepatitis a. Acute or flare b. Carrier c. Chronic Cirrhosis a. Mild (compensated) b. Severe (decompensated) 1 4 1 3 1 3 1 3 1 3 1 1 Initiation 3/4* 1 1 2 3 Continuation 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 2 1 2 1 2 1 1 2 3 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 2/3* 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 3/4* 2 2 2 2 2 3 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
3/4*
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Liver tumors a. Benign i. Focal nodular hyperplasia ii. Hepatocellular adenoma b. Malignant (hepatoma) Anemias Thalassemia Sickle cell disease Iron-deficiency anemia Solid organ transplantation Solid organ transplantation a. Complicated: graft failure (acute or chronic), rejection, cardiac allograft vasculopathy b. Uncomplicated Drug interactions Antiretroviral therapy a. Nucleoside reverse transcriptase inhibitors (NRTIs) b. Non-nucleoside reverse transcriptase inhibitors (NNRTIs) c. Ritonavir-boosted protease inhibitors Anticonvulsant therapy a. Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine) b. Lamotrigine Antimicrobial therapy a. Broad-spectrum antibiotics b. Antifungals c. Antiparasitics d. Rifampicin or rifabutin therapy 1 1 3* 1 1 3* 1 1 1 1 1 2* 1 1 1 1 1 1 1 1 1 1 1 1 3* 1 1 1 1 1 3* 3* 1 2* 1 1 2* 2* 1 2* 2/3* 2* 2/3* 2* 1* 1 1 1 Initiation 2/3* Continuation 2* Initiation 2/3* Continuation 2* 2* 2 2 2 2 2 4 2 2 2 Initiation 3 Continuation 2 Initiation 3 Continuation 2 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 4 4 3 3 3 3 3 3 3 3 1 1 2 2 2 2 2 1
3*
3*
2*
2/3*
2*
2/3*
2*
COC: combined oral contraceptive; P: combined hormonal contraceptive patch; R: combined hormonal vaginal ring; POP: progestin-only pill; DMPA: depot medroxyprogesterone acetate; IUD: intrauterine device; LNG-IUD: levonorgestrel-releasing IUD; Cu-IUD: copper IUD; BMI: body mass index (weight [kg]/height [m 2]); DVT: deep venous thrombosis; VTE: venous thromboembolism; CHC: combined hormonal contraceptive; PE: pulmonary embolism; hCG: human chorionic gonadotropin; PID: pelvic inflammatory disease; STI: sexually transmitted infection; HI V: human immunodeficiency virus; AIDS: acquired immunodeficiency syndrome; NRTI: nucleoside reverse transcriptase inhibitor; NNRTI: non-nucleoside reverse transcriptase. * Consult the appendix for this contraceptive method for a clarification to this classification. Initiation refers to a condition already present when the contraceptive is begun. Continuation refers to a condition that develops after initiation of the method. Clarification: For women with other risk factors for VTE, these risk factors might increase the classification to a "4"; for example, smoking, deep venous thrombosis/pulmonary embolism, known thrombogenic mutations, and peripartum cardiomyopathy. The breastfeeding recommendations are divided by month in US Medical Eligibility Criteria for Contraceptive Use, 2010 . They have been divided by days for purposes of integration with the postpartum recommendations. Condition that exposes a woman to increased risk as a result of unintended pregnancy. Some studies suggest that women using progestin-only injectable contraception might be at increased risk for HIV acquisition; other studies do not show this association. CDC reviewed all available evidence and agreed that the data were not sufficiently conclusive to change current guidance. However, because of the inconclusive nature of the body of evidence on possible increased risk for HIV acquisition, women using progestin-only injectable contraception should be strongly advised to also always use condoms (male or female) and take other HIV preventive measures. References: 1. Update to CDC's U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: Revised Recommendations for the Use of Contraceptive Methods During the Postpartum Period. MMWR Morb Mortal Wkly Rep 2011; 60:878. 2. Update to CDC's U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: Revised Recommendations for the Use of Hormonal Contraception Among Women at High Risk for HIV Infection or Infected with HIV. MMWR Morb Mortal Wkly Rep 2012; 61:449. Reproduced with permission from: US Medical Eligibility Criteria for Contraceptive Use 2010, with data adapted from the World Health Organization Medical Eligibility Criteria for Contraceptive Use, 4th edition.
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