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What’s new in larc land

What’s new in larc land

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What’s new in larc land

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  1. What’s new in larc land Kate Debiec, MD August 28, 2013

  2. ACOG COMMITTEE OPINION # 539, OCTOBER 2013 • Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine Devices • “When choosing contraceptive methods, adolescents should be encouraged to consider LARC methods. IUDs and the contraceptive implant are the best reversible method for preventing unintended pregnancy, rapid repeat pregnancy and abortion in young women.”

  3. ACOG COMMITTEE OPINION #539, OCTOBER 2013 • “With top-tier effectiveness, high rates of satisfaction and continuation, and no need for daily adherence, LARC methods should be first-line recommendations for all women and adolescents.”

  4. ACOG COMMITTEE OPINION #539, OCTOBER 2013 • 42% of 15-19 year olds have had sex • Nonuse, inconsistent use and short acting birth control are common • Continuation rates higher for LARCs (86%) vs short acting methods (55%) at 12 months • Unintended pregnancy 22 x higher for women using short acting methods than LARCs

  5. Skylavsmirena

  6. Comparison of Bleeding with LNg IUD

  7. Nexplanonvsimplanon • Bioequivalent: Etonorgestrel 68 mg Implanon (not available) Nexplanon

  8. Nexplanon • Amenorrhea ~20% • Unscheduled bleeding (45/90 days for women who d/c’d and 16/90 days for women who continued) • 15% d/c rate in U/S

  9. Deciding on method • Patient counseling • Online quiz

  10. Procedure challenges • Difficult placement • Uterine perforation • Cervical laceration • Lost strings • Vasovagal syncope • Difficult Nexplanon removal

  11. Difficult placement • Position of uterus • Tenaculum: anterior lip/posterior lip • Full bladder • Misoprostol • (Dilators and Ultrasound Guidance)

  12. Uterine perforation • Signs: • Clinical signs of visceral or vascular injury (abdominal distention, excessive bleeding, excessive pain, hypotension) • Uterine sound, dilator, or IUD passes beyond the expected length • The most common site of uterine perforation is the fundus • Major visceral or vascular injury less common with blunt objects (sounds, IUDs) • Disappearing strings

  13. Uterine Perforation • Management: • If recognized at time of placement, discontinue procedure, remove IUD (if deployed) • Monitor • Abdominal exploration if concerns for major vascular injury • Consider different cervical prep, ultrasound guidance

  14. Cervical Laceration • Pressure • Silver nitrate • Tamponade

  15. Lost IUD STrings • Cytobrush • Ultrasound • X-ray

  16. Vasovagal Syncope • Vasovagal syncope: • Typical triggers: emotional or orthostatic stress such as venipuncture (experienced or witnessed), painful or noxious stimuli, fear of bodily injury • Symptoms: prodrome/persistence of nausea, pallor, and diaphoresis • Syncope usually short duration and in the sitting or standing position • Supine position restores adequate blood flow to the brain • Full recovery may be delayed

  17. Difficult Nexplanon removal • Palpate device? • Yes  change incision location, depth • No  imaging, vascular referral