Unintended Pregnancy in the College Student with Chronic Disease: Why It Shouldn’t Happen and What’s Next?

MP Malee, PhD,MD,MBA

May 30, 2014

DISCLAIMER

I have no actual or potential conflict of interest in relation to this educational activity or presentation.

What We Will Cover…….

1. Intended and unintended pregnancies and the role of

birth control in these statistics

2. Characterize the habits of our healthcare client

3. What acute and chronic issues prompt a visit?

4. Prescription drugs: use/misuse/abuse

5. Correlate of unintended pregnancy: potential for fetal/

neonatal and long-term consequences of maternal

behaviors and medication exposures

6. Common complaints, diagnoses, and treatments

7. Common chronic diseases and management

8. Contraceptive options in chronic disease

9. Summary thoughts

Intended and Unintended Births in the US: 1982-2010

• 37% of births in the US are unintended at the time of conception, essentially unchanged since 1982.

• The proportion of unintended births declined significantly between 1982 and 2006-2010 among married, non-Hispanic white women.

• Unintended births are more likely among:• unmarried women, • African-American women• women with less education• women with less income

Percentage of Births that were Intended at Conception by Mother’s Age, Marital Status, and Education, 2006-2012

• Age: In those 15-19y/o and 20-24y/o, 23% and 50%, respectively, had births that were intended at conception

• Marital Status: 33% of those not married or cohabiting, 49% of those cohabiting, and 77% of those married had births that were intended at conception.

• Education: Intended births at conception varies with education--college degree (83%), some college (63%), high school diploma (60%), less than high school diploma (59%).

So unintended pregnancies are LESS likely in our college population, but they do occur.

Non-use of Contraception and Unintended Births

Reasons for non-use of contraception, offered by 19.2% of the over 4 million women who gave birth each year included:

-36% ‘thought that they couldn’t get pregnant’……

*NO difference by age, marital status, income,

but IS a difference in educational level—

26% with some college education vs

42% with a HS education or less

So education and available resources are key, and that’s where we can make a difference!

So now we know about the stats for intended and unintended births in the majority age group of our cohort, and a bit about their thoughts regarding birth control.

What else do we know about our college healthcare clients?

Who Are Our Healthcare Clients?

• Characterized in the National College Health Assessment; Spring 2013 (ACHA)

• Participants:153 schools, majority of which 4+ year public institutions, 123k students (34% response)

• **59% characterize their health as very good or excellent, and 91% as good, very good or excellent

• **Importantly, 53% of respondents reported a dx and/or tx for a health issue in the past 12 months

• What do we know about their habits, healthy and otherwise?

What About Their Habits?

• Alcohol: any use in the past 30 days- 65%, male (M) = female (F)

• Cigarettes: any use past 30 days- 17% (M) vs 12% (F)

• Marijuana: any use past 30 days- 21% (M) vs 15% (F)

• All other drugs combined (incl cigars, cocaine, amphetamines, hallucinogens, anabolic steroids, club drugs): 20% (M) vs 9% (F)

• Risk behavior when drinking alcohol eg unprotected sex, considered suicide, did something that they later regretted: 54% (M) vs 50% (F)

• Use of prescription drug NOT prescribed for them: 16% (M) vs

14% (F)

What About Their Habits?

• Sexual behavior: 70% of students reported sexual activity within the last 12 months; 56% of sexually active students used birth control, 62% mostly/always use a protective barrier, and 60% use OCPs

• 16% reported using (or that their partner used) the ‘morning after pill’ within the past 12 months, with an unintentional pregnancy rate of 1.8%

So what complaints prompt a HC visit?

Proportion of Students Reporting Diagnosis or Treatment for the Following Health Problems within Past 12 Months • Allergies--19%• Sinus infection--15.6%• Back pain--12.5%• Strep throat--9.7%• Urinary tract infection--9.5%• Asthma--8.4%• Migraine headache; ADHD – both @ 7.6%• Broken bone/fracture/sprain--6.9%• Bronchitis--5.8%• Psychiatric condition—5.7%

2013 ACHA NCHA II

Categories of HC Client Concerns: Mental Health

Mental healthcare issues require considerable resources, andaccount for almost 20 percent of total student HC visits!

Represented mental health diagnoses include: anxiety, depression, ADHD, eating disorders, adjustment reaction, bipolar/psychosis, and alcohol abuse.

So they seek continuity HC for mental health issues…What other diagnoses prompt continuity care?

Continuity Care in College Students

• Involves 5-15% of the total college population

• Dx include eg allergies (20%), asthma (9%), chronic illness (5-12%), underweight (3-6%), obesity (11.9-12.6%)

• Many on medications, and some on several medications, as seen on the next slide

Drug Use and Misuse/Abuse

• Many of the drugs used/misused/abused by college-aged students are prescription drugs

• 50% of college students are offered a prescription drug for nonmedical purposes by their sophomore year; 12% of students acknowledge misusing a prescription opioid in their lifetime

• According to the NIDA, women are 55% more likely to be prescribed drugs that can be abused, such as narcotics and tranquilizers, putting them at greater potential risk for misuse/abuse

Use/Misuse/Abuse What Medications Are Involved? Stimulants

• Stimulants such as eg Ritalin (methylphenidate) and Adderall, (dextroamphetamine), are prescribed for ADHD, narcolepsy, and short-term management of weight loss

• Only 30.5% with a Rx for ADHD acknowledged taking the medication as directed

• 62% diverted the medication to someone without a prescription

• Potential of misuse for anorexic effects, heightened attention/wakefulness, academic enhancement, hallucinations, euphoria and altered perceptions

Use/Misuse/Abuse:Stimulants

• 6.7% of women acknowledged using stimulants NOT prescribed for them,• Caucasian women are 2-4 times more likely to

abuse stimulants of any other race/ethnicity

• In another report, 11% acknowledged using prescription stimulants in nonmedical settings in the past year, and 36% have used them at least once in their lifetime!• Withdrawal symptoms include fatigue, depression,

and sleep disturbances

Use/Misuse/Abuse What Medications Are Involved? Opioids

• Opioids (hydrocodone / oxycodone), prescribed for pain relief and act by blocking pain perception; medical risks include respiratory depression/death• Caucasian women are more likely to abuse

prescription pain relievers than women of another races/ethnicities

• 23% of women aged 18-34y/o reported taking pain relievers NOT prescribed for them

Other Issues with Opioids… • Overdose characterized by sedation and

may be accompanied by aspiration, respiratory depression, death

• Often co-formulated with eg acetaminophen, aspirin, ibuprophen…..so overuse can lead to liver damage/failure or GI bleeding

• Chronic exposure can lead to dependence; withdrawal is uncomfortable (and can be fatal for the fetus if the client is pregnant)

Use/Misuse/Abuse: Sedatives and Tranquilizers

• Sedatives (barbiturates) and tranquilizers (benzodiazepines) including valium and xanax, are often prescribed for anxiety, panic attacks, sleeping disorders

• 2.4% reported using sedatives not prescribed for them• Caucasian women reportedly abuse sedatives and

tranquilizers more frequently than other races/ethnicities

Use/Misuse/Abuse: Sedatives and Tranquilizers

• Long-term use/abuse can result in dependence/addiction

• Abrupt withdrawal can result in rebound seizures, as well as other acute medical and psychiatric manifestations

Abuse of Prescription Medications: Potential Consequences

Include addiction, episodic hypertension, tachycardia, tachypnea, irregular cardiac rhythm, hyperthermia, heart failure, seizure, hostility, paranoia, overdose, increased risk for STDs

A potential also exists for sharing/selling prescribed medications…..

Is there sharing and selling of prescription drugs?

• Yes! 35.8% ‘diverted’ a prescribed medication at least once!

• The most commonly diverted medications were ADHD medications (stimulants and non-stimulants), with a 62% diversion rate, and prescription analgesics (opioids and prescription NSAIDs), with a 35% diversion rate.

‘Diverted’ Medications

• Other classes of diverted medications include asthma and allergy medications eg antihistamines, steroids; other psychotropic meds including antidepressants, anxiolytics, anti-psychotics and tranquilizers; other non-psychotropic meds included muscle relaxants, gastric secretion inhibitors, etc

• Sharing was the most common method of diversion at 34%, with sales at 9%

So What Do We Have So Far?

• We have an ‘at risk’ population relative to alcohol abuse

• We have an ‘at risk’ population relative to tobacco abuse, all other drugs of abuse, and use of prescription drugs that are and are NOT prescribed for them

• We have an ‘at risk’ population relative to sexual activity in the absence of birth control

Anything Else?

• We have an ‘at risk’ population relative to medications and drugs of abuse and naiveté regarding the potential maternal and fetal effects in the event of an unplanned pregnancy

• Anything else?

• Yes—correlates of unintended pregnancies!

Correlates of Unintended Pregnancies-Delay in seeking or absence of prenatal care which is associated with an increased risk of adverse outcomes eg low birth weight, neonatal mortality: 19% vs 8.2%

-Medical care by Medicaid (as an indicator of resources available to care for the child): 65% vs 35%

-Reduced rates of breastfeeding, noting that breastfeeding is associated with decreased infections/SIDS for offspring, and reduced risk of T2 DM in woman….from 39% to 26%!! Breastfeeding is encouraged!

So although these longer-term consequences are significant, there are additional consequences that are equally and perhaps even more important…….

Correlates of Unintended Pregnancies:

Potential Fetal/Neonatal and Long-Term Consequences of Maternal Behaviors and Exposures

Drugs of Use and Abuse

Drug of Abuse: Alcohol

• In all, of the 80 percent of college students who drink alcohol, half "binge drink“ (about four drinks in two hours for women and five in two hours for men), according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

• Not surprisingly, binge drinking appears to exert a greater effect than the same volume across a longer period of time (eg 4 drinks in one day vs 1 drink a day for 4 days)

• What about alcohol in pregnancy?

Drug of Abuse: Alcohol and Pregnancy

• Alcohol freely crosses placenta

• Known to be teratogenic; can have chronic nonreversible sequelae, or may seem to have no apparent sequelae

• No exact dose:response relationship: maternal age, ethnicity, genetic factors, and pattern of alcohol consumption appear to affect outcome of offspring

Drug of Abuse: Alcohol Potential Fetal/Neonatal Effects

Fetal Alcohol Spectrum Disorder includes:

Fetal Alcohol Syndrome

-a commonly identified cause of mental retardation, poor growth, often evident in the fetus, persisting in infancy and childhood; a chronic nonreversible sequelae of maternal alcohol use

-prevalence at 1-7/1000 live births, and higher if also include alcohol-related neurodevelopmental disorders

Fetal Alcohol Syndrome Cont’d

• FAS includes abnormalities in 1) growth, with growth restriction, noted in utero, often with microcephaly, persisting thru infancy and childhood; 2) CNS abnormalities, reflected in impairment of self-regulation, cognition and adaptive functioning; in infancy, manifested as irritability, regulatory problems eg sleep, attention; and 3) facial dysmorphia

• In childhood, microcephaly and short stature persist; CNS manifestations include hyperactivity, developmental delay, hypotonia, learning disabilities, MR, poor attention and concentration skills, and deficits in memory and reasoning

Substance Abuse: Tobacco • Smoking during pregnancy is associated with:

-abruption

-PROM

-abnormal placentation

-preterm labor and delivery

-low birthweight

-neonatal mortality rate above unexposed (RR=1.2-1.4)

-neonatal hypertonicity, excitability

-risk SIDS increased two- to four-fold

-risk T2 DM increased four-fold in offspring as young adult

-increased rate of behavioral disorders in offspring

-increased rates of asthma, decreased sperm volume

and count in offspring

Substance Use/Abuse: Opioids

• Recall that opioid meds are often prescribed/shared/sold; ‘opioid’ refers to natural or synthetic substances with morphine-like activity

• Prenatal exposure to opioids, and on occasion, sedative-hypnotics, places the baby at risk for ‘Neonatal Abstinence Syndrome’ (NAS) ie withdrawal Ss and Ss

• Rate of opioid use in US is increasing …1.9 to 5.6 per 1000 births between 2000-2009; not surprisingly, the rate of NAS also increased, from 1.2 to 3.4 cases per 1000 births

Substance Use/Abuse: Opioids

• NAS manifests with high pitched cry/irritability, sleep disturbances, tone alterations, feeding difficulties, GI disturbances; tx supportive, prn medication

• Long-term outcome: likely unremarkable, but confounded by other variables such as IUGR and its ramifications, as well as various postnatal factors, eg maternal SES, educational level, etc

Substance Abuse: Cocaine

• Associated with increased risk abruption, fetal demise, growth restriction, prematurity

• Neonatal manifestations include hyperactivity and inability to orient to environment

• Manifestations are not a function of withdrawal but instead of recent exposure, as can be detected in neonatal urine for up to 7 days after delivery

• Long-term effects are variable, often contingent on environmental factors during childhood

Substance Use/Abuse: Marijuana

• Neonates can be hyperexcitable, irritable and jittery, with an increased arousal response

• Does not affect global intelligence, but may impair sustained attention, visual memory, and analysis and integration in exposed adolescents

Substance Use/Abuse: Amphetamines

• Used to treat narcolepsy, ADHD eg Adderal and Strattera, and in the short term, obesity

• Used with caution if there’s a history of heart disease or dysrhythmia; many partner with primary caregiver to monitor pulse, SBP, DBP, as they increase dosage

• Unclear if prenatal exposure is associated with prematurity, growth restriction, congenital anomalies, and/or affects neurodevelopmental outcomes

• Unclear if increased risk ADHD in offspring is related to in utero exposure, genetic predisposition or a combination/interaction of both

Substance Use/Abuse: Antidepressants

• In the college population, antidepressants are taken more regularly and more responsibly….60% stated that they took their medication as prescribed; 20% reported never taking them.

• Six percent who did not have a Rx for antidepressants reported taking them for coping with the environment.

• It’s important to refer appropriately, discuss and document options for birth control if sexually active, and the possibility of pregnancy, +/- breastfeeding, in the choice of medication…….

Substance Use/Abuse: Antidepressants

• IF pregnancy diagnosed…

• Acknowledge the risks of suboptimal dosing given the increased volume of distribution, and of medication discontinuation

• Risk of depression relapse is 43%, greatest in first vs third trimester, and more common (68%) in those who d/c’d med before conception or in early pregnancy; the relapse rate is much less (26%) for those who maintained their medication.

Substance Use/Abuse: Antidepressants: Safety Issues• SSRIs and SNRIs are effective in the Tx of depression and

anxiety

• Large study indicates risk of fetal demise or infant mortality IS NOT INCREASED by SSRIs; risk exists for transient neonatal withdrawal

• Safety profiles generally reassuring, and if client has good response with medication, changing drugs upon a pregnancy diagnosis is not recommended; referral for further conversation re risks and appropriate fetal f/u IS appropriate

• Psychotherapy remains an important aspect of treatment during and after pregnancy

Substance Use/Abuse: Antidepressants: Safety Issues in Pregnancy

SSRIs and SNRIs include:

fluoxetine (Prozac): reassuring pregnancy safety profile; long T1/2 discourages first-line choice (accumulation in neonate)

paroxetine (Paxil): may be (controversial) associated with an increased risk of CHD, particularly VSDs (NOT first-line choice in pregnancy)

sertraline (Zoloft): many consider it first-line; some association with omphaloceles and VSDs (switching not rec)

citalopram (Celexa) and escitalopram (Lexapro): some data with increased risk VSD, anencephaly, craniosynostosis (switching not rec)

Substance Use/Abuse: Tricyclic Antidepressants (TCAs): Safety Issues

• Most studies have shown no association between TCAs and congenital anomalies

• Exposure may result in transient neonatal withdrawal

• No reported long-term effect on motor and behavioral development in exposed offspring

• Includes desipramine, nortriptyline, imipramine, amitriptyline, and clomipramine

Common Complaints, Diagnoses, and Treatments at any Student Health Center(keeping the possibility of undiagnosed pregnancy in mind……)

Tx of Respiratory Infections

• Common cold: reassurance re resolution without intervention in 10 days

• Review: data lacking re efficacy of most OTC interventions

• Favor acetaminophen, cepacol throat lozenges, lidocaine throat spray (sore throat), dextromethorphan (cough)

• Bronchitis: typically viral; consider C-Xray (r/o pneumonia; shield prn); rec many of same interventions as for common cold

• Sinusitis: ABT tx considered if eg Ss for > 10d, severe Ss and T>39; favor amoxicillin, azithromycin

• Encourage inactivated flu vaccine!

Acne TxComprehensive assessment focuses the treatment aimed at:

• 1) counteracting follicular hyperproliferation; 2) increased sebum production; 3) P. acnes proliferation; and 4) inflammation.

• Tx can include topical retinoids, benzoyl peroxide, azelaic acid, topical antibiotic, and/or an oral antibiotic

• **In a reproductive-aged women, reliable birth control guides treatment options. In its absence, topical retinoids (eg tretinoin and adapalene), both Class ‘C’, are often not prescribed; tazarotene aka tazorac (Class X; eg NTDs, cardiac anomalies) is not used, as is the case for oral isotretinoin aka accutane, Class X (eg hydrocephaly, microcephaly, cardiac, clefts)

And now for some additional chronic diseases/issues……..and why an unplanned pregnancy can be problematic

Diabetes

• Students should be aware of the necessity of BC and the importance of planning a pregnancy in the presence of T1 DM or poorly controlled T2 DM

• Most recommend that the HgbA1c be in the 5-6% range prior to attempting pregnancy to minimize the otherwise increased risk of miscarriage and congenital anomalies• Anomalies can include cardiac abnormalities as well as

renal agenesis, spina bifida and caudal regression

• For T1DMs, medication review is important, as diabetic vasculopathy may result in HTN, and the anti-hypertensive agents--ACE inhibitors and angiotensin receptor blockers--are teratogenic (oligohydramnios, microcephaly, cardiac)

Obesity

• Recommendation for weight gain in pregnancy is based on BMI (BMI > 29.9 kg/m2 =‘obese’; rec gain=15-25#)

• Obesity is associated with an increased risk of:

-gestational diabetes

-pregnancy-related hypertension,

-congenital malformations (clefts, CHD,

GI abnormalities eg gastroschisis,

anorectal atresia, hydrocephalus)

-sleep apnea

-fetal growth abnormalities

-fetal demise

Inflammatory Bowel Disease• Students should be aware of the necessity of BC and the

importance of planning a pregnancy in the presence of IBD

• Active disease at the time of conception is associated with 70% risk of flare/disease worsening in pregnancy

• Medication exposure

-consider short courses metronidazole

-sulfasalazine can be continued

-glucocorticoids should be avoided in the first tri if

possible (placental 18-hydroxylase), and thereafter

used in lowest possible dosage

(incr risk HTN, GDM, PPROM, IUGR,

Addisonion crisis)

Inflammatory Bowel Disease

• Medication exposure cont’d

-Azathioprine, mercaptopurine and cyclosporin can

be used in pregnancy, preferably at lowest possible dosage; not associated with congenital

abnormalities

-*Methotrexate is contraindicated (skeletal abnormalities); discontinue at 3 mos before conception (fat stores)

-Infliximab (Remicade), and other anti-tumor necrosis

factor agents, can be used until the beginning of the third trimester; since it crosses the placenta, there is concern that it might place the newborn at

increased risk of infection and perhaps affect efficacy

of vaccinations

Seizure Disorders

• Students should be aware of the necessity of BC and the importance of planning a pregnancy in the presence of seizure disorders

• Noncompliance with recommended medications is as high as 50%

• Hormonal contraception at risk for failure due to potential effect of anti-epilepsy drugs (AEDs) on activation of P450 cytochrome system

• Discourage 3 or more alcoholic drinks as associated with increased risk of seizures

• *Folate supplementation (400ug) is routinely appropriate given potential effect of some AEDs on folate stores. If planning pregnancy, ACOG recs 4g/day to decrease risk NTDs

Seizure Disorders

• Risk of fetal malformations sec to medications is 4-6% vs the population estimate of 2-3%

• Avoid polytherapy, if possible, as associated with 6-9% risk malformation

• Avoid valproate if possible if BC use is unreliable as linked with increased incidence anomalies, especially NTDs, as well as 90% with abnormal facial features (minor dysmorphisms) and poorer neurodevelopmental outcome in offspring (eg IQ with dose-related decrease); recently reported <5% increased risk autism spectrum disorder in offspring of valproate-exposed pregnancy

• Dilantin is associated with clefts, CHD and GU abnormalities

• Phenobarbital is associated with CHD, orofacial malformations, and GU malformations

Seizure Disorders• Carbamazepine (tegretol) is strongly associated with NTDs and GU

abnormalities

• Lamictal is associated with a 2-3% rate of major malformation with first trimester exposure, but as high as 11% when paired with valproate

• Topamax is associated with an increased risk of oral clefts, at 16x the background rate

• Keppra is low risk for anomalies at less than 1% when monotherapy

• ***Emphasize and document importance of pregnancy planning in this population and effective BC until that time

SUMMARY THUS FAR….

We have a population at risk for use/abuse of prescription drugs and use of recreational drugs, as well as a population with appropriate use of prescribed medications for assigned diagnoses.

We can agree that planning pregnancy is always a good thing, but certainly necessary in many who are medicated for active and/or chronic diagnoses

Diagnoses Associated with Increased Risk for Adverse Health Event as a Result of Unintended Pregnancy (WHO, 2009)

• Diabetes• Epilepsy• Hypertension• HIV/AIDS• Sickle cell disease• SLE• Thrombogenic mutations• TB

What about contraception?

In a student with chronic disease,

contraception options present a challenge

Contraception

• Encourage contraception, document the discussion, and provide a referral as appropriate

• A discussion re potential options for contraception includes family history

(?VTE, APLA?), habits (? tobacco),

current diagnoses and current medications

• Review available methods relative to their effectiveness and convenience

Contraception

• Review possible side effects; eg breakthrough bleeding/amenorrhea with OCPs, DMPA; rash/itching at site of transdermal patch

• Problems with OCP adherence? May prompt a suggestion for extended cycle, continuous use pill, or an alternate form of BC

• Include conversation re condoms to prevent STDs, associated with infertility, ectopic pregnancy and chronic pelvic pain, as well as availability of emergency contraception

Contraception Options• Vaginal ring: changed every 3 weeks

• DMPA (depo provera): injection q 3 months

• Contraceptive implants last up to 3 years, and recommended by ACOG for adolescents

• IUDs: copper IUDs, progesterone-releasing IUDs, and unmedicated (inert) IUDs also recommended by ACOG for adolescents; as an aside, copper IUDs also an effective method of post-coital contraception if inserted within 5 days of unprotected intercourse

• Continuation rates as high as 80% for IUDs and as low as 30% for vaginal ring

LARC Long-Acting Reversible Contraception• Copper IUD: ‘T’-shaped; approved for up to 10 yr use,

with failure rate comparable to tubal ligation; common adverse effects are abnormal bleeding and pain

• Levonorgestrel intrauterine system: ‘T’-shaped; in addition to effects on sperm migration/viability and the change in transport of or damage to ovum, it also suppresses endometrial development and affects cervical mucus. Approved for 5 yrs, low failure rate; typically doesn’t inhibit ovulation but diminishes menses; some experience hormone-related effects such as HA, breast tenderness

--Complications include expulsion (5%), failure, and

perforation (1/1000)

--No increased risk PID or infertility

LARC Cont’d

• Contraceptive implants: placed subdermally; core material of the rod-like implant contains etonogestrel and allows for controlled release over 3 years; suppresses ovulation (HPO axis), thickens cervical mucus and alters endometrial lining

• Most effective form of reversible contraception, with a typical use pregnancy rate of 0.05%

• Changes in menstrual bleeding pattern common; other c/o include GI, HAs, breast pain, weight gain

• Complications insertion/removal uncommon (1-2%)• Fertility returns rapidly post removal

LARC Cont’d-Who’s Eligible?

• ACOG considers nulliparous women and adolescents candidates for LARC BC methods, including IUDs

• Evidence suggests they’re more effective and have higher rates of satisfaction vs OCPs

• Evidence suggests no increased risk PID or infertility

• Insertion ok at any time of cycle if pregnancy test negative; ok immediately post abortion or miscarriage in the absence of septic abortion

• Coincidental condom use appropriate prn as STI protection

Contraception and Chronic Disease• Hormonal contraception is an issue for those with valvular

disease (unless treated with an anticoagulant), HTN ( incr risk MI and CVA) and APLA, and also some with eg SLE (+/- APLA, thrombocytopenia)

• Hormonal contraceptives can be an issue for those taking anti-seizure medication, except for valproate, as clearance is increased, and anti-seizure medication effectiveness likely decreased

• Depo-provera has a continuation rate in adolescents of 47%, and is associated with about 6 pregnancies per 100 women per year; can be considered for those with APLA, HTN, tobacco abuse

Contraception and Chronic Disease: DM• No specific form of BC is contraindicated in DM

• WHO and CDC recommend hormonal contraception (lowest effective dose) for those with DM, in the absence of tobacco abuse, HTN, vasculopathy, and <35y/o

• OCPs with estrogen dose <35ug have no adverse effects on CH2O metabolism, plasma glucose, insulin sensitivity

• Other estrogen/progesterone preparations eg patch, ring, not well studied in DM

• DMPA and progesterone-only pills also ok

• Copper IUDs and progesterone-releasing IUD similarly ok for DM

Contraception andChronic Disease: Seizure Disorder• Four-fold increase in OCP failure in this population sec to

induction of hepatic enzymes by commonly prescribed anti-seizure medications

• Some data indicate that OCPs can be considered if prescribe increased dosage of anti-seizure med, together with extended cycle OCP regimens with shorter pill-free intervals

• AED meds do not affect hormone levels in those using hormone-releasing IUDs (Mirena) and/or depo-provera; these methods are considered as effective as OCPs for this population*

• Since the efficacy of the ‘morning after’ pill may be similarly affected by AEDs, two doses (one q 12hr) of levonorgestrel 1.5mg is often recommended

Conclusions

• Circling back to the title of this presentation ie Unintended Pregnancy in the Uninformed College Student with Chronic Disease: Why It Shouldn’t Happen and What’s Next?, I would like to emphasize the following points…..

• Seize opportunities for education at each HC visit

• Acknowledge possibility of and document a discussion of high risk behaviors with all clients, including abuse of EtOH, tobacco, and recreational drugs, unprotected sex, abuse/sale/sharing of prescription medications and potential consequences

Conclusions

• Partner with your continuity clients with chronic disease diagnoses—medical and psychiatric. Encourage medication compliance and reliable birth control. Refer to Women’s Health as appropriate, and document topics covered during visits.

• Capitalize on the expertise of other providers, within and perhaps outside of the college health community, for advice and resources

THANK YOU!