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CDC Updates Its Guidelines on Postpartum Contraceptive Use
In recognition of excess risk for venous thromboembolism after delivery, timing of postpartum initiation of combined hormonal contraception is restricted.

The U.S. Medical Eligibility Criteria for Contraceptive Use, first published in 2010 by the CDC (JW Womens Health Jun 24 2010), continue to evolve as new data are incorporated. Now, a new update provides guidance about postpartum contraceptive use. The immediate postpartum period — defined as the first 42 days following delivery — is associated with 22- to 84-fold higher risk for venous thromboembolism (VTE) than that in nonpregnant or nonpostpartum reproductive-age women. The modest excess risk for VTE associated with estrogen-containing contraceptives has prompted a recommendation that use of these contraceptive options be restricted during the postpartum period. Fertile ovulation is unlikely until at least 42 days postpartum, lending support to delayed use of these methods. Highlights of the updated guidelines are as follows:

•Combined hormonal contraceptives should not be used during the first 21 days postpartum (category 4; unacceptable health risk).
•During postpartum days 21 through 42, women without risk factors for VTE can begin combined hormonal contraceptives (category 2; advantages generally outweigh risks).
•Presence of risk factors (e.g., age 35, previous VTE, preeclampsia, recent cesarean delivery) warrant a category 3 rating (risks usually outweigh advantages) with a possible increase to category 4 in the presence of other VTE risk factors (e.g., obesity, smoking).
•After 42 days postpartum, use of combined hormonal contraceptives is unrestricted in non–breast-feeding women.
•Recommendations for progestin-only methods (levonorgestrel-releasing intrauterine devices, implants, depot medroxyprogesterone acetate injections, and progestin-only pills) remain unchanged; such methods (as well as copper intrauterine devices) can be initiated immediately postpartum.
Comment: Excess risk for VTE during the early postpartum period drives these more-restrictive recommendations for combined hormonal contraceptive use. This new CDC guidance does not change recommendations specific to breast-feeding women (MMWR Recomm Rep 2010; 59:1). Many U.S. women have additional risk factors for VTE; we must target changes in lifestyle factors such as smoking and obesity, while tailoring contraceptive prescribing practices during the postpartum period.

— Anne A. Moore, WHNP/ANP-BC, FAANP

Published in Journal Watch Women's Health July 28, 2011

Citation(s):
Centers for Disease Control and Prevention (CDC). 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 Jul 8; 60:878.
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