Summary of Changes from US MEC, 2010

a. <21 days postpartum

4

b. 21 to <30 days postpartum

i. With other risk factors for VTE (e.g., age ≥35 years, previous VTE, thrombophilia, immobility, transfusion at delivery, peripartum cardiomyopathy, BMI ≥30 kg/m², postpartum hemorrhage, postcesarean delivery, preeclampsia, or smoking)

2

2

2

3

CHCs: For women with other risk factors for VTE, these risk factors might increase the classification to a category 4.

ii. Without other risk factors for VTE

2

2

2

3

c. 30–42 days postpartum

i. With other risk factors for VTE (e.g., age ≥35 years, previous VTE, thrombophilia, immobility, transfusion at delivery, peripartum cardiomyopathy, BMI ≥30 kg/m², postpartum hemorrhage, postcesarean delivery, preeclampsia, or smoking)

1

1

1

3

CHCs: For women with other risk factors for VTE, these risk factors might increase the classification to a category 4.

ii. Without other risk factors for VTE

1

1

1

2

d. >42 days postpartum

1

1

1

2

Postpartum (nonbreastfeeding women)

a. <21 days postpartum

4

b. 21–42 days postpartum

i. With other risk factors for VTE (e.g., age ≥35 years, previous VTE, thrombophilia, immobility, transfusion at delivery, peripartum cardiomyopathy, BMI ≥30 kg/m², postpartum hemorrhage, postcesarean delivery, preeclampsia, or smoking)

1

1

1

3

CHCs: For women with other risk factors for VTE, these risk factors might increase the classification to a category 4.

ii. Without other risk factors for VTE

1

1

1

2

c. >42 days postpartum

1

1

1

1

IUDs: Insertion of IUDs among postpartum women is safe and does not appear to increase health risks associated with IUD use such as infection. Higher rates of expulsion during the postpartum period should be considered as they relate to effectiveness, along with patient access to interval placement (i.e., not related to pregnancy) when expulsion rates are lower.

Breastfeeding: Breastfeeding provides important health benefits for mother and infant. The U.S. Department of Health and Human Services recommends increasing the proportion of infants initially breastfed, exclusively breastfed through 6 months of life, and continuing breastfeeding through at least 1 year of life as key public health goals (1).

i. Breastfeeding

1

2

ii. Nonbreastfeeding

1

1

IUDs: Insertion of IUDs among postpartum women is safe and does not appear to increase health risks associated with IUD use such as infection. Higher rates of expulsion during the postpartum period should be considered as they relate to effectiveness, along with patient access to interval placement (i.e., not related to pregnancy) when expulsion rates are lower.

Breastfeeding: Breastfeeding provides important health benefits for mother and infant. The U.S. Department of Health and Human Services recommends increasing the proportion of infants initially breastfed, exclusively breastfed through 6 months of life, and continuing breastfeeding through at least 1 year of life as key public health goals (1).

IUDs: Insertion of IUDs among postpartum women is safe and does not appear to increase health risks associated with IUD use such as infection. Higher rates of expulsion during the postpartum period should be considered as they relate to effectiveness, along with patient access to interval placement (i.e., not related to pregnancy) when expulsion rates are lower.

Breastfeeding: Breastfeeding provides important health benefits for mother and infant. The U.S. Department of Health and Human Services recommends increasing the proportion of infants initially breastfed, exclusively breastfed through 6 months of life, and continuing breastfeeding through at least 1 year of life as key public health goals (1).

d. Postpartum sepsis

Multiple risk factors for atherosclerotic cardiovascular disease (e.g., older age, smoking, diabetes, hypertension, low HDL, high LDL, or high triglyceride levels)

Superficial venous disorders

b. Superficial venous thrombosis (acute or history)

3

CHCs: Superficial venous thrombosis might be associated with an increased risk for VTE. If a woman has risk factors for concurrent DVT (e.g., known thrombophilia or cancer) or has current or history of DVT, see recommendations for DVT/PE. Superficial venous thrombosis associated with a peripheral intravenous catheter is less likely to be associated with additional thrombosis and use of CHCs may be considered.

1

i. Without aura (This category of migraine includes menstrual migraine.)

1

1

1

1

2

ii. With aura

1

1

1

1

Multiple sclerosis

a. With prolonged immobility

1

1

1

2

1

3

b. Without prolonged immobility

1

1

1

2

1

1

For all subconditions of gestational trophoblastic disease, classifications are based on the assumption that women are under close medical supervision because of the need for monitoring of β-hCG levels for appropriate disease surveillance.

b. Confirmed gestational trophoblastic disease (after initial evacuation and during monitoring)

c. Other factors related to STDs

2

2

2

2

IUD initiation: Most women do not require additional STD screening at the time of IUD insertion. If a woman with risk factors for STDs has not been screened for gonorrhea and chlamydia according to CDC STD treatment guidelines (2), screening may be performed at the time of IUD insertion and insertion should not be delayed.

DMPA: 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. Expansion of contraceptive method mix and further research on the relationship between hormonal contraception and HIV infection are essential. These recommendations will be continually reviewed in light of new evidence.

HIV infection
For women with HIV infection who are not clinically well or not receiving ARV therapy, this condition is associated with increased risk for adverse health events as a result of pregnancy (Box 2).

a. Clinically well receiving ARV therapy

1

1

1

1

b. Not clinically well or not receiving ARV therapy

2

1

2

1

Cystic fibrosis
This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 2).

1

1

1

2

1

1

Persons with cystic fibrosis are at increased risk for diabetes, liver disease, gallbladder disease, and VTE (particularly related to use of central venous catheters) and are frequently prescribed antibiotics. Categories assigned to such conditions in U.S. MEC should be the same for women with cystic fibrosis who have these conditions. For cystic fibrosis, classifications are based on the assumption that no other conditions are present; these classifications must be modified in the presence of such conditions.

Implants, DMPA, POP, CHCs: Certain drugs to treat cystic fibrosis (e.g., lumacaftor) might reduce effectiveness of hormonal contraceptives, including oral, injectable, transdermal, and implantable contraceptives.

Antiretroviral therapy

a. Nucleoside reverse transcriptase inhibitors (NRTIs)

i. Abacavir (ABC)

1/2

1

1/2

1

1

1

1

1

ii. Tenofovir (TDF)

1/2

1

1/2

1

1

1

1

1

iii. Zidovudine (AZT)

1/2

1

1/2

1

1

1

1

1

iv. Lamivudine (3TC)

1/2

1

1/2

1

1

1

1

1

v. Didanosine (DDI)

1/2

1

1/2

1

1

1

1

1

vi. Emtricitabine (FTC)

1/2

1

1/2

1

1

1

1

1

vii. Stavudine (D4T)

1/2

1

1/2

1

1

1

1

1

b. Nonnucleoside reverse transcriptase inhibitors (NNRTIs)

i. Efavirenz (EFV)

1/2

1

1/2

1

2

1

2

2

Implants, DMPA, POP, CHCs: Evidence suggests drug interactions between efavirenz and certain hormonal contraceptives. These interactions might reduce the effectiveness of the hormonal contraceptive.

ii. Etravirine (ETR)

1/2

1

1/2

1

1

1

1

1

iii. Nevirapine (NVP)

1/2

1

1/2

1

1

1

1

1

iv. Rilpivirine (RPV)

1/2

1

1/2

1

1

1

1

1

c. Ritonavir-boosted protease inhibitors

i. Ritonavir-boosted atazanavir (ATV/r)

CHCs: Theoretically, drug interactions might occur between certain ritonavir-boosted protease inhibitors and certain hormonal contraceptives that might reduce the effectiveness of the hormonal contraceptive.

CHCs: Theoretically, drug interactions might occur between certain ritonavir-boosted protease inhibitors and certain hormonal contraceptives that might reduce the effectiveness of the hormonal contraceptive.

CHCs: Theoretically, drug interactions might occur between certain ritonavir-boosted protease inhibitors and certain hormonal contraceptives that might reduce the effectiveness of the hormonal contraceptive.

iv. Ritonavir-boosted lopinavir (LPV/r)

1/2

1

1/2

1

1

1

1

1

CHCs: Theoretically, drug interactions might occur between certain ritonavir-boosted protease inhibitors and certain hormonal contraceptives that might reduce the effectiveness of the hormonal contraceptive.

CHCs: Theoretically, drug interactions might occur between certain ritonavir-boosted protease inhibitors and certain hormonal contraceptives that might reduce the effectiveness of the hormonal contraceptive.

d. Protease inhibitors without ritonavir

CHCs: Concern exists that interactions between FPV and hormonal contraceptives leading to decreased levels of FPV might diminish effectiveness of the antiretroviral drug.

iii. Indinavir (IDV)

1/2

1

1/2

1

1

1

1

1

CHCs: Evidence suggests drug interactions between certain protease inhibitors and certain hormonal contraceptives. These interactions might reduce the effectiveness of the hormonal contraceptive.

e. CCR5 co-receptor antagonists

i. Maraviroc (MVC)

1/2

1

1/2

1

1

1

1

1

f. HIV integrase strand transfer inhibitors

i. Raltegravir (RAL)

1/2

1

1/2

1

1

1

1

1

ii. Dolutegravir (DTG)

1/2

1

1/2

1

1

1

1

1

iii. Elvitegravir (EVG)

1/2

1

1/2

1

1

1

1

1

g. Fusion inhibitors

i. Enfuvirtide

1/2

1

1/2

1

1

1

1

1

Psychotropic medications

a. SSRIs

1

1

1

1

1

1

St. John’s wort

1

1

2

1

2

2

NA

IUD: The IUD is not indicated during pregnancy and should not be used because of the risk for serious pelvic infection and septic spontaneous abortion.

ECPs: Although this method is not indicated for a woman with a known or suspected pregnancy, no harm to the woman, the course of her pregnancy, or the fetus if ECPs are inadvertently used is known to exist.

1

1

UPA: Breastfeeding is not recommended for 24 hours after taking UPA because it is excreted in breast milk with highest concentrations in the first 24 hours, and maximum maternal serum levels are reached 1-3 hours after administration. Mean UPA concentrations in breast milk decrease markedly from 0 to 24–48 hours and then slowly decrease over 5 days (3). Breast milk should be expressed and discarded for 24 hours after taking UPA.

1

1

1

1

1

1

1

2

2

1

1

1

1

1

1

1

1

1

2

3

1

2

1

1

1

Sexual assault

2

1

IUD: Women who have experienced sexual assault are at increased risk for STDs. According to CDC STD treatment guidelines, routine presumptive treatment of chlamydia, gonorrhea, and trichomonas is recommended after sexual assault (2). Women with current purulent cervicitis or chlamydial infection or gonococcal infection should not undergo IUD insertion (category 4).