What contraception options are suitable for a post-cesarean delivery woman with obesity, weighing 128kg, and potentially other comorbidities such as hypertension and diabetes?

Contraception for Post-Cesarean Women with Obesity

For a post-cesarean woman weighing 128kg with obesity, hypertension, and diabetes, long-acting reversible contraception (LARC)—specifically the copper IUD, levonorgestrel IUD, or etonogestrel implant—is the optimal choice and can be initiated immediately postpartum. 1

Immediate Postpartum LARC: The Preferred Option

IUDs can be inserted within 10 minutes after placental delivery following cesarean section, classified as Category 2 (benefits outweigh risks), or after 4 weeks postpartum when they become Category 1 (no restrictions). 1 The implant can be inserted any time during the delivery hospitalization. 1, 2

Why LARC is Superior for This Patient

• All LARC methods are Category 1 (no restriction) for obesity (BMI ≥30 kg/m²), making them ideal for a 128kg woman. 1
• LARC methods are estrogen-free, eliminating venous thromboembolism (VTE) concerns that are particularly relevant given this patient's multiple VTE risk factors: obesity, post-cesarean status, and potentially hypertension. 1
• For diabetes and hypertension, copper IUDs remain Category 1, while levonorgestrel IUDs are Category 1-2 depending on vascular complications. 1
• The etonogestrel implant is Category 1-2 for most cardiovascular conditions including controlled hypertension and diabetes. 1

Critical Timing Considerations Post-Cesarean

This patient has multiple VTE risk factors (obesity BMI ≥30, post-cesarean delivery, age if ≥35, hypertension, diabetes), which significantly impacts contraceptive timing: 1

• Before 21 days postpartum: Combined hormonal contraceptives (CHCs) are Category 4 (unacceptable risk) for ALL women due to extremely elevated VTE risk. 1, 2
• 21-42 days postpartum with VTE risk factors: CHCs remain Category 3 (risks outweigh benefits). 1
• After 42 days: CHCs are still Category 2 (theoretical risks) for obesity alone. 1

Specific Method Recommendations by Priority

First-Line: LARC Methods

1. Copper IUD (Paragard)

   • Category 1 for obesity, diabetes, and hypertension 1
   • Can be inserted within 10 minutes of placental delivery (Category 2) or after 4 weeks (Category 1) 1
   • No hormonal effects on metabolic conditions 1
   • Contraindicated only if puerperal sepsis present (Category 4) 1

2. Levonorgestrel IUD (Mirena)

   • Category 1 for obesity 1
   • Category 1-2 for adequately controlled hypertension and diabetes without vascular disease 1
   • Same insertion timing as copper IUD 1
   • May improve dysmenorrhea and reduce menstrual blood loss 1

3. Etonogestrel Implant (Nexplanon)

   • Category 1 for obesity 1
   • Category 1-2 for controlled hypertension and diabetes 1
   • Can be inserted immediately postpartum during hospitalization 1, 2
   • Highly effective with 0.05% failure rate 3

Second-Line: Progestin-Only Methods

Progestin-only pills (POPs) are Category 1 for immediate postpartum use and Category 1-2 for hypertension/diabetes, but require perfect daily adherence. 1, 3

• Can be started immediately postpartum in both breastfeeding and non-breastfeeding women 2, 3
• Typical failure rate of 5% (vs. 0.5% perfect use) due to missed pills 3
• Category 2 for systolic BP 140-159 or diastolic 90-99 mmHg 1
• Critical pitfall: Must be taken within 3 hours of scheduled time daily; backup contraception needed for 2 days if >3 hours late 1, 3

Depot medroxyprogesterone acetate (DMPA/Depo-Provera) is Category 2 for postpartum use and Category 2-3 for cardiovascular risk factors. 1

• Category 2 for obesity and postpartum period 1
• Category 2-3 for hypertension depending on severity 1
• Category 3 for multiple cardiovascular risk factors 1
• Concern: May worsen metabolic parameters in diabetic patients 1

Third-Line: Combined Hormonal Contraceptives (Use with Extreme Caution)

CHCs are Category 2 for obesity alone but become Category 3-4 when combined with other risk factors present in this patient. 1

• Obesity (BMI ≥30) + post-cesarean + <42 days postpartum = Category 3-4 1
• Adequately controlled hypertension alone = Category 3 1
• Multiple cardiovascular risk factors (obesity + hypertension + diabetes) = Category 3-4 1
• Absolute contraindication before 21 days postpartum 1, 2

If CHCs are considered after 42 days postpartum, the patient must understand the significantly elevated VTE risk given her obesity and comorbidities. 1, 4

Special Consideration: Bariatric Surgery History

If this patient has had malabsorptive bariatric surgery (Roux-en-Y gastric bypass), oral contraceptives are Category 3 (not recommended) due to reduced absorption. 1

• LARC methods remain Category 1 and are unaffected by bariatric surgery 1, 5
• Contraceptive patch and ring are Category 1 post-bypass (not affected by gut absorption) 1
• All oral methods should be avoided after malabsorptive procedures 1, 5

Breastfeeding Considerations

If breastfeeding, all LARC methods and progestin-only methods are appropriate, but CHCs should be avoided until after 42 days and preferably avoided entirely. 1, 2

• CHCs are Category 3-4 for breastfeeding women <42 days postpartum with VTE risk factors 1
• CHCs may reduce milk production even after 42 days (Category 2) 1, 6
• All progestin-only methods and IUDs do not affect milk production 2, 6

Common Pitfalls to Avoid

• Never prescribe CHCs before 21 days postpartum—this is an absolute contraindication with Category 4 classification 1, 2
• Do not assume obesity alone makes CHCs acceptable—the combination of obesity + post-cesarean + hypertension + diabetes creates unacceptable VTE risk 1, 4
• Avoid oral contraceptives if patient has history of malabsorptive bariatric surgery 1, 5
• Do not insert IUD if puerperal sepsis is present (Category 4 contraindication) 1
• Remember that fertility can return as early as 25 days postpartum in non-breastfeeding women—contraception should not be delayed 2

Practical Implementation Algorithm

For immediate postpartum contraception (during delivery hospitalization):

1. Offer IUD insertion within 10 minutes of placental delivery (if no sepsis) 1
2. Offer etonogestrel implant insertion before hospital discharge 1, 2
3. Provide progestin-only pills as bridge method if LARC declined 2, 3

For contraception initiated at postpartum visit (≥4 weeks):

1. First choice: IUD insertion (now Category 1) 1
2. Second choice: Implant insertion if not done postpartum 1
3. Third choice: Progestin-only pills or DMPA (with counseling about adherence/metabolic effects) 1, 3
4. Avoid CHCs given multiple cardiovascular risk factors 1, 4