Background: Obstetrical analgesia remains a matter of controversy because of the fear of neurotoxicity of local anesthetics on demyelinated fibers or their potential relationship with subsequent relapses. Objective: To assess the impact of neuraxial analgesia on the risk of relapse during the first 3 months post-partum, with a focus on women who experienced relapses during pregnancy. Methods: We analyzed data of women followed-up prospectively during their pregnancies and at least 3 months post-partum, collected in the Pregnancy in Multiple Sclerosis (PRIMS) and Prevention of Post-Partum Relapses with Progestin and Estradiol in Multiple Sclerosis (POPARTMUS) studies between 1992–1995 and 2005–2012, respectively. The association of neuraxial analgesia with the occurrence of a post-partum relapse was estimated by logistic regression analysis. Results: A total of 389 women were included, 215 from PRIMS and 174 from POPARTMUS. In total, 156 women (40%) had neuraxial analgesia. Overall, 24% experienced a relapse during pregnancy and 25% in the 3 months post-partum. Women with a pregnancy relapse were more likely to have a post-partum relapse (odds ratio (OR) = 1.83, p = 0.02), independently of the use of neuraxial analgesia. There was no association between neuraxial analgesia and post-partum relapse (OR = 1.08, p = 0.78). Conclusion: Neuraxial analgesia was not associated with an increased risk of post-partum relapses, whatever multiple sclerosis (MS) activity during pregnancy.

Injectable contraceptives are a valid option in every family planning program. Contraceptives which are administered every 2 or 3 months, containing only progestogen agents (DepoProvera, Noristerat) have proven efficacious and do not show long-term safety problems. They differ from other contraceptives in their long lasting action and by not presenting the contraindications of the estrogens. Their most prominent side-effect is the irregularity of cyclic bleeding. Although bleeding irregularities are not life threatening, many users stop the treatment for that reason. Monthly contraceptives comprising progestogens and estrogens, maintain or improve the high efficacy of the earlier forms and have the added benefit of allowing bleeding to resemble the physiologic one. This increases acceptability and the continuation rate. There is no long-term inconvenience. At this point, the greatest experience is with the formulation known as Topasel or Perlutal. Other formulations (Cyclofem, Mesigyna) are beginning to be commercialized and their characteristics must still be confirmed through daily use. Indications, contraindications, precautions and warnings for the use of monthly injectable contraceptives are basically identical to those of the combined oral contraceptives, as are the side-effects. Efficacy, though, proves to be superior, which can be correlated to a simpler method of use and less risk of error when using it. Main motivation factors are: efficacy, simplicity in usage, reversibility and confidentiality.

A survey among users and health personnel participating in the Salvadorian Social Security Institute (ISSS) Family Planning Program revealed interest in including a monthly preparation for injection as a contraceptive method offered by this Institution. The formulation containing dihydroxyprogesterone acetophenide (DHPA) 150 mg + estradiol enantate (E2EN) 10 mg was chosen for conducting an open and prospective study of efficacy and tolerability. Between January 1992 and March 1994, 7054 women were treated with this product for a total of 60010 months. A sample composed of 4505 women treated at this Institution confirmed that average users are young, have one or two children, do not show a particular geographical distribution and choose the monthly injection instead of oral contraceptives as the first contraceptive method or for the puerperium. The study formulation showed a high efficacy (Pearl Index: 0.018) and tolerability (general withdrawal rate throughout the study: 27.09%). The most frequent adverse events included bleeding disorders, headache and mastalgia; their incidence decreased spontaneously from the sixth month (3.9%), reaching 0% after two years. Treatment was discontinued due to adverse events in 3.47% of women. No significant bodyweight or systolic and diastolic blood pressure alterations were observed. Based on these results, the monthly injectable contraceptive was included in the basic product list at ISSS.