Esophageal varices in pregnancy: Strategies to optimize maternal and fetal outcomes

Table 5 Contraceptive options in women with cirrhosis and portal hypertension

Method	WHO MEC category (compensated liver disease)	WHO MEC category (decompensated cirrhosis/portal hypertension with varices)	Key recommendations
Barrier method	1	1	Less effective alone; encourage for dual protection
Combined oral contraceptives	3	4	Avoid due to estrogenic effects; may worsen cholestasis and increase thrombosis risk
Injectable medroxyprogesterone acetate	2	3	Effective, but caution due to risk of bone loss; osteoporosis is common in cirrhosis
Progestin implant/LNG-IUS	1	2	Highly effective; preferred long-acting reversible options
Copper IUCD	1	2-3 (if severe anemia)	Acceptable if anemia is controlled; monitor for bleeding
Female sterilization	1 (if medically fit)	2-3	Surgical risk increased by collaterals and coagulopathy; laparotomy may be safer than laparoscopy

Medical eligibility criteria category definitions: 1 = No restriction; 2 = Advantages generally outweigh risks; 3 = Risks usually outweigh advantages; 4 = Unacceptable health risk. WHO: World Health Organization; MEC: Medical eligibility criteria.