gpraj

View Original

Quick start contraception

Dr Rajesh Varma

This synopsis is based upon FSRH guideline Quick Starting Contraception (April 2017)

HSUP
CHC
POP
IMP
DMPA
LNG-EC
UPA-EC
Cu-IUD
LNG-IUS

High-sensitivity urine pregnancy test: detects hCG ≥ 20 mIU/m. Needs to be performed ≥ 21 days after the last UPSI before pregnancy can be excluded
Combined hormonal contraception
Progestogen-only pill
Progestogen-only implant
Depot medroxyprogesterone acetate (i.m or s.c)
Levonorgestrel Emergency Contraception
Uilipristal acetate Emergency Contraception
Copper intrauterine device
Levonorgestrel intrauterine system

Quick starting contraception

  1. The conventional approach is to start contraception on the first day of a normal (expected) menstrual period, where there is no risk of existing pregnancy, and the contraceptive method becomes immediately effective.

  2. Women may be considered for emergency contraception if they are concerned about unintended pregnancy following UPSI.
    Pregnancy can be reasonably excluded if an HSUP is negative at 21 days or more after the last UPSI.
    Therefore, regardless of whether she takes emergency contraception (EC), she has the option of waiting until the beginning of her next period or until the risk of pregnancy has been excluded, before commencing a long-term method contraception.

  3. Quick starting contraception refers to the method of starting contraception at a time other than the start of the menstrual cycle.

  4. Additional initial contraceptive precautions (barrier or abstinence) are required until the quick start hormonal contraceptive method becomes effective.

  5. When quick starting contraception, there will sometimes be a small risk that the woman is already pregnant or that EC will fail or that she will conceive during the time before quick start contraceptive method becomes effective. A follow-up HSUP is always recommended, no sooner than 21 days after the last episode of UPSI.

SCENARIO 1: reasonably certain woman is not pregnant

Woman is not pregnant (negative HSUP) AND is reasonably certain to be not at risk of pregnancy from any recent UPSI episode.
Quick start options: ANY contraceptive method with additional initial contraceptive precautions
Quick start options include: IMP, DMPA, CHC, POP AND Cu-IUD and LNG-IUS

SCENARIO 2: risk of very early pregnancy following recent UPSI (pregnancy cannot be reliably excluded)

Woman is not pregnant (negative HSUP) AND there is potential risk of very early pregnancy from recent UPSI

Advise the woman:

  1. There is a risk of ongoing pregnancy from the UPSI which is too early to be detectable by a urine pregnancy test.

  2. Pregnancy cannot be reliably excluded unless the HSUP ≥21 days after the last UPSI.

  3. She may be suitable for emergency contraception to reduce the risk of unwanted pregnancy following the recent UPSI
    Following emergency contraception, quick start hormonal options include: IMP, DMPA, CHC, POP
    If Cu-IUD is used as emergency contraception, then this also achieves immediate ongoing quick start contraception
    If UPA-EC is administered, then wait 5 days before quick starting hormonal contraception (IMP, DMPA, CHC, POP)
    If LNG-EC is administered, then immediately quick start hormonal contraception (IMP, DMPA, CHC, POP)

  4. Alternatively, if she is not suitable for emergency contraception, accepts there is a risk of ongoing pregnancy from the UPSI AND she prefers not to delay starting contraception, then the same quick start hormonal options may be offered: IMP, DMPA, CHC, POP (Cu-IUD and LNG-IUS should not be inserted as pregnancy cannot be reliably excluded)

  5. Recommend a follow-up HSUP ≥21 days after the last UPSI
    21 days after the last UPSI will identify any pregnancy resulting from the UPSI or unsuccessful use of emergency contraception (if used)
    28 days after quick starting contraception will also identify pregnancies resulting from UPSI that occurred before the quick start contraceptive method became effective.

SCENARIO 3 Woman’s choice of contraceptive method is not available or is not appropriate at the time of presentation

Offer bridging method of contraception that can be quick started.

Additional contraceptive precautions required before quick start method becomes effective

Additional contraceptive precautions (barrier or abstinence) are required until the quick start contraceptive method becomes effective.
0 days for Cu-IUD (could also be inserted in the role of emergency contraception)
2 days for POP (traditional, desogestrel)
7 days for IMP, DMPA, CHC (oral pill, transdermal patch, vaginal ring), Cu-IUD, LNG-IUS
9 days for CHC-Qlaira

Pregnancy is diagnosed after quick starting contraception

Advise the woman:

  1. Quick start hormonal method used is unlikely to be harmful to the fetus and is not considered a medical reason for termination on the grounds of fetal exposure to quick start hormone.

  2. If she wishes to continue with the pregnancy, stop (CHC, POP) or remove (IMP, Cu-IUD, LNG-IUS) contraceptive if <12w (will improved pregnancy outcome but is associated with a small risk of miscarriage).

  3. If she wishes to terminate the pregnancy
    Stop CHC or POP until termination, then immediately restart after termination (no additional contraceptive precautions required)
    Continue IMP or DMPA after termination (no additional contraceptive precautions required)
    Remove Cu-IUD or LNG-IUS
    If received DMPA, she is at slightly higher risk of failed abortion following mifepristone administration