CONTRACEPTION AFTER ABORTION Nicola Cochrane MB BCh BAO

CONTRACEPTION AFTER ABORTION Nicola Cochrane MB BCh BAO MRCGP DRCOG MSc GP, LARC Tutor, SATU FME

Financial Disclosure I have no financial interests or relationships to disclose

Abortion statistics England & Wales 2017 39% of women who had an abortion had one or more previous abortions www. gov. uk/dh

Medical abortion Surgical abortion < 9 weeks Community 9‐ 12 weeks Hospital <12 weeks or ex circumstances

Medical abortion: Medical history & examination HCG Positive If sure of dates & < 9 weeks (or 12 weeks in hospital) IF UNSURE OF DATES or = 12 weeks ULTRASOUND Counselling & contraception support STI Screening Medication (include analgesia eg NSAID) Mifepristone 200 mg oral (if <49 days) Then after 24‐ 48 hours Misoprosotol 400 mcg if <49 d 800 mcg if between 49 – 63 d vaginal, buccal or sublingual

Mifepristone an anti progestogenic steroid, sensitises the myometrium to prostaglandin‐induced contractions and ripens the cervix. Contraindications Acute porphyrias , chronic adrenal failure; suspected ectopic pregnancy (use other specific means of termination); uncontrolled severe asthma NB Competes with progesterone receptors for 5 days after use

Surgical abortion Vacuum aspiriation Dilatation & evacuation +/‐ medical methods NB Incomplete medical abortion may require vacuum aspiration

What Contraception were they using prior to this pregnancy? Is this a contraception failure? Is it rape? Were they using ANY contraception?

Factors associated with Crisis Pregnancy in Ireland Bourke et al, RCSI , 2015 Number % None Low efficacy Medium efficacy High efficacy

Cochrane database Systematic Review 2014 Contraception interventions for women seeking abortion Estimated that 40% of all pregnancies worldwide are unintended and most of these are due to the non‐use or failure of contraceptive methods (WHO 2007). Women who seek abortion services are a vulnerable population group Women who sought abortion were shown to be more motivated than their counterparts to use effective and safe contraception after the service procedure Effective post‐abortion care should include comprehensive intervention approaches, including personalized family planning counselling, with a wide availability of contraceptive methods and good quality of follow‐up service.

England’s Teenage Pregnancy Strategy: a hard-won success , Lancet 2016 UK almost halved Teenage pregnancy rates by 2015. The Teenage Pregnancy Strategy was a complex, intersectoral, and multicomponent intervention, informed by available evidence on likely effective strategies to reduce pregnancies, from inception throughout its funding period over 10 years to 2015. 1 Whole government approach to administration across all sectors 2 Prevention efforts including HIGH QUALITY Sex Education & access to effective contraception 3 Better support of teenage parents including completion of education and access to secure housing

Contraception is an essential element of high quality abortion care

What contraception is best?

Long Acting Reversible Contraceptives available in Ireland INJECTION Medroxyprogesterone 150 mg/ml IM 12 weekly injection IMPLANT Etonogestrel 68 mg subdermal implant, 3 year licence INTRA UTERINE DEVICES Levonorgestrel 52 mg & 19 mg Intra uterine systems , 5 year licence Copper Intra uterine devices eg TSafe 380 A QL, TT 380 Slimline 10 years Mini. TT 380 Sl. , Nova T 380 5 years

Surgical abortion Any contraception including Intra uterine device placement at time of procedure BUT Higher rate of Expulsion 27. 5% vs 4% in delayed insertion BJOG 2017; 124 Korjamo et al

Medical abortion It’s a little more complicated……. Mifepristone may interfer with hormonal contraception for 5 days after Medroxyprogesterone IM may increase incomplete abortion rate by 2. 7% Intra uterine devices cannot be inserted until pregnancy ended Etonogestrel subdermal implant can be inserted immediately

Evidence Effects of Depot Medroxyprogesterone Acetate Injection Timing on Medical Abortion Efficacy and Repeat Pregnancy: A Randomized Controlled Trial. Obstet Gynecol. 2016; 128(4): 739. Raymond et al Immediate versus delayed insertion of an etonogestrel releasing implant at medical abortion‐a randomized controlled equivalence trial. Hum Reprod. 2016; 31(11): 2484 , Hognert et al Effect of Immediate Compared With Delayed Insertion of Etonogestrel Implants on Medical Abortion Efficacy and Repeat Pregnancy, Obstet Gynecol. 2016 Feb; 127(2): 306‐ 12 Raymond et al Expulsions and adverse events following immediate and later insertion of a levonorgestrel‐releasing intrauterine system after medical termination of late first‐ and second‐trimester pregnancy: a randomised controlled trial. BJOG. 2017; 124(13): 1965. Epub 2017 Aug 16. Korjamo et al Immediate postabortal insertion of intrauterine devices, Cochrane Database Syst Rev. 2014; Okusanya et al Provision of intrauterine contraception in association with first trimester induced abortion reduces the need of repeat abortion: first‐ year results of a randomized controlled trial. Hum Reprod. 2015 Nov; 30(11): 2539‐ 46. Epub 2015 Sep 14. Pohjoranta et al Immediate postabortion access to IUDs, implants and DMPA reduces repeat pregnancy within 1 year in a New York City practice. Contraception. 2014 Feb; 89(2): 103‐ 8. Epub 2013 Nov 6. Langston et al Impact of long‐acting reversible contraception on return for repeat abortion. Am J Obstet Gynecol. 2012 Jan; 206(1): 37. e 1‐ 6. Epub 2011 Jul 13. Rose et al

In a nutshell Long Acting Reversible Contraception post abortion is the most effective, safest and convenient method of reducing crisis pregnancy

Pre abortion contraception counselling Discussion, education on effectiveness , individual factors & personal choice Post abortion counselling suitable options choice timing Planning appointment if delay required

No contraception • Rape, not normally sexually active • No longer sexually active • Just not ready

Combined Hormonal contraception is less reliable BUT efficacy and safety AND compliance may be improved by counselling and prescribing 365 Continuous Pill UKFSRH May 2018

LARC Medroxyprogesterone although safe and useful bridging may increase failure rates in Medical abortion Copper IUD and LNG IUS are highly effective, safe and convenient BUT delayed insertion may be preferable post surgical TOP to reduce expulsion rate AND must be delayed post Medical abortion until confirmation that the woman is no longer pregnant Subdermal implant Etonogestrel is most effective, safe, convenient and suitable immediately after Surgical and Medical abortion

UK FSRH TRAINING FOR ABORTION CARE

Challenges How do we design a system of consistent high quality Pre & post abortion Contraceptive counselling for every woman seeking TOP in Irish Reproductive Health? Can we ensure all providers are adequately trained with skills to offer full CHOICE of contraception? Is it reasonable to promote subdermal implants to all women ? When we know compliance and continuance is greatest with Copper IUD and Levonorgestrel IUS how do we ensure women return for follow up insertion? How do we improve our Sex Education for younger and mature women to promote uptake of most effective contraception and reduce and prevent Crisis pregnancy in Ireland? What about Indemnity?

Good sexual and reproductive health is a state of complete physical, mental and social well‐being in all matters relating to the reproductive system. It implies that people are able to have a satisfying and safe sex life, the capability to reproduce, and the freedom to decide if, when, and how often to do so. UNFPA