Postabortion Contraception

Fertility can return within about 2 weeks of a first or second trimester abortion or miscarriage, and ovulation may precede the first bleed, so contraception begins at the time of the abortion or within 7 days. Offering a method before discharge reduces repeat unintended pregnancy and repeat abortion.

Assessment. Confirm that the abortion is complete, exclude retained products, genital tract infection and significant genital injury, and record gestation, mode of evacuation, haemorrhage, sepsis, anaemia, Rhesus status, HIV status, medicines and the patient's plan for the next pregnancy. Postabortion contraception is offered after any spontaneous, induced or ectopic outcome.

Sepsis and injury. If infection is suspected or there is significant injury to the genital tract, an intrauterine device or sterilisation is delayed until treatment and recovery. Hormonal methods and condoms can still be started.

Pregnancy exclusion. Within 7 days after an abortion or miscarriage, pregnancy is reasonably excluded; later, one of the usual criteria or a test is needed.

Return to fertility. Rapid. Ovulation may occur by day 14, so delay beyond 7 days adds avoidable risk.

Eligibility.

Method comparison. Implants and intrauterine devices give the highest protection with the lowest user effort; injectables and pills give an immediate start. Combined pills may be used because there is no postpartum thrombosis effect, but venous thromboembolism risk factors still apply.

Interactions. Efavirenz, rifampicin and enzyme-inducing antiseizure medicines reduce combined pill, progestin-only pill and implant effect; offer an intrauterine device or DMPA.

Special groups. Adolescents and women living with HIV are eligible for all these methods by the same rules. After ectopic pregnancy, progestin-only pills carry a category 2 caution with a history of ectopic pregnancy, while other methods are category 1.

Regimen lines.

• Copper T 380A or levonorgestrel 52 mg device: insert immediately after evacuation or within 12 days, only after infection is excluded; no backup; up to 12 years and 5 years.

• Etonogestrel 68 mg rod or levonorgestrel two 75 mg rods: subdermal, immediately; no backup; replace at 3, 5 or 3 years by system.

• DMPA 150 mg intramuscularly or 104 mg subcutaneously every 13 weeks, up to 4 weeks late; norethisterone enanthate 200 mg every 8 weeks, up to 2 weeks late; given within 7 days, no backup; after 7 days, if reasonably not pregnant, backup 7 days.

• Combined pill (ethinylestradiol 30 micrograms with levonorgestrel 150 micrograms) daily from the day of evacuation; no backup if started within 7 days of the abortion; otherwise backup 7 days.

• Progestin-only pill daily, immediately; no backup within 7 days of the abortion, otherwise backup 2 days.

• Condoms from the first intercourse.

Rhesus. Give anti-D immunoglobulin where indicated; it does not affect the choice of method.

Follow up. Review at about 2 weeks and again at 3 to 6 weeks after an intrauterine device; give clear return instructions for bleeding, pain or fever.

Intrauterine device after abortion. Expulsion risk is higher after second trimester abortion; perforation is rare. If perforation is suspected during insertion, stop, remove the device and instruments, keep the patient at rest, start an intravenous line, monitor vital signs and abdominal signs, and refer for surgical review if there is severe pain, guarding or instability.

Infection. Fever, foul discharge, lower abdominal pain or tenderness: treat for pelvic infection with antibiotics, and remove the device if there is no improvement within a few days.

Bleeding. Heavy or prolonged bleeding needs exclusion of retained products; treat with ibuprofen 800 mg three times daily for 5 days or tranexamic acid 500 mg three times daily for 5 days when no thrombosis risk exists.

Red flags. Heavy bleeding, foul discharge, fever, severe pain, shock.

Referral and escalation. Refer retained products, sepsis, suspected perforation and suspected ectopic pregnancy urgently.