Long-acting reversible contraception immediately after medical abortion: systematic review with meta-analyses

Abstract

BACKGROUND Long-acting reversible contraceptives (LARCs) are safe, effective and convenient post-abortal methods. However, there is concern that some LARCs may reduce the effectiveness of abortifacient drugs or result in other adverse outcomes. OBJECTIVE AND RATIONALE We undertook two systematic reviews to examine the early administration of LARCs in women undergoing medical abortion with mifepristone and misoprostol. (i) For women who are having a medical abortion and who plan to use a progestogen-only contraceptive implant or injectable, does administration of the contraception at the same time as mifepristone influence the efficacy of the abortion? (Implant/injectable review). (ii) For women who have had a medical abortion, how soon after expulsion of the products of conception is it safe to insert an intrauterine contraceptive device/system? (LNG-IUS/Cu-IUD review). SEARCH METHODS On 19 November 2018, we searched Embase Classic, Embase; Ovid MEDLINE(R) including Daily and Epub Ahead-of-Print, In-Process and Other Non-Indexed Citations; the Cochrane Library; Cinahl Plus; and Web of Science Core Collection. Eligible studies were randomised controlled trials (RCTs), in English from 1985 (Implant/injectable review) or 2007 (LNG-IUS/Cu-IUD review) onwards, conducted in women undergoing medical abortion with mifepristone and misoprostol and studying either (i) simultaneous administration of mifepristone and a progestogen-only contraceptive implant or injectable compared to administration >24 h after mifepristone, or (ii) immediate insertion of intrauterine contraception after expulsion of the products of conception compared to early insertion (≤7 days) or to delayed insertion (>7 days) or early compared to delayed insertion. One author assessed the risk of bias in the studies using the Cochrane Collaboration checklist for RCTs. All the outcomes were analysed as risk ratios and meta-analysed in Review Manager 5.3 using the Mantel–Haenszel statistical method and a fixed-effect model. The overall quality of the evidence was assessed using GRADE. OUTCOMES Two RCTs (n = 1027) showed lower ‘subsequent unintended pregnancy’ rates and higher ‘patient satisfaction’ rates, and no other differences, after simultaneous administration of mifepristone and the implant compared to delayed administration. One RCT (n = 461) showed higher ‘patient satisfaction’ rates after simultaneous administration than after delayed administration of mifepristone and the injectable, but no other differences between these interventions. Three RCTs (n = 536) found no differences other than higher copper IUC uptake after early compared to delayed insertion at ≤9 weeks of gestation and higher rates of IUC expulsion, continuation and uptake after immediate compared to delayed insertion at 9+1–12+0 weeks of gestation and higher IUC continuation rates after immediate compared to delayed insertion at 12+1–20+0 weeks of gestation. The quality of this evidence ranged from very low to high and was mainly compromised by low event rates, high attrition and no blinding. WIDER IMPLICATIONS The contraceptive implant or injectable should be offered on the day of taking mifepristone. Intrauterine methods of contraception should be offered as soon as possible after expulsion of the pregnancy.

Safety and Benefits of Contraceptives Implants: A Systematic Review

“…The ENG-releasing subdermal implant could be employed immediately after a surgical abortion [190][191][192] or on the same day of mifepristone assumption, without an increase in pregnancy risk compared to the delayed placement 4-8 weeks after the procedure [195][196][197]199]. It has been shown to be effective in improving symptomatic endometriosis with reduction in pain severity and menstrual symptoms (dysmenorrhea and dyspareunia) [201,210,211]; ENG therapeutic efficacy for pain relief is not inferior to other progestins [209,210].…”

“…In a retrospective study, Park et al [198] demonstrated that the administration of a progestin-based contraceptive such as an ENG implant or DMPA injection on the same day as mifepristone for medical abortion did not alter the successful abortion rates [198]. In a recent systematic review and meta-analysis, Schmidt-Hansen et al [199] showed that after abortion, the risk of subsequent unintended pregnancy was lower for patients treated with the etonogestrel implant simultaneously with mifepristone compared to delayed treatment both after three (risk ratio = 0.10; 95% CI, 0.01 to 1.94; p = 0.13) and six months (risk ratio = 0.22; 95% CI, 0.06 to 0.78; p = 0.02). Therefore, in women undergoing pharmacological pregnancy termination, contraceptive implant insertion should be offered on the day of mifepristone [199].…”

Acceptability of immediate postpartum and post‐abortion long‐acting reversible contraception provision to adolescents: A systematic review

“…44 Alternatively, this may also be observed due to contraception indications at the time of taking mifepristone for medical abortion when the implant is the only suitable LARC option. 79 Preference for non-LARC methods or no contraception was associated with relative socioeconomic disadvantage compared with those preferring LARC, and the belief that LARC methods are ineffective, among a sample of mostly African-American and Latinx pregnant adolescents. 62 These participants reported experiences typically congruous with poorer contraceptive self-efficacy, including not discussing contraception with parents and not perceiving themselves as autonomous decision-makers.…”

“…The increase in uptake of IPA LARC methods, driven by contraceptive implant availability in New Zealand, could also reflect adolescents’ preference for this method over Cu‐IUD/LNG‐IUS 44 . Alternatively, this may also be observed due to contraception indications at the time of taking mifepristone for medical abortion when the implant is the only suitable LARC option 79 …”

Effect of herbal medicine Shenghua decoction on uterine bleeding after early medical abortion

“…Most induced abortions were performed in the first trimester. [ 2 ] Induced abortion in the first trimester could be performed surgically (by manual or electric vacuum aspiration) or with medication. Though both methods have similar complete abortion rates, medical abortion is more natural and less harmful for its simplicity of operation.…”