1. Contraception after miscarriage: options, timing, effectiveness Anne Burke, MD, MPH Associate Professor, Dept. GYN/OB Director, Family Planning Fellowship

2. Terminology  Much of the literature discusses contraceptive use after induced abortion  We can discuss as applicable  Fewer studies look at contraception after miscarriage or menstrual regulation  “Abortion” can be spontaneous or induced  WHO guidance uses the term abortion  Because WHO uses those terms, we will discuss them here

3. Contraception after miscarriage  Can start many methods immediately  Why wait to ovulate?  Postpartum: Over half by 39 days  As early as day 25  (6 weeks = 42 days  do the math)  Post-abortion or post miscarriage  As soon as 10 days  At least 50% of women will ovulate within 3 weeks

4. Resources

5. Does type of management matter?  Uterine aspiration  1st vs. 2nd trimester?  Medical management  How soon?  Why wait?  What about IUD?  Many studies on induced abortion?

7. Contraception after abortion (miscarriage): WHO MEC categories CHCPOPDMPAImplantsLNG-IUDCu-IUD 1 st tri111111 2 nd tri111122 Septic111144 Source: WHO MEC 2010

8. Combined hormonal methods after miscarriage  Why not?  Pregnancy is over  Don’t miss the opportunity  No increased rate of side effects, irregular bleeding  No difference in coagulation parameters or increased risk of thrombotic events

9. Don’t attribute risk where there isn’t Combined hormonal contraceptivesMEC Category < 21 days postpartum 4 After 1st trimester abortion 1 After 2nd trimester abortion 1 After septic abortion 1

10. Progestin pills and injectables after miscarriage  Can start immediately  No increased risk of side effects or adverse events  No reason to delay

11. Long-acting reversible methods after miscarriage  Implants  Not teratogenic  Highly effective  No reason to wait  IUD  Confirm empty uterus  Rule out infection

12. IUD after medical abortion Day 5-9 vs. 2 weeks Saav, et al 2012 1 week vs. 4-6 weeks Shimoni, et al 2011

13. IUD after surgical abortion 1 st tri: Immediate vs. 2-6 weeks Bednarek, et al 2011 2 nd tri: Immediate vs. 3-6 weeks Hohmann, et al 2012

14. Post-miscarriage LARC: How well does it work?  What are the effects on repeat pregnancy?  Recent study (January 2014)  Group 1: no immediate LARC available  Group 2: immediate LARC available  Results (Group 1 vs. Group 2):  LARC initiation in 12 months: 11% vs. 46% (p<0.05)  Repeat pregnancies in 12 months: 27% vs. 15% Langston, et al, Contraception, 2014

15. Repeat pregnancy in first year Aileen M. Langston, Sophie L. Joslin-Roher, Carolyn L. Westhoff. Immediate postabortion access to IUDs, implants and DMPA reduces repeat pregnancy within 1 year in a New York City practice. Contraception, Volume 89, Issue 2, 2014, 103 – 108.

16. Quality of care is important  Contraceptive use after menstrual regulation  Study done in Bangladesh (N=915)  Increased use of contraception after high-quality clinic services (92% vs. 78%, p<0.05)  Odds of contraceptive use higher based on service quality (poor vs. moderate vs. high)  Odds ratio 1.9 (95% CI: 1.1-2.9) for moderate  OR 3.0 (95% CI: 1.4 – 6.4) for high-quality Sultana, et al, IJGO 2013

17. Summary  Start contraception ASAP  Offer choice, but lead with the best!