FIGO INITIATIVE

Contraception following abortion and the treatment of incomplete abortion

Kristina Gemzell-Danielsson
a,
, Helena Kopp Kallner
a
, Anibal Fandes
b
a
Department of Women and Childrens Health, Division of Obstetrics and Gynecology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
b
Department of Obstetrics and Gynecology, University of Campinas (UNICAMP) and Center for Research in Human Reproduction (CEMICAMP), Campinas, SP, Brazil
a b s t r a c t a r t i c l e i n f o
Keywords:
FIGO initiative
Incomplete abortion
Long-acting reversible contraception
Postabortion care
Postabortion contraception
Prevention
Unsafe abortion
Family planning counseling and the provision of postabortion contraception shouldbe anintegratedpart of abor-
tion and postabortion care to help women avoid another unplanned pregnancy and a repeat abortion. Postabor-
tion contraception is signicantly more effective in preventing repeat unintended pregnancy and abortion when
it is providedbefore womenleave the healthcare facility where they receivedabortion care, and when the chosen
method is a long-acting reversible contraceptive (LARC) method. This article provides evidence supporting these
two critical aspects of postabortion contraception. It suggests that gynecologists and obstetricians have an ethical
obligation to do everything necessary to ensure that postabortion contraception, with a focus on LARC methods,
becomes anintegral part of abortionand postabortion care, inline withthe recommendations of the International
Federation of Gynecology and Obstetrics and of several other organizations.
2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction
Contraceptive counseling andthe provisionof contraceptive methods
should be an integrated part of any abortion care or postabortion care
to help women avoid another unplanned or unwanted pregnancy and
the risk, in many cases, of an unsafe abortion. It is for that reason that
postabortion contraception is one of the strategies proposed by the
International Federation of Gynecology and Obstetrics (FIGO) Initiative
for the Prevention of Unsafe Abortion and its Consequences [1].
Recent evidence has shown that postabortion contraception should
comply with two attributes to ensure maximum effectiveness in
preventing a repeat unintended pregnancy and, possibly, a repeat safe
or unsafe abortion. First, it should be provided before the woman leaves
the healthcare facility where she received the abortioncare, and second,
preference should be given to long-acting reversible contraceptives
(LARC), or at least depot-medroxyprogesterone acetate (DMPA). This
paper reviews the evidence supporting these two recommendations.
2. Recovery of fertility after abortion
An uncomplicated abortion has no negative consequences on a
womans future fertility. Ovulation can occur as early as 8 days after
an abortion and 83% of women ovulate during the rst cycle following
an abortion [2,3]. Fertility after a surgical abortion does not differ from
that following a rst-trimester medical abortion. In addition, more
than half the women have sexual intercourse within 2 weeks after the
induced abortion, at least in some northern European countries [4].
Therefore, offering and initiating use of an effective contraceptive
method without any delay after a pregnancy termination or following
treatment of an incomplete abortion should be standard care. Notwith-
standing, initiating use of hormonal or intrauterine contraceptives
(IUDs, including both the copper-IUD and the levonorgestrel-releasing
intrauterine system [LNG-IUS]), is often routinely delayed until the
rst postabortion menstrual period, with women then being referred
for contraceptive counseling and to receive a contraceptive method,
instead of receiving these services on site at the time of the abortion
or postabortion care.
3. The safety of providing contraception immediately following
an abortion
The World Health Organizations (WHO) medical eligibility criteria
for contraceptive use states that the use of combined hormonal
methods (pills, patch, vaginal ring, and injectable contraceptives) and
progestin-only pills may be initiated immediately after an abortion
[5]. The process involved in a medical or surgical rst-trimester abor-
tion, including postabortion bleeding, is unaffected by immediately ini-
tiating one of these contraceptive methods. Furthermore, use of these
methods was not associated with more adverse effects or adverse
vaginal bleeding outcomes, or with any clinically signicant changes
in coagulation parameters compared with women who used a placebo,
an copper-IUD, a non-hormonal contraceptive method, or who delayed
International Journal of Gynecology and Obstetrics xxx (2014) xxxxxx
Corresponding author at: Department of Women and Childrens Health, Division of
Obstetrics and Gynecology, Karolinska Institutet, Karolinska University Hospital, 17176
Stockholm, Sweden. Tel.: +46 8 5177 2128; fax: +46 8 5177 4314.
E-mail address: kristina.gemzell@ki.se (K. Gemzell-Danielsson).
IJG-07913; No of Pages 4
http://dx.doi.org/10.1016/j.ijgo.2014.03.003
0020-7292/ 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics
j our nal homepage: www. el sevi er . com/ l ocat e/ i j go
Please cite this article as: Gemzell-Danielsson K, et al, Contraception following abortion and the treatment of incomplete abortion, Int J Gynecol
Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.03.003
initiation of combined oral contraceptives (COCs) [613]. Therefore,
these methods can and should be started on the same day as misopros-
tol is used for a medical abortion, on the day of surgery in cases of
surgical abortion, or on the day of discharge from hospital following
treatment of an incomplete abortion or spontaneous abortion. A possi-
ble exception is the vaginal ring. There is limited evidence on initiating
use of the vaginal contraceptive ring immediately following a rst-
trimester medical or surgical abortion; however, no serious adverse
events and no infection related to use of the ring were found during 3
follow-up cycles after an abortion [14]. However, if bleeding is heavy,
insertion of the ring may be delayed, but for no longer than 5 days. If
the delay exceeds 5 days, a back-up with barrier methods of contracep-
tion is recommended.
Implants are routinely inserted immediately after a rst-trimester
surgical abortion, although most studies on implants are limited to levo-
norgestrel (LNG)-releasing implants [1517].
WHOs medical eligibility criteria states that IUDs can be inserted
immediately after a rst-trimester, spontaneous, or induced abortion
[5]. However, it is important to note that all studies on postabortion
insertion listed by WHO are limited to surgical evacuation or surgical
abortion, with no data on medical abortions [1822].
There was no difference in the risk of complications between imme-
diate and delayed insertion of IUDafter surgery. Furthermore, no differ-
ences were foundwithrespect to safety or inthe expulsionrate withthe
postabortion insertion of an LNG-IUS compared with a copper-IUD [23,
24]. In cases of septic abortion, IUDs should not be inserted until the in-
fection has been successfully treated. In these cases, alternative contra-
ceptive methods should be offered in the meantime.
In some studies, a slightly higher expulsion rate was observed with
the immediate postabortion insertion of an IUD compared with de-
layed insertion [25,26]. However, immediate insertion results in an
increase in the number of women who in fact receive the IUD, as
discussed below.
The risk of IUD expulsion when the device is inserted immediately
following surgical abortion or uterine evacuation seems to increase
with gestational length and uterine size. The risk of expulsion is greater
when the IUD is inserted following a second-trimester abortion com-
pared with a rst-trimester abortion [27,28].
It has also been shown that an IUD can be inserted as soon as expul-
sion has been conrmed incases of medical abortion [2931]. Expulsion
rates were no higher if the IUD was inserted 1 week after a medical
abortion or during a 34-week postabortion follow-up visit [31]. Fur-
thermore, no correlation was found between endometrial thickness or
ultrasound ndings and expulsion [31]. In addition, early insertion of
the LNG-IUS reduced the number of days of heavy bleeding following
a medical abortion [31].
Progestin-only injectable contraceptives (DMPA or norethisterone
enanthate) can be administered immediately following a surgical,
medical, or spontaneous abortion [32,33].
While DMPA is frequently used following abortion and postabortion
care, no studies have yet been published on the initiation of this contra-
ceptive method on the day of misoprostol administration in cases of
medical abortion.
With reference to sterilization, WHOs medical eligibility criteria
states that this procedure can be performed after an uncomplicated
abortion, but should be avoided in the case of any complication [5].
However, regret after sterilization is more common among younger
women and men (b30 years of age) [3436] and when sterilization is
performed postpartum or within the rst year after delivery [36]. In
line with those ndings, sterilization should not be performed routinely
at the time of an abortion in young women, but other alternative forms
of effective, acceptable contraception should be offered, and indeed,
should always be available where abortion services are provided.
Barrier methods can be initiated as soon as required; however,
according to WHO medical eligibility criteria, the diaphragm and cap
are unsuitable until 6 weeks after a second-trimester abortion [5].
When there is a risk of transmission of a sexually transmitted in-
fection (STI) or of HIV, it is important that dual protection be recom-
mended, with the simultaneous use of condoms and another more
effective contraceptive method. Emergency contraceptive pills should
be offered to women relying on less effective methods.
Natural family planning methods cannot be used until the menstrual
cycle has resumed.
4. The effectiveness of providing contraception immediately
following abortion on method use and in preventing
repeat pregnancies
A randomized study on the immediate versus delayed insertion of
an IUD after a surgical abortion showed that all women scheduled for
immediate insertion were indeed inserted with an IUD. On the other
hand, 42% of the women who expressed a desire to use this method,
but were scheduled to return for later insertion, ultimately failed to
return for insertion of the method [25]. Furthermore, women who had
a successful early insertion were more likely to still be using an IUD
6 months later compared with women who had an IUD inserted some
weeks after an abortion [25].
A study carried out in New York City compared two cohorts
of abortion patients, the rst in which the women had to return to
initiate use of an IUD, implants, or DMPA, and another in which the
women could initiate these methods before leaving the clinic after
the pregnancy termination. While 27.3% of the women whose initia-
tion of contraception was delayed got pregnant within the following
12 months, only 15% of those who initiated use of the method imme-
diately following abortion did so. Similarly, 17.7% of the women whose
initiation of the method was delayed had a repeat abortion within the
following year compared with 9.9% of those who initiated contracep-
tion immediately following the abortion [37]. Another study carried
out in Finland also found a signicantly lower rate of repeat abortion
when any contraceptive method was provided immediately after abor-
tion compared with scheduling the woman to return and initiate the
method later [38].
After a medical abortion, common practice is to wait 34 weeks or
until the rst menstrual period following the abortion before inserting
an implant or an IUD, thus incurring a potential risk of a new preg-
nancy. This has been considered a possible disadvantage of medical
abortion compared with surgical abortion. The practice of delayed in-
sertion may also discourage women from using a LARC method owing
to the need to return for several follow-up visits. This applies par-
ticularly to settings where women have to travel long distances for
abortion care or where services are poor or expensive. Changes are
currently taking place in clinical practice in many settings so that
implants are now inserted on the day of misoprostol administration
in cases of medical abortions and postabortion care. However, few
data are available on insertion performed at the time of mifepristone
or misoprostol administration.
Signicantly more women randomized to early initiation of use
returned for IUD insertion compared with women scheduled for de-
layed insertion following a medical abortion, conrming the ndings
of immediate versus delayed insertion in cases of surgical abortion [31].
5. Preference for long-acting reversible contraceptives
Several studies have shown that LARC methods such as the IUD and
contraceptive implants are signicantly more effective in preventing
unwanted pregnancy and repeat abortion than short-acting methods
such as the combined pill, patch, and vaginal ring, or barrier methods
suchas the condomor diaphragm[33,3842]. Studies conductedmostly
in Northern Europe and North America involving LARC and pill users
have found similar rates of unintended pregnancy and repeat abortion,
with the rate among users of LARC methods being one-third to half of
that found in users of the combined pill. In some studies, the risk of
2 K. Gemzell-Danielsson et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxxxxx
Please cite this article as: Gemzell-Danielsson K, et al, Contraception following abortion and the treatment of incomplete abortion, Int J Gynecol
Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.03.003
repeat abortion in DMPA users was found to be signicantly lower than
in pill users [40]; however, other investigators failed to nd any differ-
ence between DMPA and combined pill users [33,41], or reported a
much greater efcacy with DMPA in preventing repeat abortion after
having excluded those women who had discontinued use [43].
One large study showed that when a LARC method is provided free
of charge, thus eliminating the barrier of the high upfront cost, the num-
ber of women choosing to use a LARC method is very high, reaching
two-thirds of all acceptors [44]. Moreover, in a further analysis of that
same study carried out in Saint Louis, USA, a rapid reduction was
found in the rate of repeat abortion to less than half that found in
other populations in the same region or in comparison with the average
rate for the country as a whole [38]. The greatest challenge to the reduc-
tion in the rate of repeat abortion in less resourced countries, where
the burden of unsafe abortion is highest, is to identify mechanisms to
reduce the cost of LARC methods and to overcome other barriers to
the acceptance of LARC immediately after abortion.
6. Conclusion
The care of a womanrequesting pregnancy terminationor treatment
of an incomplete abortion will not be comprehensive or adequate if
family planning counseling and the provision of an effective contracep-
tive method do not form an integral part of such care. We should never
forget that the great majority of these women have rmly decided not
to have a baby in the near future. If they become pregnant again, there
is a very high risk that the pregnancy will result in another abortion,
safe or unsafe, depending on the legal status andthe availability of abor-
tion services in the country in which they live.
There is no doubt that the opportunity to prevent another unin-
tended pregnancy and repeat abortion is largely and signicantly
greater if the women are already using an effective contraceptive
method at the time of their discharge from hospital, more so if that
method is a LARC. When the woman opts to use DMPA following abor-
tion, the rates of repeat abortion are high, similar to those found with
the use of oral contraceptives. Obstetricians and gynecologists have the
ethical obligation to provide benets and prevent harm occurring to
patients under their care [45]. Therefore, there is no excuse for not
doing everything possible to ensure that these women leave the
healthcare unit already protected against an unintended pregnancy
in accordance with the consensus statement on postabortion family
planning drawn up by FIGO and other organizations [45,46].
Conict of interest
The authors have no conicts of interest.
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Please cite this article as: Gemzell-Danielsson K, et al, Contraception following abortion and the treatment of incomplete abortion, Int J Gynecol
Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.03.003