Contraception + MTOP Flashcards
Sian is a 39 year old patient who lives rurally approx. 5 hours drive West of Rockhampton. She has undergone an MTOP @8+3 weeks gestation via telehealth. You contact her 15 days after she took mifepristone for her follow-up assessment. She gives a history of bleeding and passing clots after taking
misoprostol, which settled into light bleeding for a few days.
She feels well and has no fever. Her breasts are slightly tender but her nausea has resolved. She did her LSUP test today which was positive.
What next steps would you take?
a. Reassure Sian and suggest she does a HSUP in 2 weeks
b. Advise Sian that her symptoms are within normal limits and to seek medical advice if her next menses don’t arrive
c. Advise Sian that she needs an ultrasound scan
d. Advise Sian to have a serum HCG
D serum BHCG
What Serum BHCG level suggest successful MTOP?
What are the advantages/disadvantages?
> 80% decline at least 6 days after taking mifepristone is predictive of successful abortion.
Disadvantages Invasive Cost Inconvenience Delay in results
Advantages
Early detection of decline in levels
Accessible
Useful for VEMA or PUOL
When do BHCG levels peak in pregnancy?
week 10
46000 - 186,000
Management of post MTOP infection?
Infection «1%
Broad spectrum antibiotics (oral or IV) including cover for
anaerobes, chlamydia and gonorrhoea
Refer to Therapeutic Guidelines:
E.g. doxycycline (100mg BD) or azithromycin (1g stat)
+ amoxicillin/clavulanate 875/125 mg orally, bd for 14 days
or
metronidazole 400mg bd for 10 days
USS findings:
Anechoic structure in endometrial cavity measures 9.3mm,
no yolk sac, no fetal pole. (TAS and TVS)
Impression: findings in keeping with an early gestation sac
approximating 5 weeks gestation
Serum HCG: 1900 IU/L
Which of the following is not an appropriate course of
action?
a) Arrange a repeat USS in 1 week
b) Prescribe MS-2 Step as per routine instructions
c) Repeat serum HCG in 48 hours
d) Prescribe MS-2 Step with HCG tracking
b) Prescribe MS-2 Step as per routine instructions
IUP not confirmed
25 year old Kayla attends for her postnatal check up and asks to restart the pill for contraception. Her baby is 6 weeks old and she is breastfeeding with a supplementary bottle feed overnight. She has not had sex since having the baby
Which is the following is the correct option regarding the
postpartum use of the COC in women with no medical comorbidities?
a. The COC can be recommenced immediately after childbirth
in women with no medical co-morbidities
b. COC commencement should be delayed until 6 months after
childbirth in breastfeeding women
c. COC can be commenced 4 weeks after childbirth in
breastfeeding women
d. COC can be commenced 6 weeks after childbirth in
breastfeeding women
d. COC can be commenced 6 weeks after childbirth in
breastfeeding women
Regarding initiation of contraception in the postpartum period,
which of the following is the correct answer?
a) DMPA initiation should be delayed until day 21 postpartum in
breastfeeding women
b) Implanon insertion should be delayed until day 14
postpartum in breastfeeding women
c) If not inserted during caesarean section or within 48 hours of
birth, insertion of an IUD should be delayed until ≥4 weeks
postpartum
d) The COC can be safely initiated without restriction anytime
postpartum in breastfeeding and non-breastfeeding women
C
DMP ans SDI immediately
non-breast feeding women COC 21 days
Regarding IUD insertion after childbirth, which of the following is
correct?
a. The IUD should be inserted either immediately after birth or
within the first 14 days
b. If not inserted within 48 hours of childbirth, insertion of a
LNG-IUS should be delayed until 6 weeks
c. For immediate postpartum IUD placements, the risk of
expulsion is greater for placement after vaginal compared
with C-section deliveries
d. Women at higher risk of VTE should have insertion of a LNGIUS postponed until 28 days postpartum
c. For immediate postpartum IUD placements, the risk of
expulsion is greater for placement after vaginal compared
with C-section deliveries
Insertion within first 48 hours (of vaginal or caesarean
delivery) is safe = UKMEC 1
Expulsion rates higher than at 4-6 weeks postpartum
Lower expulsion rate at caesarean than vaginal
delivery
• Insertion 48 hours to < 4 weeks: wide range of expulsion rates
= UKMEC 3
• Insertion ≥ 4 weeks = UKMEC 1
• Rate of perforation is very low: rates highest during lactation
and in first 36 weeks postpartum
Combined hormonal contraceptive is contraindicated in the
following women?
a) A 33 year old women with a BMI of 34kg/m2
b) A 48 year old woman with vasomotor symptoms
c) A 22 year old women who is 4 weeks postpartum (not
breastfeeding)
d) A 28 year old woman with migraine with aura (no episode
for 12 months)
D
BMI 30-34 is UKMEC 2
>35yrs UKMEC 3, stop age 50
non-BF with no additional VTE Risk >21days post partum UKMEC 2
Migraine with aura UKMEC 4 unless >5years ago then UKMEK 3
Non-migrainous
• Migraine without aura, any age
• Migraine with aura, any age
• History (≥5 yrs ago) of migraine with aura any age
• Main points are:
• CHC UKMEC 4 if aura
• CHC UKMEC 3 if history of migraine with aura (>5 years)
• CHC UKMEC 3 for continuation if develops migraine with aura
All other methods UKMEC 1 or 2
What are the Fraser guidelines?
For contraception prescribing.
The young person understands the professionals advice
The young person cannot be persuaded to inform their
parents
The young person is likely to begin or to continue having
sex with or without contraceptive treatment
Unless the young person receives contraceptive
advice/treatment their health is likely to suffer
(mental/physical)
Best interests to receive advice or treatment
Must also be gillick competent
Which of the following would you advise for Nadi?
a) She should have her Mirena IUS changed now
b) She should have the Mirena IUS removed as she is likely
to be menopausal and doesn’t need contraception
c) The mirena IUS should be left in situ and her FSH level
should be checked
d) The mirena IUS should be left in situ and she should be
offered transdermal estrogen
C
IUD can be removed 1 year after high FSH
Mirena inserted at 45yrs can remain until age 55yrs if used for contraception or heavy menstrual bleeding
Diagnosis of menopause is made retrospectively after 1 year of
amenorrhoea
Average age of menopause is 51 years
Stop contraception:
• 2 years after LMP if <50 years of age
• 1 year after the LMP if ≥50 years of age
• At age 55 years
If > 50 years and wishing to stop contraception, check FSH level
FSH >30IU/L discontinue method after 1 more year
IU methods should be removed after the menopause
Aged 50 years stop CHC and DMPA and switch to another
method if required
Implant, POP, LNG-IUS can continue over aged 50 years
if required
Stephanie, age 21 had UPSI 80 hours ago
LMP 12/7 ago
P0+2 (STOP 3 months ago, MTOP 12 months ago)
BMI 29; DH nil; PMH nil remarkable
She has been offered a copper-IUD for EC however is certain she
doesn’t want this option
Which of the following would be the most efficacious option
for Stephanie in terms of preventing an unplanned
pregnancy?
a) 30mg ulipristal acetate PO stat
b) 60mg ulipristal acetate PO stat
c) 1.5mg Levonorgestrel PO stat
d) 3 mg Levonorgestrel PO stat
A) 30mg UPA
If <96hrs and around high risk time of cycle then UPA if Copper IUD is declined
If UPA-EC is taken, its effectiveness for EC could be reduced if progestogen is taken in the following 5 days. Quick start of suitable hormonal contraception should therefore be delayed for 5 days (120 hours)
Copper IUD inserted within 5 days unprotected sex ( > 99% effective) Can insert up to 5 days after ovulation regardless of when UPSI
has occurred. Can insert later than this in cycle if no more than 5 days after earliest UPSI in that cycle
Can be kept as ongoing contraception
Failure rate about 26 or weight >70kgs
In order to reliably exclude pregnancy a urinary B-HCG should be
undertaken:
a) 14 days after the last episode of unprotected sexual
intercourse (UPSI)
b) 21 days after the last UPSI
c) 28 days after her LMP UPSI
d) The day the next menses are due
B
or 5 weeks post LMP
Pregnancy cannot be excluded by an HSUP*
(25mIU/ml) until ≥21 days after the last UPSI
If quick started how many days of bridging contraception/abstinence is needed for the following: COCP COCP Qlaira POP PO implant/injectable
COCP 7 days
COCP Qlaira 9 days
POP 2 days
PO implant/injectable 7 days
A woman has unprotected sexual intercourse 7 days after an
abortion. Which of the following statements is false?
a. All methods of emergency contraception are suitable
b. An emergency intrauterine device cannot be considered
c. If a subdermal implant is quick started with levonorgestrel
emergency contraception, 7 days of additional contraception is
needed
d. If ulipristal acetate is given, a woman should wait 5 days before
quick starting a hormonal method of contraception
B
IUD can be considered, it is the most effective method
Emergency contraception is indicated for a woman who has
had unprotected sexual intercourse after childbirth from:
a. 7 days
b. 14 days
c. 21 days
d. 28 days
C 21 days
Which of the following contraceptive methods acts primarily by inhibition of ovulation? A. Copper-T 380 IUD B. Progestogen only pill C. Etonogestrel contraceptive implant D. LNG- IUD E. Caya diaphragm
C
To be effective, the contraceptive diaphragm must be left in place after sex for at least: a) 1 hour b) 6 hours c) 12 hours d) 24 hours
B
Regarding DMPA (DepoProvera) which of the following is True?
a) Its use is contraindicated in under 16’s
b) It is ideal to be used as a “quick start” method
c) Long term use is associated with an increase in hip fracture
risk
d) It can be continued until age 50
D
Can be used as quick start but not preferred
In Australia, clinicians should refer to the following guideline for safe contraceptive prescribing: a) AUSMEC b) USMEC c) UKMEC d) WHOMEC
C
UKMEC category 3 means:
a) The method should not be prescribed in this patient
b) The benefits of the method outweigh the risks of using the
method
c) The risks of the method generally outweigh the benefits of
this method
d) There are 3 separate contraindications for this method
C
