Case 29.8 – Unplanned Pregnancy & Contraception [SDL]
Category: Endocrine & Reproductive Symptoms | Discipline: Obstetrics & Gynaecology | Setting: General Practice
Learning Objectives
This is a self-directed learning (SDL) case. Use the key learning points below to guide your independent study of unplanned pregnancy and emergency contraception.
Key Topics to Cover
- Epidemiology: 45% of pregnancies in UK are unplanned, 1 in 3 women will have an abortion by age 45
- Initial assessment (presenting with unplanned pregnancy):
- Confirm pregnancy: Urine βhCG (positive 14 days after conception, ~day 28 of cycle), transvaginal USS (gestational sac visible 5 weeks gestation)
- Establish gestational age: Last menstrual period (LMP), USS dating (crown-rump length <14 weeks)
- Explore options (non-directive counselling):
- Continue pregnancy: Antenatal care, adoption if desired
- Abortion: Medical or surgical (patient choice)
- Exclude ectopic pregnancy: Pain, bleeding, empty uterus on USS, βhCG plateau/slow rise
- Emergency contraception (post-unprotected intercourse):
- 1. Copper IUD (Cu-IUD) - MOST EFFECTIVE (\>99% efficacy):
- Can be inserted up to 5 days after unprotected sexual intercourse (UPSI) OR up to 5 days after earliest estimated ovulation (whichever is later)
- Mechanism: Prevents implantation (toxic to sperm/ova, prevents fertilization)
- Advantages: Most effective, can be left in situ for ongoing contraception (10 years), no hormonal side effects
- Disadvantages: Invasive procedure, risk of infection (PID), heavier/painful periods
- 2. Ulipristal acetate (UPA / ellaOne) - SECOND-LINE (98% efficacy if taken within 24 hours):
- Single oral dose (30mg) - effective up to 120 hours (5 days) after UPSI
- Mechanism: Selective progesterone receptor modulator → delays/inhibits ovulation
- Advantages: More effective than levonorgestrel (especially 72-120 hours), non-invasive
- Disadvantages: Delayed next period (may cause anxiety), cannot use hormonal contraception for 5 days after (UPA antagonizes progesterone)
- BMI >26 or weight >70kg: Consider double dose (60mg - off-label) or Cu-IUD (UPA efficacy may be reduced)
- 3. Levonorgestrel (Levonelle) - THIRD-LINE (95% efficacy if taken within 24 hours):
- Single oral dose (1.5mg) - effective up to 72 hours (3 days) after UPSI
- Mechanism: Delays/inhibits ovulation (ineffective if ovulation already occurred)
- Advantages: Available over-the-counter (pharmacy), can start hormonal contraception immediately
- Disadvantages: Less effective than UPA (especially 48-72 hours), efficacy reduced if BMI >26 (consider double dose 3mg or Cu-IUD)
- Key counselling:
- Efficacy decreases with time - earliest possible administration best
- Not 100% effective - pregnancy test if period delayed >7 days
- Does NOT protect against future UPSI - start regular contraception immediately (or use Cu-IUD for ongoing contraception)
- STI risk: Offer STI screening if unprotected sex
- Abortion (termination of pregnancy) - Legal Framework:
- UK law (Abortion Act 1967, amended 1990):
- Legal up to 24 weeks gestation if continuing pregnancy involves greater risk to physical/mental health of woman/existing children than termination (Clause C - >98% of abortions)
- Legal up to term if: Severe fetal abnormality incompatible with life (Clause E), or grave risk to mother's life/health (Clause B/D)
- Requires 2 doctors to sign HSA1 form confirming legal grounds
- Northern Ireland: Abortion legal since 2020 (similar to England/Wales)
- Methods of abortion:
- Medical abortion (up to 10 weeks gestation - can be used up to 24 weeks):
- Regimen:
- Mifepristone 200mg oral (anti-progesterone → stops pregnancy) - Day 1
- Misoprostol 800mcg buccal/vaginal (prostaglandin → induces uterine contractions, expels pregnancy) - 24-48 hours later (Day 2-3)
- Home medical abortion: Can take both medications at home (up to 10 weeks) - approved 2020 (COVID-19 pandemic), now permanent
- Efficacy: 95-98% (≤9 weeks), decreases with gestation
- Process: Bleeding/cramping starts 1-4 hours after misoprostol, pregnancy expelled within 4-6 hours (heavy bleeding 1-2 weeks)
- Follow-up: Urine pregnancy test 3 weeks later (confirm complete abortion), or USS if ongoing symptoms
- Complications: Incomplete abortion (2-5% - requires surgical evacuation), infection (1%), ongoing pregnancy (\<1%)
- Surgical abortion:
- Vacuum aspiration (suction curettage) - up to 14 weeks:
- Performed under local anesthetic + sedation or general anesthetic
- Cervix dilated, suction catheter inserted to evacuate uterus
- Duration: 5-10 minutes, day case
- Efficacy: >99%
- Dilation and evacuation (D&E) - 14-24 weeks:
- Cervical preparation (mifepristone + misoprostol 24-48 hours before), then surgical evacuation under general anesthetic
- More complex procedure, higher complication risk
- Advantages: Quicker (single visit), predictable timing, less bleeding than medical
- Complications: Uterine perforation (\<1%), cervical trauma (\<1%), infection (1%), incomplete evacuation (1%)
- Post-abortion contraception:
- Start immediately (fertility returns quickly - ovulation within 2 weeks)
- LARC recommended: IUD (Cu-IUD or LNG-IUS), implant (Nexplanon), depot injection (Depo-Provera) - highest efficacy, prevent repeat unplanned pregnancy
- Cu-IUD: Can be inserted immediately after surgical abortion or after medical abortion is complete
- Hormonal contraception: Can start day of mifepristone (medical abortion) or immediately after surgical abortion
- Fraser competence (Gillick competence) - Contraception/abortion in under-16s:
- Legal framework: Under-16s can consent to contraception/abortion if Fraser competent (without parental consent)
- Fraser criteria (ALL must be met):
- Young person understands advice and has sufficient maturity to understand implications
- Cannot persuade young person to inform parents or allow clinician to inform parents
- Young person is likely to continue having sex with/without contraception
- Young person's physical/mental health likely to suffer without contraception/abortion
- Young person's best interests require contraception/abortion without parental consent
- Safeguarding: Assess for coercion, abuse, exploitation - follow local safeguarding policies (may need to breach confidentiality if serious risk of harm)
- Encourage parental involvement but respect young person's confidentiality if Fraser competent
- Key ethical/legal principles:
- Non-directive counselling: Provide unbiased information on all options (continue pregnancy, abortion, adoption)
- Autonomy: Patient's decision (not clinician's moral/religious views)
- Confidentiality: Absolute (unless safeguarding concerns)
- Conscientious objection: Clinicians can refuse to participate in abortion (Abortion Act 1967 Section 4) BUT must refer to another clinician (cannot obstruct access to care)
Recommended Resources
Refer to your lecture notes, textbooks (e.g., Oxford Handbook of Obstetrics & Gynaecology), and online resources (RCOG guidelines, FSRH guidelines, BPAS, MSI Reproductive Choices) to explore these topics in detail.