4. Timing of post-abortion contraception

Transcription

1 Web annexes: Medical management of abortion: evidence summary* 4. Timing of post-abortion contraception * This publication forms part of the WHO guideline entitled Medical Management of Abortion. The full guideline and other web annexes are available at: 1

2 WHO/RHR/18.37 World Health Organization 2018 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. Medical management of abortion: evidence base for timing of post-abortion contraception. Geneva: World Health Organization; Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at Sales, rights and licensing. To purchase WHO publications, see To submit requests for commercial use and queries on rights and licensing, see Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is bei ng distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. 2

3 Contents Recommendation 4a: Timing of post-abortion hormonal contraception initiation, except for intrauterine device (IUD)... 1 Comparison 1: Immediate (after mifepristone administration) compared with delayed (at or after follow-up visit) initiation of hormonal contraception: implant... 1 Summary of Findings table for Comparison Forest plots for Comparison Comparison 2: Immediate (after mifepristone administration) compared with delayed (at or after follow-up visit) initiation of hormonal contraception: depot medroxyprogesterone acetate (DMPA)... 6 Summary of Findings table for Comparison Recommendation 4b: Timing of post-abortion intrauterine device (IUD) placement... 1 Comparison: Placement of an IUD at a follow-up visit compared with placement of an IUD at an interval visit after medical abortion regimens... 1 Summary of Findings table for Comparison... 1 Forest plots for Comparison

4 Recommendation 4a: Timing of post-abortion hormonal contraception initiation, except for intrauterine device (IUD) Comparison 1: Immediate (after mifepristone administration) compared with delayed (at or after follow-up visit) initiation of hormonal contraception: implant Summary of Findings table for Comparison 1 Outcome Anticipated absolute effect * (95% CI) Relative effect Risk with delayed Risk with immediate (95% CI) initiation of initiation of contraceptive contraceptive implant implant Efficacy: ongoing pregnancy 8 per per 1000 (1 60) Efficacy: any treatment, medical or surgical, to complete abortion b Efficacy: completed without surgical intervention Efficacy: contraceptive effectiveness, including unintended pregnancy (failure) Safety: serious adverse events; assessed by hospitalization, transfusion, surgery beyond uterine aspiration, death Side-effects: additional abortion procedures needed due to bleeding (minor) 82 per per 1000 (66 145) 950 per per 1000 ( ) 32 per per 1000 (2 20) g RR 1.02 ( ) RR ( ) RR 0.99 ( ) RR ( ) g No. of participants (studies) Certainty of the evidence (GRADE) 1 LOW a VERY LOW c,d LOW e,f LOW h Comment Our confidence in the direct estimate is limited; the true effect may be substantially different from the estimate of the effect Our confidence in the direct estimate is limited; the true effect may be substantially different from the estimate of the effect No direct evidence identified Our confidence in the direct estimate is limited; the true effect may be substantially different from the estimate of the effect No direct evidence identified No direct evidence identified Bleeding is reported either as duration of bleeding and proportion with heavier bleeding than heavy period or implant removal due to bleeding No study provided detailed information about additional medical or surgical abortion procedures required due to heavy bleeding 1 Grading of Recommendations Assessment, Dev elopment and Ev aluation more information: w w.gradeworkinggroup.org Recommendation 4a: Timing of post-abortion hormonal contraception initiation, except for intrauterine device (IUD) 1

5 Outcome Anticipated absolute effect * (95% CI) Relative effect Risk with delayed Risk with immediate (95% CI) initiation of initiation of contraceptive contraceptive implant implant Side-effects: contraception discontinued due to bleeding (minor) Side-effects: pain/abortion-related pain Acceptability of immediate contraception before abortion (i.e. not disappointed with assignment; rated as pleased or neutral); assessed by patient report Acceptability of contraception at 6 months (very satisfied, fairly satisfied, plus neither dissatisfied nor satisfied); assessed by patient report Continuation rates of implant at 6 months 42 per per 1000 (19 97) 479 per 1000 j 521 per 1000 ( ) j 875 per per 1000 ( ) 467 per per 1000 ( ) 669 per per 1000 ( ) RR 1.03 ( ) RR 1.09 ( ) j RR ( ) RR 1.28 ( ) RR 1.17 ( ) No. of participants (studies) 538 (1 RCT) (1 RCT) Certainty of the evidence (GRADE) 1 VERY LOW d,i VERY LOW d,k LOW l VERY LOW i,m VERY LOW i,n Comment No direct evidence identified CI: confidence interval; RCT: randomized controlled trial; RR: risk ratio * The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). Hognert et al. 2 measured pain but did not report pain by group Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group grades of evidence High certainty: We are very confident that the true effect is close to the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: Our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of th e effect. Very low certainty: We have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect. Explanations a. 95% CI for surgery to complete abortion and any extra surgical or medical treatment to complete abortion include both appreciable benefit and harm. b. Includes surgery for ongoing pregnancy, surgeries for other reasons, and additional medical treatment. No details provided fo r nature or reason of other surgeries. c. Moderate risk for one study and low for the other. d. Downgraded by two: (1) 95% CI crosses 1 and (2) total number of events is < 300. e % attrition in one study, low in other. f. 95% CI crosses 1. g. Intention to treat (ITT) not performed. They excluded women who did not have 6 months of follow-up or those who were followed up but were missing pregnancy data. The denominator we use is the number originally randomized (ITT) and our CI assumes both worst case and best case scenarios (e.g. all excluded either did not become pregnant or all became pregnant). Recommendation 4a: Timing of post-abortion hormonal contraception initiation, except for intrauterine device (IUD) 2

6 h. Concern about outcome assessment: pregnancy at 6 months (contraceptive failure) was defined by the patient not actively reporting being pregnant (self-report) resulting in issues both of accuracy as it relates to pregnancy status early in pregnancy and the need to actively report the pregnancy for it to be coun ted. i. High attrition approximately 30% attrition in immediate and 43% attrition in delayed. j. Measured on scale of 0 10; scores of 8 or higher were considered to be severe. k. Outcome measures not described in protocol; or methods rating scale using 0 10, but categorized as 7 or less, 8 or greater; or missing. l. Concern about high attrition 28% immediate and 36% delayed at 6 months; no blinding of outcome assessment. m. Event rate is < 300 cases. n. Loss to follow-up between % in immediate and % in delayed groups. References 1. Raymond EG, Weaver MA, Tan YL, Louie KS, Bousiéguez M, Lugo-Hernández EM, et al. Effect of immediate compared with delayed insertion of etonogestrel implants on medical abortion efficacy and repeat pregnancy: a randomized controlled trial. Obstet Gynecol. 2016;127(2): Hognert H, Kopp Kallner H, Cameron S, Nyrelli C, Jawad I, Heller R, et al. Immediate versus delayed insertion of an etonogestrel releasing implant at medical abortion a randomized controlled equivalence trial. Hum Reprod. 2016;31(11): Recommendation 4a: Timing of post-abortion hormonal contraception initiation, except for intrauterine device (IUD) 3

7 Forest plots for Comparison 1 Analysis 1. Efficacy: additional procedures to complete abortion Analysis 2. Efficacy: completion without surgical intervention Analysis 3. Efficacy: contraceptive effectiveness immediate versus delayed implant Recommendation 4a: Timing of post-abortion hormonal contraception initiation, except for intrauterine device (IUD) 4

8 Analysis 4. Continuation rates of implant at 6 months Recommendation 4a: Timing of post-abortion hormonal contraception initiation, except for intrauterine device (IUD) 5

9 Comparison 2: Immediate (after mifepristone administration) compared with delayed (at or after follow-up visit) initiation of hormonal contraception: depot medroxyprogesterone acetate (DMPA) Summary of Findings table for Comparison 2 Outcome Anticipated absolute effect * (95% CI) Relative effect Risk with delayed Risk with immediate (95% CI) initiation of DMPA initiation of DMPA Efficacy: ongoing pregnancy 8 per per 1000 (8 166) Efficacy: additional procedures to complete abortion Efficacy: completed without surgical intervention Efficacy: contraceptive effectiveness immediate vs delayed (failure) Safety: serious adverse events; assessed by hospitalization, transfusion, surgery beyond uterine aspiration, death Side-effects: additional abortion procedures due to bleeding (minor) Side-effects: discontinued contraception due to bleeding (minor) Side-effects: pain/abortion-related pain 114 per per 1000 (70 192) 51 per per 1000 (29 132) 30 per 1000 c 22 per 1000 (7 69) c RR 4.20 ( ) RR 1.01 ( ) RR 1.22 ( ) RR 0.75 ( ) c No. of participants (studies) ,c Certainty of the evidence (GRADE) LOW a LOW b LOW b VERY LOW b,d,e Comment Our confidence in the direct estimate is limited; the true effect may be substantially different from the estimate of the effect Our confidence in the direct estimate is limited; the true effect may be substantially different from the estimate of the effect No direct evidence identified Our confidence in the direct estimate is limited; the true effect may be substantially different from the estimate of the effect No direct evidence identified No direct evidence identified Bleeding is reported either as duration of bleeding or proportion with heavier bleeding than heavy period No detailed information provided about additional medical or surgical abortion procedures required due to heavy bleeding No direct evidence identified 445 per 1000 f 467 per 1000 ( ) f RR 1.05 ( ) f 461 VERY LOW b,g Recommendation 4a: Timing of post-abortion hormonal contraception initiation, except for intrauterine device (IUD) 6

10 Outcome Anticipated absolute effect * (95% CI) Relative effect Risk with delayed Risk with immediate (95% CI) initiation of DMPA initiation of DMPA Acceptability of immediate contraception before abortion (i.e. not disappointed with assignment; rated as pleased or neutral); assessed by patient report 890 per per 1000 ( ) RR 1.10 ( ) No. of participants (studies) 461 Certainty of the evidence (GRADE) VERY LOW b,d,h Comment CI: confidence interval; RCT: randomized controlled trial; RR: risk ratio * The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). Not defined in methods or protocol Data related to whether participants are not disappointed (i.e. neutral or pleased) with assignment, prior to abortion or contraception GRADE Working Group grades of evidence High certainty: We are very confident that the true effect is close to the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: Our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect. Very low certainty: We have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect. Explanations a. 95% CI for surgery to complete abortion and any extra surgical or medical treatment to complete abortion include both appreci able benefit and harm. b. Downgraded by two: (1) 95% CI includes both possible harm and possible benefit; and (2) total number of events is < 300. c. Intention to treat (ITT) not performed. They excluded women who did not have 6 months of follow-up or those who were followed up but were missing pregnancy data. The denominator we use is the number originally randomized (ITT) and our CI assumes both worst case and best case scenarios (e.g. all excluded either did not become pregnant or all became pregnant). d. Outcome measure not described in methods of paper nor in registered protocol. Data presented in abstract indi cates satisfaction with group assignment. e. Concern about outcome assessment: pregnancy at 6 months (contraceptive failure) was defined by the patient not actively reporting being pregnant (self-report) resulting in issues both of accuracy as it relates to pregnancy status early in pregnancy and the need to actively report the pregnancy for it to be counted. f. Measured on scale of 0 10; scores of 8 or higher were considered to be severe. g. Outcome measures intent and assessment not reported in registered protocol or methods. h. Outcome measure is satisfaction with group assignment in the study. Unclear whether this is driven by satisfaction with abortion, contraception, study follow-up or other study-related differences in the groups. No description is provided in either of two related studies or their protocols to understand how this was asked. Also patients were significantly different at baseline which was more dramatic than the change in groups over time. This is not accounted for. Reference 1. Raymond EG, Weaver MA, Louie KS, Tan YL, Bousiéguez M, Aranguré-Peraza AG, et al. Effects of depot medroxyprogesterone acetate injection timing on medical abortion efficacy and repeat pregnancy: a randomized controlled trial. Obstet Gynecol. 2016;127(2): Recommendation 4a: Timing of post-abortion hormonal contraception initiation, except for intrauterine device (IUD) 7

11 Recommendation 4b: Timing of post-abortion intrauterine device (IUD) placement Comparison: Placement of an IUD at a follow-up visit compared with placement of an IUD at an interval visit after medical abortion regimens Summary of Findings table for Comparison Outcome Anticipated absolute effect * (95% CI) Relative effect Risk with delayed Risk with immediate (95% CI) initiation of an IUD placement of an IUD (3 6 weeks after (5 7 days after mifepristone) mifepristone) Efficacy: contraceptive effectiveness including unintended pregnancy at 6 months Efficacy: contraceptive effectiveness including unintended pregnancy at 12 months Efficacy: need for further intervention (uterine evacuation) post-iud placement due to retained tissue/bleeding (efficacy of medical abortion) Safety: post-iud placement infection 27 per per 1000 (0 60) 120 per per 1000 (18 111) 0 per per 1000 (0 0) 77 per per 1000 (46 191) Safety: perforation 6 months 0 per per 1000 (0 0) Safety: perforation 12 months 0 per per 1000 (0 0) Safety: expulsion at 6 months 92 per per 1000 (50 224) Safety: expulsion at 12 months 38 per per 1000 (0 0) RR 0.12 ( ) RR 0.37 ( ) RR ( ) RR 1.21 ( ) RR 0.91 ( ) RR 0.87 ( ) RR 1.14 ( ) RR 0.48 ( ) No. of participants (studies) (1 RCT) (3 RCTs) (2 RCTs) 1, (1 RCT) (1 RCT) 3 5 Certainty of the evidence (GRADE) LOW a,b VERY LOW b,c LOW b,d,e LOW b,c,f h LOW a,b VERY LOW b,c LOW a,b VERY LOW b,c Comment We are uncertain about the effect of this outcome because the certainty of the evidence is low We are uncertain about the effect of this outcome because the certainty of the evidence is very low because the certainty of the evidence is low because the certainty of the evidence is low because the certainty of the evidence is low because the certainty of the evidence is very low because the certainty of the evidence is low because the certainty of the evidence is very low Recommendation 4b: Timing of post-abortion intrauterine device (IUD) placement 1

12 Safety: bleeding post-iud resulting in additional procedures Safety: death 0 per per 1000 (0 0) Side-effects: bleeding, contraception discontinued Side-effects: pain at IUD insertion (scale 0 10) Acceptability of/satisfaction with IUD Continuation rates of IUD at 6 months Continuation rates of IUD at 12 months Overlaps with need for further intervention post- IUD No events reported Korjamo et al. 4,5 reports bleeding problems defined as additional contact or an intervention needed but they did not differentiate between the two RR 1.03 ( ) 558 (3 RCTs) 1 5 VERY LOW b,c,i because the certainty of the evidence is very low Unable to derive GRADE outcome as either not reported or not disaggregated per group The mean side-effects pain at IUD insertion was 0 The mean side-effects pain at IUD insertion in the intervention group was 0 (0 0) 90 (1 RCT) 4 MODERATE j There is probably little or no difference in the pain experienced with IUD insertion when initiation is immediate or delayed following medical abortion for gestations up 63 days No direct evidence identified 608 per per 1000 ( ) 391 per per 1000 ( ) RR 1.09 ( ) RR 1.58 ( ) (1 RCT) 3 MODERATE a,i VERY LOW c,h CI: confidence interval; RCT: randomized controlled trial; RR: risk ratio * The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). There may be little or no difference in the continuation rate of IUD use at 6 months between women who received immediate versus delayed IUD insertion post-medical abortion because the certainty of the evidence is very low GRADE Working Group grades of evidence High certainty: We are very confident that the true effect is close to the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: Our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect. Very low certainty: We have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of e ffect. Explanations a. Risk of bias: downgraded 1: loss to follow-up variable but one study had 24% in delayed placement group. b. Imprecision: downgraded 1 level as studies are relatively small and outcome is an example of a rare event. c. Risk of bias: downgraded 2 levels as loss to follow-up is > 20% in one study. d. Risk of bias: no downgrade: duration of time of follow up is variable across studies (6 versus 12 months); although assuming that need for an intervention either for retained tissue due to the medical abortion following IUD placement would occur within several months postplacement and all studies reported over this time period. Recommendation 4b: Timing of post-abortion intrauterine device (IUD) placement 2

13 e. Risk of bias: downgraded 2 levels: studies varied in exclusion of subjects who needed uterine evacuation prior to IUD insertion. All studies utilized ultrasound to dete rmine if ongoing pregnancy, missed abortion, or thick endometrium triggering evacuation occurred prior to IUD placement. Thus, interventions were already performed prior to IUD placement in all studies making it unlikely of an intervention being necessary post-iud placement. f. Risk of bias: downgraded 1 level: one study enrolled women with lower risk of women as routine sexually transmitted infection (STI) screening occurred. g. Risk of bias: no downgrade: duration of time to determine outcome is variable across studies; although assumption would be that likely infection due to post-medical abortion/iud would occur within several months post-procedure and all studies reported over this time period. h. Inconsistency: no downgrade: only one study accounted for all of the infections reported. i. Risk of bias: no downgrade: duration of time of follow up to determine outcome is variable across studies; although assumption would be that likely a death due to medical abortion and IUD placement would occur within several months post-procedure and all studies reported over this time period. j. Inconsistency: downgraded 1 level: only one study provided pain at insertion data that could be summarized in GRADE format. References 1. Saav I, Stephansson O, Gemzell Danielsson K. Early versus delayed insertion of intrauterine contraception after medical abortion a randomized controlled trial. PLoS One. 2012;7(11):e Shimoni N, Davis A, Ramos ME, Rosario L, Westhoff C. Timing of copper intrauterine device insertion after medical abortion: a randomized controlled trial. Obstet Gynecol. 2011;118(3): Korjamo R, Mentula M, Heikinheimo O. Immediate versus delayed initiation of the levonorgestrel-releasing intrauterine system following medical termination of pregnancy 1 year continuation rates: a randomised controlled trial. BJOG. 2017;124(13): Korjamo R, Mentula M, Heikinheimo O. Fast-track vs. delayed insertion of the levonorgestrel-releasing intrauterine system after early medical abortion: a randomized trial. Contraception. 2017;96(5): Korjamo R, Mentula M, Heikinheimo O. Expulsions and adverse events following immediate and later insertion of a levonorgestre l releasing intrauterine system after medical termination of late first- and second-trimester pregnancy: a randomised controlled trial. BJOG. 2017;124(13): Recommendation 4b: Timing of post-abortion intrauterine device (IUD) placement 3

14 Forest plots for Comparison Analysis 1. Efficacy: contraceptive effectiveness at 6 months Analysis 2. Safety: infection Recommendation 4b: Timing of post-abortion intrauterine device (IUD) placement 4

15 Analysis 3. Safety: expulsion at 6 months Analysis 4. Continuation rate at 6 months Recommendation 4b: Timing of post-abortion intrauterine device (IUD) placement 5