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ECTOPIC PREGNANCY 53
5000 mIU/mL. No fetal cardiac activity should be present, and the size of the ectopic mass should be
relatively small (e.g., <3 to 4 cm). An hCG level lower than 5000 mIU/mL raises the risk of treatment
failure by 5.5 times.
Intramuscular MTX is the most common route of administration, and both single- and multiple-
dose protocols exist. Single-dose MTX is more than 90% effective, has fewer side effects, and does
not require folinic acid rescue therapy. Common side effects (seen in 30% of patients) include severe
pelvic pain (usually days 3 to 7 after initiating therapy), stomatitis, and conjunctivitis. However, more
rare and severe reactions (e.g., hepatotoxicity, pulmonary toxicity, myelosuppression, nephrotoxicity)
are possible.
The day MTX is given is considered day 1, and hCG levels should fall by at least 15% between
days 4 and 7 (it is not unusual for hCG levels to rise on days 1 to 3). If a 15% decline is not achieved,
an additional dose of MTX per week can be given to a maximum of three additional doses until the
hCG falls by 15%. After three additional doses have been given, a lack of decline is considered treat-
ment failure, and surgical treatment should be performed.
14. What does surgical management of an ectopic pregnancy involve, and who is
eligible?
Indications for surgical management include hemodynamic instability, suspicion of rupture, contraindi-
cations to MTX, or treatment failure. The most common procedure is laparoscopy with salpingostomy
or salpingectomy. In a salpingostomy, the fallopian tube is incised, the ectopic pregnancy is removed,
and the tube is left to heal by secondary intention. This method preserves future fertility through
that fallopian tube, but it does carry the risk of leaving some trophoblastic tissue in the fallopian
tube (termed a persistent ectopic pregnancy). Patients should be followed with weekly hCG levels
until these levels are undetectable. A salpingectomy is removal of the fallopian tube with the ectopic
pregnancy; although it does not preserve future fertility on that side, it has an extremely low risk of
persistent ectopic pregnancy.
BiBliography
1. American College of Obstetricians and Gynecologists. Medical management of ectopic pregnancy. ACOG practice bul-
letin no. 94. Obstet Gynecol. 2008;111:1479–1485.
2. Barnhart K. Ectopic pregnancy. N Engl J Med. 2009;361:379–387.
3. Connolly A, Ryan DH, Stuebe AM, Wolfe HM. Reevaluation of the discriminatory and threshold levels of Serum β-hCG in
early pregnancy. Obstet Gynecol. 2013;121:65–70.
4. Lobo RA. Ectopic pregnancy. In: Lentz GM, Lobo RA, Gershenson DM, et al., eds. Comprehensive Gynecology. 6th ed.
Philadelphia: Mosby; 2013.
5. Murray H, Baadkah H, Bardell T, Tulandi T. Diagnosis and treatment of ectopic pregnancy. CMAJ. 2005;173:905–912.
6. Stovall TG, Ling FW, Carson SA, Buster JE. Serum progesterone and uterine curettage in differential diagnosis of ectopic
pregnancy. Fertil Steril. 1992;57:456–457.
KEY POINTS: ECTOPIC PREGNANCY
1. Ectopic pregnancy is the most common cause of maternal pregnancy-related death in the first
trimester.
2. The most significant risk factor for ectopic pregnancy is a history of salpingitis resulting from
sexually-transmitted infections such as Chlamydia infection or gonorrhea.
3. The most common symptoms of an ectopic pregnancy are abdominal pain and vaginal bleeding.
4. A quantitative hCG of more than 1500 mIU/mL with no evidence of an IUP visualized on TVUS is
concerning for an ectopic pregnancy.
5. The management of an ectopic pregnancy can be either medical or surgical, depending on the
patient’s preference and the clinical characteristics.
6. Consider heterotopic pregnancy in any patient who has recently undergone ART.
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54
1. What percentage of pregnancies is unintended?
Approximately 51% of pregnancies are unintended. Of these, 20% are unwanted, and 31% are
mistimed.
2. What percentage of pregnancies ends in abortion?
Approximately 20% of all pregnancies end in abortion; among unintended pregnancies, this rises to 4
out of every 10.
3. What are the major methods used to terminate a pregnancy?
• Medical abortion
• Surgical abortion: either dilation and curettage (D&C) or dilation and evacuation (D&E)
• Labor induction
4. At what gestational age are abortions most often performed?
Almost 90% of abortions occur in the first trimester; 30% of all abortions occur at 6 weeks or earlier,
and less than 1% of abortions are performed after 20 weeks.
5. What workup is needed before offering or performing an abortion?
• A complete history and physical examination
• Ultrasound scan to confirm pregnancy and determine gestational age
• Hemoglobin or hematocrit if anemia is suspected
• Rh testing; if a woman is Rh negative, RhD immunoglobulin should be administered at the time of
the procedure
6. How does gestational age affect the type of abortion that can be offered?
• Less than 9 weeks: Medical or surgical options can be offered based on the patient’s preference.
Evidence-based medical regimens are most effective for pregnancies of less than 49 days.
• 9 to 13 weeks: Both medical and surgical options can still be offered, although medical abortions at
this gestational age are typically done in an inpatient setting.
• More than 13 weeks: Surgical abortion or labor induction can be offered.
7. What are the major differences between medical and surgical abortions in the first
trimester?
Table 13-1 provides a comparison of medical and surgical abortions.
8. What percentage of abortions is completed medically?
Fifteen percent to 20% of all abortions are completed medically.
9. What medications are used for medical abortions? How do they work?
• Mifepristone (RU-486): a progesterone antagonist that causes decidual necrosis of the uterine
lining, softening of the cervix, and increased contractility of the uterus. It is most commonly used in
combination with a prostaglandin.
• Misoprostol: a prostaglandin that is used off-label for medical abortion and labor induction. It
can be administered orally, buccally, or vaginally, and it is most effective when combined with
mifepristone.
• Methotrexate: a folate antimetabolite that interferes with DNA synthesis and the implantation
process. Before mifepristone became available, it was used in combination with misoprostol. At
present, this regimen is rarely used.
10. What are the most common regimens used for medical abortions? How do their
success rates differ?
Regimens approved by the Food and Drug Administration (FDA) are based on the original regimen
registered in France in the 1980s. More recent evidence-based regimens have proved to be superior
in terms of cost, safety, efficacy, and incidence of adverse effects (Table 13-2). Misoprostol-only
CHAPTER 13
INDUCED ABORTION
Lirona Katzir, MD
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INDUCED ABORTION 55
regimens are only 84% to 85% effective and have a significantly higher incidence of adverse effects
compared with combined regimens.
11. What are the major side effects of the medications used for medical abortions?
Bleeding and cramping are the most common side effects experienced by women undergoing a
medical abortion. Other common side effects include nausea (20% to 60%), vomiting (5% to 40%),
headaches (10% to 40%), diarrhea (1% to 35%), dizziness (10% to 40%), and thermoregulatory
effects (10% to 60%) such as warmth, hot flushes, fever, or chills.
12. What are the major complications of medical abortion?
Major complications are hemorrhage requiring emergency D&C, incomplete abortion requiring further
management, and postabortal infections. Depending on the regimen used, less than 5% of patients
will require a D&C. Overall, the rate of complications is less than 1%.
Table 13-1. Major Differences Between Medical And Surgical Abortions
in the First Trimester
MEDICAL ABORTION SURGICAL ABORTION
Usually avoids an invasive procedure Involves an invasive procedure
Usually avoids anesthesia and requires only
oral pain medication
May require sedation or local anesthesia
Can be completed in the privacy of a home Completed in the clinic, office, or operating room
May take days to weeks to complete Generally completed at the time of the procedure
Higher rates of cramping; bleeding not
commonly perceived as “light”
Bleeding commonly perceived as “light”
Generally a multistep procedure, requiring at
least two visits
Generally a single-step process, requiring only one
visit
Follow-up required to ensure that the abortion
is completed
Most cases do not require follow-up
Success rates ∼95% Success rates ∼99%
Table 13-2. Food and Drug Administration–Approved Regimen Versus
Evidence-Based Regimens for Induced Abortion
FDA-APPROVED REGIMEN EVIDENCE-BASED REGIMENS
Gestations up to 49 days Gestations up to 63 days
Regimen:
Mifepristone 600 mg orally followed by
misoprostol 400 μg orally
48 hours later
Regimens:
Mifepristone 200 mg orally followed by misoprostol 800 μg
vaginally, buccally, or sublingually 24-48 hours later
(Alternatively, misoprostol can be can administered vaginally
6-8 hours after mifepristone)
Timing between mifepristone and
misoprostol administration cannot
be varied
More flexibility in timing between mifepristone and misopros-
tol (<6 hours up to 48 hours depending on route)
Must return to the office or clinic for
misoprostol administration
Can self-administer misoprostol in the privacy of a home
Greater time to expulsion Less time to expulsion
More expensive Lower cost
Efficacy: 92%
(rates are higher at earlier gestations)
Efficacy: 95%-99%
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56 GENERAL GYNECOLOGY
13. What are contraindications to medical abortion?
• Allergy or intolerance to mifepristone or misoprostol
• Suspected or confirmed ectopic pregnancy
• Severe anemia, known coagulopathy, or anticoagulant therapy
• Severe liver, renal, cardiovascular, or respiratory disease
• Patients who are unreliable or unable to be contacted for follow-up
14. What are the different techniques used to perform a surgical abortion?
• Less than 13 weeks: A D&C can be performed in the office with a mechanical vacuum aspirator
(MVA), or a suction D&C can be performed in a procedure room with an electric vacuum aspiration
system (EVA). Specimens should always be inspected for villi.
• More than 13 weeks: In the second trimester, D&Cs and D&Es are typically performed in an
operating or procedure room with either anesthesia or analgesia and sedation. After 14 weeks of
gestation, D&Es are the standard procedure and may require cervical preparation.
• Prophylactic antibiotics are recommended during surgical abortions to prevent infection.
15. What are the major complications of surgical abortions?
Surgical abortions are extremely safe, with very low complication rates. Rare complications include
uterine perforation (0.5%), hemorrhage (0.1% to 0.7%), postabortal infection (0.1% to 4%), incom-
plete abortion (<1%), and cervical laceration (3%). Abortions are safest early in pregnancy; although
the risk is very low, mortality increases with each week of gestation.
16. What is the preferred method of second trimester termination?
The patient’s preference, the provider’s comfort, cost, safety, indication, and logistics should all
be taken into consideration when determining the method of pregnancy termination in the second
trimester. Compared with labor induction, D&Es by experienced providers are associated with lower
complication rates (4% versus 29%). The most common complication of second trimester labor induc-
tion is retained placenta (20%), which can increase the risk of postabortal hemorrhage and the need
for a D&C.
17. How is a second trimester surgical termination performed?
Depending on gestational age, cervical preparation may be required. This can be accomplished
with cervical ripening agents (typically misoprostol) or osmotic dilators before the procedure. Once
anesthesia or adequate sedation is achieved, further cervical dilation may be needed. When sufficient
dilation is achieved, amniotic fluid is aspirated, and the uterine cavity is evacuated with the use of
grasping forceps.
18. Is induced fetal demise necessary before second trimester abortions?
No. Although no evidence exists to recommend for or against routine induced fetal demise before an
abortion, it is a commonly employed technique. It can be done by intraamniotic or intrafetal injection
with digoxin, transection of the umbilical cord, or fetal intracardiac injection of potassium chloride.
In cases of abortion by labor induction after 20 weeks of gestation, induced fetal demise may be
preferred for the patient’s comfort and to avoid transient fetal survival.
19. When is labor induction performed, and what methods are used?
Labor induction is an alternative to a surgical abortion. It is often preferred in cases with fetal anoma-
lies to provide an intact fetus for autopsy. It can be performed with mifepristone, cervical ripening
agents such as misoprostol, or mechanical dilation. Intravenous oxytocin may be used with later
gestations.
20. How soon after an abortion can birth control be initiated?
Oral contraceptives, the transdermal patch, the vaginal ring, and subdermal implants can be initiated
on the same day as the administration of misoprostol or the surgical procedure. Intrauterine devices
can be placed immediately following surgical abortion or as early as 1 week following a completed
medical abortion.
21. What was the impact of the 1973 U.S. Supreme Court decision in Roe v. Wade?
• Roe v. Wade legalized abortion across the United States.
• Before Roe v. Wade, illegal abortions accounted for 17% of maternal deaths. This rate has dramati-
cally decreased to approximately 0.6 deaths per 100,000 procedures.
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INDUCED ABORTION 57
BiBliography
1. American College of Obstetricians and Gynecologists. Second trimester abortion. ACOG practice bulletin no. 135. Obstet
Gynecol. 2013;121:1394–1406.
2. American College of Obstetricians and Gynecologists. Medical management of first trimester abortion. ACOG practice
bulletin no. 143. Obstet Gyecol. 2014;123:676–692.
3. Borgatta L, Kapp N. Society of Family Planning. Clinical guidelines: labor induction abortion in the second trimester.
Contraception. 2011;84:4–18.
4. Guttmacher Institute. Fact sheet: facts on induced abortion worldwide; 2012. Available at
http://www.guttmacher.org/pubs/fb_IAW.html. Accessed October 22, 2015.
5. Guttmacher Institute. Fact sheet: induced abortion in the United States; 2014. Available at
http://www.guttmacher.org/pubs/fb_induced_abortion.html. Accessed October 22, 2015.
6. Sawaya GF, Grady D, Kerlikowske K, Grimes DA. Antibiotics at the time of induced abortion: the case for universal
prophylaxis based on a meta-analysis. Obstet Gynecol. 1996;87:884.
KEY POINTS: INDUCED ABORTION
1. More than 50% of pregnancies are unintended.
2. Pregnancies can be terminated medically or surgically.
3. Most complications are related to incomplete abortion, hemorrhage, and infection.
4. Abortions are now among the safest procedures for women in the Unites States.
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58
1. What methods of contraception are currently available to women in the United
States?
• Abstinence, withdrawal, and fertility awareness
• Permanent sterilization (tubal ligation, tubal occlusion, vasectomy)
• Hormonal
• Oral contraceptive pills (OCPs; combination estradiol and progestin or progestin only)
• Injectable progestin (depot medroxyprogesterone acetate)
• Subdermal implant (etonogestrel implant)
• Vaginal ring (etonogestrel and ethinyl estradiol)
• Transdermal patch (norelgestromin and ethinyl estradiol)
• Intrauterine device (IUD)
• Levonorgestrel IUD
• Copper IUD
• Barrier methods
• Condoms
• Diaphragm
• Cervical cap
• Contraceptive sponge
• Spermicides
• Emergency contraception (oral levonorgestrel, ulipristal acetate, high-dose oral contraceptives, or
copper IUD)
2. What percentage of women will have an unintended pregnancy in the first year of
using contraception, and what percentage of women will continue to use contra-
ception after 1 year?
This depends on the method used (Table 14-1).
CHAPTER 14
CONTRACEPTION
Elena Martinez, MD
Table 14-1. Percentage of Women in the United States Who Experience an
Unintended Pregnancy During the First Year of Typical Use and
the First Year of Perfect Use of Contraception and the Percentage
Continuing Use at the End of the First Year
Percentage of Women Experiencing
an Unintended Pregnancy Within
the First Year of Use (%)
PERCENTAGE
OF WOMEN
CONTINUING USE
AT 1 YEAR (%)*
COLUMN (4)
METHOD
COLUMN (1)
TYPICAL USE
†
COLUMN (2)
PERFECT USE
‡
COLUMN (3)
No method
§
85 85 —
Spermicides
¶¶
28 18 42
Fertility awareness–based
methods
24 — 47
Standard Days method
¶
— 5 —
TwoDay method
¶
— 4 —
Ovulation method
¶
— 3 —
Symptothermal method
¶
— 0.4 —
Withdrawal 22 4 46
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CONTRACEPTION 59
Table 14-1. Percentage of Women in the United States Who Experience an
Unintended Pregnancy During the First Year of Typical Use and
the First Year of Perfect Use of Contraception and the Percentage
Continuing Use at the End of the First Year (Continued)
Percentage of Women Experiencing
an Unintended Pregnancy Within
the First Year of Use (%)
PERCENTAGE
OF WOMEN
CONTINUING USE
AT 1 YEAR (%)*
COLUMN (4)
METHOD
COLUMN (1)
TYPICAL USE
†
COLUMN (2)
PERFECT USE
‡
COLUMN (3)
Sponge — — 36
Parous women 24 20 —
Nulliparous women 12 9 —
Condom
#
Female 21 5 41
Male 18 2 43
Diaphragm** 12 6 57
Combined pill and
progestin-only pill
9 0.3 67
Evra patch 9 0.3 67
NuvaRing 9 0.3 67
Depo-Provera (depot
medroxyprogesterone
acetate)
6 0.2 56
IUCs
ParaGard (copper T) 0.8 0.6 78
Mirena (LNG) 0.2 0.2 80
Implanon 0.05 0.05 84
Female sterilization 0.5 0.5 100
Male sterilization 0.15 0.1 100
LAM is an effective, temporary method of contraception.
††
IUC, Intrauterine contraceptive; LAM, lactational amenorrhea method; LNG, levonorgestrel.
*Among couples attempting to avoid pregnancy, the percentage of couples who continue to use a method for 1 year.
†
Among typical couples who initiate use of a method (not necessarily for the first time), the percentage of cou-
ples who experience an accidental pregnancy during the first year if they do not stop use for any other reason.
Estimates of the probability of pregnancy during the first year of typical use for spermicides and the diaphragm
are taken from the 1995 National Survey of Family Growth (NSFG) corrected for underreporting of abortion;
estimates for fertility awareness–based methods, withdrawal, the male condom, the oral contraceptive pill,
and Depo-Provera are taken from the 1995 and 2002 NSFG corrected for underreporting of abortion.
‡
Among couples who initiate use of a method (not necessarily for the first time) and who use it perfectly (both
consistently and correctly), the percentage of couples who experience an accidental pregnancy during the first
year if they do not stop use for any other reason.
§
The percentages of becoming pregnant in columns (2) and (3) are based on data from populations where
contraception is not used and from women who cease using contraception to become pregnant. Among such
populations, approximately 89% of women become pregnant within 1 year. This estimate was lowered slightly
(to 85%) to represent the percentage of women who would become pregnant within 1 year among women
now relying on reversible methods of contraception if they abandoned contraception altogether.
¶¶
Foams, creams, gels, vaginal suppositories, and vaginal film.
¶
The ovulation and TwoDay methods are based on evaluation of cervical mucus. The Standard Days method
avoids intercourse on cycle days 8 through 19. The symptothermal method is a double-check method based
on evaluation of cervical mucus to determine the first fertile day and evaluation of cervical mucus and tem-
perature to determine the last fertile day.
#
Without spermicides.
**With spermicidal cream or jelly.
††
However, to maintain effective protection against pregnancy, another method of contraception must be used
as soon as menstruation resumes, the frequency or duration of breastfeeding is reduced, bottle feedings are
introduced, or the baby reaches 6 months of age.
Modified from Trussell J. Contraceptive failure in the United States. Contraception. 2011;83:397-404.
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60 GENERAL GYNECOLOGY
3. What is the most commonly used contraceptive in the United States?
The OCP. First approved for use in 1960, OCPs have evolved into a safe and popular option. This
is likely because of their relative safety profile for the average user, the flexibility to start, stop, or
manipulate regimens, and their multiple noncontraceptive benefits.
4. How do OCPs work?
OCPs work through progestin- and estrogen-mediated effects.
• Progestins
• Suppress both luteinizing hormone (LH) and follicle stimulating hormone (FSH), thus preventing
ovulation
• Thicken cervical mucus and hamper sperm transport
• Induce endometrial gland atrophy and decrease the likelihood of embryo implantation
• May alter secretions and motility of the fallopian tubes, thereby interfering with fertilization
• Estrogen
• Suppresses both LH and FSH, although to a lesser effect than progestins
• Potentiates the antigonadotropin effects of progestins, thus enhancing their effects
• Importantly, stabilizes the endometrium and prevents irregular shedding
5. What are the noncontraceptive benefits of OCPs?
• Decreases in menstrual flow, anemia, primary dysmenorrhea, risk of symptomatic pelvic inflam-
matory disease, risk of ectopic pregnancy, and incidence of benign breast disease (fibroadenomas,
fibrocystic changes)
• Reduced risk of ovarian and endometrial cancer
• Improvement in hirsutism and acne
6. What is the primary risk associated with combination OCPs?
Venous thromboembolism (VTE) is the most common, serious side effect of estrogen-containing hor-
monal contraception. The highest risk is thought to occur during the first year of use, and an increased
risk persists until discontinuation. However, the absolute risk is low.
7. What are other risks associated with OCPs?
Stroke and myocardial infarction, although the absolute risk is still very low.
8. What are some common therapeutic uses of OCPs?
• Menstrual disorders: Primary dysmenorrhea in most women can be successfully treated with
OCPs. OCPs can also be used to treat both heavy bleeding and intermenstrual bleeding, and high
doses (three or four pills a day) of combination formulations can effectively suppress acute epi-
sodes of bleeding. Once the bleeding has stopped, the regimen can be tapered and then stopped to
allow for withdrawal bleeding.
• Endometriosis: A Cochrane Collaboration review supported the use of OCPs for long-term
treatment.
• Hyperandrogenism: OCPs suppress ovarian, adrenal, and peripheral androgen metabolism. The
estrogen component of OCPs also increases sex hormone–binding globulin levels and inhibits
5α-reductase in the skin, thus resulting in lower levels of dihydrotestosterone. For more informa-
tion on this topic, see Chapter 26.
• Hypoestrogenic states: OCPs have been used in women with hypothalamic amenorrhea as a
method of hormone replacement therapy. OCP use in the perimenopausal period can prevent
pregnancy, regulate uterine bleeding, and treat vasomotor and vaginal dryness symptoms. Estrogen
replacement in the form of OCPs can also benefit patients who are amenorrheic after radiation
therapy, chemotherapy, or bilateral oophorectomy.
• Menstrual migraines: Likely triggered by changes in estrogen levels immediately before menses,
these headaches occur immediately before the onset of menses and not at any other time during
the cycle. Continuous OCP dosing, with no withdrawal, is most effective at prevention.
9. What is the association of OCPs with cancer?
• Ovarian cancer: Users of OCPs are less likely to develop epithelial ovarian cancer, with the risk
decreasing by 40% with as little as 3 to 6 months of OCP use. The protective effect persists for at
least 15 years after OCP discontinuation.
• Endometrial cancer: OCP users are 50% less likely to develop endometrial cancer, with the risk
reduced by 20% with 1 year of use, 40% with 2 years of use, and 60% with 4 or more years of use.
This reduction in risk also persists for at least 15 years after discontinuation.
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CONTRACEPTION 61
• Breast cancer: In the past, concern existed that OCPs were an independent risk factor for develop-
ing breast cancer. However, the 2002 Women’s CARE Study by the National Institute of Child Health
and Human Development established that current or former OCP use was not associated with an
increased risk of breast cancer.
• Cervical cancer: Although a 2014 quantitative review of the link between OCPs and cervical
cancer showed that long-term (>5 year), current, or recent OCP use is related to a nearly twofold
increased risk of cervical cancer, this risk levels off after stopping OCP use and approaches base-
line within 10 years.
10. What are contraindications to OCP use?
• Known presence or history of VTE or pulmonary embolism
• History of stroke, coronary artery disease, or ischemic heart disease
• Diabetes with microvascular complications (neuropathy, retinopathy) or duration of more than
20 years
• History of estrogen-dependent cancer
• Migraines with focal neurologic symptoms (aura)
• Age older than 35 years in the setting of smoking more than 20 cigarettes a day
• Poorly controlled hypertension (blood pressure >160/100 mm Hg) or in the setting of vascular
disease
• Active liver disease
• Major surgical procedure with prolonged immobilization
• Personal history of acquired or inherited thrombophilia
11. What are the other forms of hormonal contraception?
• Depot medroxyprogesterone acetate: This is given as an intramuscular injection of 150 mg every
12 weeks. Amenorrhea is common after 1 year of use (50%), and headaches are the most common
nonmenstrual side effects. Although transient bone mineral density (BMD) loss may occur, it is
comparable to loss seen with lactation and reverses on discontinuation. Neither the World Health
Organization (WHO) nor the American College of Obstetricians and Gynecologists (ACOG) recom-
mends restricting its use or performing BMD testing in women who use it.
• Etonogestrel subdermal implant: A single rod containing 68 mg of etonogestrel is placed in the
subcutaneous tissue of the upper arm in the supracondylar area. Lasting up to 3 years, this method
carries the lowest failure rate for any contraceptive at 0.05 pregnancies in the first year of use.
Common side effects include irregular bleeding, amenorrhea, gastrointestinal difficulties, head-
aches, acne, breast tenderness, and weight gain; the continuance rate for this method, however, is
84% at 1 year.
• Etonogestrel and ethinyl estradiol vaginal ring: A flexible vaginal ring that delivers 120 μg/day
of etonogestrel and 15 μg/day of ethinyl estradiol remains in place for 3 weeks, followed by a ring-
free week. Common side effects include headache, vaginitis, leucorrhea, and ring slippage. The
continuation rate at 1 year is 68%.
• Norelgestromin and ethinyl estradiol transdermal patch: One patch containing 6 mg norelge-
stromin and 0.75 mg ethinyl estradiol is applied once a week for 3 consecutive weeks, followed by
a patch-free week. The most common side effects are headache and nausea. Conflicting evidence
exists regarding a potential increase in VTE risk (compared with OCPs) with this method.
12. What is the effect of hormonal contraception on an unsuspected pregnancy?
The use of any hormonal method of contraception early in an unsuspected pregnancy has not been
shown to increase the risk of congenital anomalies or early pregnancy loss.
13. What is emergency contraception and how does it work?
Emergency contraception is intended for use after unprotected intercourse to prevent pregnancy. It
works by inhibiting or delaying ovulation, and it may also impair endometrial receptivity to implanta-
tion. Other possible mechanisms include interference with corpus luteum function, thickening of cervi-
cal mucus, and alterations in tubal transport of sperm, egg, or embryo. It does not interrupt or harm an
already established pregnancy.
14. What are the forms of emergency contraception?
• Levonorgestrel pill (1.5 mg): 89% effective if taken within 72 hours of unprotected intercourse, can
be taken up to 120 hours with less efficacy. Slightly less effective in women with a BMI >25-30. Side
effects are minimal and mostly include nausea and vomiting. Available without a prescription.
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62 GENERAL GYNECOLOGY
• Ulipristal acetate pill (30 mg): This is 89% effective when taken up to 120 hours after unprotect-
ed intercourse and is slightly less effective in women with a body mass index (BMI) greater than
35. Side effects include headache, nausea, and abdominal pain. It is available by prescription only.
• High-dose combination OCPs (Yuzpe method): 100 μg of ethinyl estradiol and 0.5 to .075 mg of
levonorgestrel are divided into two doses and taken 12 hours apart. This is 74% effective if taken by
72 hours after unprotected intercourse. Major side effects include headache, nausea, and vomiting.
• Copper IUD: This can be inserted up to 7 days after ovulation to prevent pregnancy and is 99.9%
effective.
15. How does an IUD prevent pregnancy?
An IUD induces a local inflammatory reaction that renders the uterus an unfavorable environment
for pregnancy. This reaction also alters sperm motility or integrity and tubal fluids, thus interfering
with ova and sperm transport and interaction. IUDs are appropriate for use in both nulliparous and
adolescent women, and insertion can be performed at any point in the menstrual cycle as long as a
diagnosis of pregnancy is excluded.
16. What are the different types of IUD?
• Copper IUD: This releases copper ions that enhance the inflammatory response and reach concen-
trations that are toxic for spermatozoa. The continuation rate is 78% at 1 year, and the failure rate
is 0.6%. The most common side effects are dysmenorrhea and heavy bleeding, seen in approxi-
mately 10% of women.
• Levonorgestrel IUD: This provides additional protection by inducing endometrial gland atrophy and
thickening cervical mucous. The continuation rate is 80% at 1 year, and the failure rate is 0.2%.
The most common side effects are breakthrough bleeding and amenorrhea. Systemic side effects
can also occur and include headaches, nausea, breast tenderness, and ovarian cysts.
17. What are contraindications to IUD insertion?
• Confirmed or suspected pregnancy
• Known or suspected pelvic malignant disease
• Undiagnosed vaginal bleeding
• Acute or chronic pelvic infection
• Hyperbilirubinemia secondary to Wilson disease (for copper-containing devices only)
18. What are the major risks associated with IUD use?
• Displacement of the device that leads to difficult removal
• Uterine perforation
• Pelvic infection
The IUD itself does not cause pelvic infection. In general, it is believed that the risk of pelvic inflam-
matory disease is greater with an IUD in place when a woman has a sexually transmitted infection.
A WHO multicenter review estimated the overall risk of pelvic inflammatory disease to be concen-
trated in the first 20 days after insertion, when the risk was sixfold higher, than at later times. The
ACOG supports the practice of screening asymptomatic women at the time of IUD insertion and
treating for infection in the case of a positive result, without the need to remove the IUD.
19. What are barrier methods of contraception?
Barrier methods of contraception provide a physical barrier that prevents sperm and ovum interaction,
and some forms also use a spermicidal chemical to help decreasing the odds of pregnancy. Barrier
methods include male and female condoms, diaphragms, cervical caps, and sponges. Benefits include
protection against some sexually transmitted infections (depending on the barrier method used),
provision of immediate protection without much advance planning, easy access, and the absence of
systemic side effects. Disadvantages comparatively higher failure rates, discomfort with placement or
use, and possible allergic reactions.
20. What are the forms of permanent sterilization?
• Tubal ligation: In this surgical procedure, the fallopian tubes are cut, thermally damaged, removed,
or otherwise destroyed. It can be performed with regional anesthesia if it is performed within the
first few days post partum; otherwise, general anesthesia is used. Less than 1% of women will
become pregnant in the first year. The risk of failure varies by the method used and the age of the
patient.
• Tubal occlusion: First approved in the United States in 2002, this is performed using hysteros-
copy and does not necessarily require general anesthesia; inert microinserts designed to initiate
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