Quick Start a LARC: Contraception initiation and pregnancy test follow up

Transcription

1 Quick Start a LARC: Contraception initiation and pregnancy test follow up Suzanne Pearson, Christina Inness, Mandy Johnson, Kathleen McNamee LARC long acting reversible contraception Implant 3 years IUD Intrauterine device 5 years or 10 years Injection 12 weeks Highest efficacy and continuation rates: Implant and IUD 1

2 3 75% chose LARC LARC benefits Contraceptive CHOICE project Women using LARC had highest satisfaction Women who used non-larc were 20 times more likely to have an unintended pregnancy than those who used LARC Continuation of IUD and implant is greater than the pill and DMPA Templeman, C. L., et al. (2000). Obstet Gynecol 95(5): Blumenthal, P. D., et al. (1994). Contraception 50(5): Lewis, L. N., D. et al. (2010). Contraception 81(5): Winner B, et al May 24;366(21):

3 Cumulative Percentage of Contraceptive Failure at 1, 2, or 3 Years, by method. PPR = Pill patch ring Winner, B., et al. (2012). The New England journal of medicine 366(21): Choice Project: Continuation rates 12 months 24 months 36 months Overall LNG IUD Cu IUD Implant DMPA Combined pill Ring LARC non LARC Aged years LARC non LARC Aged years LARC non LARC Diedrich, J. T,et al. am J Obstet Gynecol inpress 3

4 FPVs The Action Centre - a sexual and reproductive health service for young people Age <25 years Drop in service 11am-6pm Monday to Friday Around 3300 patients seen per year What did we want to know about our practice? 1. For patients new to our service, how often do we initiate a LARC vs a shorter acting method? 2. How often are we discussing (and documenting) benefits of LARC? 3. What are our rates of pregnancy test follow up after Quick Start initiation of implant 4. What can we do to improve our practice? 5. What are we doing well that others can learn from? 4

5 Contraception initiation for new patients Retrospective audit February 1 to April 30, 2014 SQL query on electronic clinical software (Best Practice): Women new to the service Present for either: initiation of new contraception other reason, with new contraceptive method initiated opportunistically Medicare Age <25 years Audit findings: Feb 1 to April 30, 2014 Number Total patients 1141 New patients 524 Contraception presentation and/or initiation Excluding 32 repeat pill and 1 repeat implant LARC chosen implant 6 IUD 2 injection Of new patients choosing new contraception: LARC chosen by 70 out of 127 = 55.1% 5

6 Contraceptive method chosen (excluding repeat supply) Method chosen Total number % Average age Implant* 62* 48.8% 19.7 IUD 6 4.7% 21.5 Injection 2 1.6% 19.0 Combined hormonal pill % 18.2 Progestogen only pill 3 2.4% 19.7 Condoms 1 0.8% 19 Diaphragm 1 0.8% 24 Emergency Contraception only 3 2.4% 16.3 No method (discussion only) 4 3.1% 19.3 Total 127 *3 patients initiated implant after taking Emergency Contraception LARC discussion Of the 160 contraception consultations 89 did not result in LARC initiation or prescription. Of these, LARC discussion was documented in: 53.9% 43.7% repeat pill consultations 59.6% other consultations 6

7 LARC initiation with Quick Start FPV uses Quick Start initiation which avoids delay or failure to return for implant insertion. Implants are usually inserted on the day of presentation. (57 out of 62 implants, plus another inserted after TOP) IUDs are prescribed and inserted later at our Box Hill clinic or at another clinic (eg. if sedation is requested). Excluding the consultations for repeat pill: LARC initiated/inserted on same day = 46.1% (59 out of 128 contraception consultations) Quick Start the informed initiation of a contraceptive method outside the time that is traditionally recommended. It may not be possible to completely exclude an early pre-existing pregnancy but if the benefits outweigh the risks then the woman and the clinician may decide to proceed. It is endorsed by the UK Faculty of Sexual and Reproductive Health, their guidance can be found using the following link:

8 Quick Start Insertion may occur on the same day or at a mutually convenient time Quick Start balances the benefits of starting contraception quickly with the chance that an early pregnancy may not be excluded. 15 Which methods for Quick Start? Contraceptive implant Combined oral contraceptive Vaginal ring and Progestogen only pill May be used for DMPA injection however it is not rapidly reversible. Not recommended for IUDs due to effect on the pregnancy. 16 8

9 When is the method effective after Quick Start? After 7 days (Pill 7 days of active hormone pills) Progestogen only pill after 3 days 17 Is there any known teratogenic effect? DMPA injection small published studies do not indicate teratogenesis Implant no published studies but teratogenicity unlikely Combined hormonal pill well studied with no risk of teratogenicity shown 18 9

10 Quick Start: what to do 1. Consider a pregnancy test. 2. If negative: Inform the woman if pregnancy can t be excluded, discuss no known effects on a pregnancy 3. Initiate method if she wants to and feasible 4. Condoms or abstain for 7 days 5. Pregnancy test (at home or in clinic) in 4 weeks with reminder/recall for implant and depot 19 Refer to FPV s Quick Start protocol and consent forms: 10

11 Pregnancy test result documented after Quick Start of implant audit: 26.7% when women were asked to return to the clinic for their pregnancy test Change in practice take home pregnancy test with SMS reminder offered audit: 80.8% with take home pregnancy test and SMS reminder All women offered a take home pregnancy test following implant insertion with Quick Start accepted. Learning from our practice: 1. For clients new to our service, how often do we initiate a LARC vs a shorter acting method? 55.1% of those starting a new method Which LARC? 62 implants, 2 injections, 6 IUDs 2. For those who continue or choose a non-larc method, how often are we discussing (and documenting) benefits of LARC? 53.9% 11

12 Learning from our practice 3. Rates of pregnancy test followup after Quick Start initiation of LARC 80.8% Increased by more than 3 times by introducing home pregnancy testing with SMS reminder Learning from our practice: 4. What can we do to improve our practice? increase discussion on benefits of LARC for pill users increase access to IUDs 5. What are we doing well that others can learn from? high rates of LARC benefits discussion normalise LARC as first line choice initiating implant without delay Quick Start improves access and uptake 12

13 Disclosure of interest Family Planning Victoria provide training in Implanon NXT for Merck Sharp & Dohme IUD insertion for Bayer Health Care Acknowledgements Thanks to FPV s CEO, Medical Director, Manager of Education and Training, Senior Nurses and all staff of FPV for their support and excellence in clinical and education work. 13

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