What Types of Contraception Are Best Following Early Pregnancy Loss?

What Types of Contraception Are Best Following Early Pregnancy Loss? 1024 683 Geri Hewitt, MD, Elise Berlan, MD, MPH and Johanna Taylor, APN

Following early pregnancy loss (EPL), miscarriage or spontaneous abortion, pregnancy tests remain positive for several weeks often creating a challenge for clinicians initiating contraception. Fertility returns rapidly after EPL and almost all adolescents may use their contraceptive method of choice immediately after the pregnancy.

Pregnancy tests detect the presence of human chorionic gonadotropin (HCG), a hormone released from the cells that become the placenta during pregnancy. HCG is detectable in the blood (10 days) and urine (two weeks) following conception. Levels rise quickly in early pregnancy doubling every 48-72 hours until the end of the first trimester where there is a leveling off. Point-of-care urine pregnancy tests are highly sensitive in detecting HCG.

Due to the limitations of pregnancy tests following EPL, routine pregnancy testing is not recommended prior to starting a contraceptive method post-abortion or miscarriage. The Centers for Disease Control and Prevention (CDC) offers evidence-based guidelines for safe contraceptive practice, the U.S. Medical Eligibility Criteria (MEC) and Select Practice Recommendations (SPR) for Contraceptive Use. Included in this guidance for clinicians are highly accurate criteria to assess the likelihood of pregnancy for the purposes of contraceptive initiation – How to Be Reasonably Certain That A Woman Is Not Pregnant.

According to the CDC Guidelines, a health care provider can be reasonably certain that a woman is not pregnant if she has no symptoms or signs of pregnancy and meets any one of the following criteria:

  • Is ≤7 days after the start of normal menses
  • Has not had sexual intercourse since the start of last normal menses
  • Has been correctly and consistently using a reliable method of contraception
  • Is ≤7 days after spontaneous or induced abortion
  • Is within four weeks postpartum
  • Is fully or nearly fully breastfeeding (exclusively breastfeeding or the vast majority [≥85%] of feeds are breastfeeds), amenorrheic, and <6 months postpartum

Nationwide Children’s Hospital and Partners For Kids® have developed the Contraception Clinical Practice Guideline to assist providers in prescribing contraceptives. As well, Pediatric and Adolescent Gynecology and BC4Teens (Adolescent Medicine) are experienced contraceptive care providers and accept referrals for contraception counseling and initiation.

Frequently Asked Questions About Care for Teens Post Early Pregnancy Loss

How long does a pregnancy test remain positive after a patient is no longer pregnant?  Does it matter how far along the patient was (which trimester after pregnancy)?

On average, a urine pregnancy test will remain positive four to six weeks following EPL. Less commonly, a positive result will persist for up to 60 days. It takes longer for HCG levels to reach zero (negative levels) in multiple gestation pregnancies and when pregnancy was completed later in the first trimester, when levels are the highest. For those experiencing EPL early in the first trimester HCG levels will return to zero sooner. In comparison, HCG levels fall to zero within just a few weeks after a full-term delivery.

When can you initiate various types of contraception after the completion of a pregnancy? Does the pregnancy outcome or mode of delivery have any impact on when or what type of contraception you can initiate?

All contraceptive methods may be initiated immediately (within seven days) following completion of a pregnancy in the first or second trimester and within four weeks postpartum, with one exception: IUDs should not be used in the context of septic abortion, a rare complication characterized by fever, severe pain and heavy bleeding. Estrogen-containing methods should be avoided if <21 days post-partum after delivery and with caution 21 to 42 days post-partum due to thromboembolic risk. Providers should review the CDC SPR criteria How to Be Reasonably Certain That A Woman Is Not Pregnant when considering contraception initiation post-pregnancy outside of the timeframes mentioned above.

When can you initiate contraception after a medication abortion? What if the pregnancy test is still positive even though the patient is no longer bleeding?

Guidelines for contraception initiation after medication abortion are no different than for miscarriage or procedural abortion. Contraception may be initiated immediately following a medication abortion. Bleeding patterns vary widely with some people experiencing only a small amount of bleeding or spotting for a few days; others may bleed for several weeks. Because a pregnancy test may be positive up to six weeks post-pregnancy completion, the best practice is not to obtain a pregnancy test. Providers should use the CDC SPR criteria How to Be Reasonably Certain That A Woman Is Not Pregnant guidelines and proceed with contraception initiation.

Relevant Resources:

  1. Nguyen AT, Curtis KM, Tepper NK, et al. U.S. medical eligibility criteria for contraceptive use, 2024. MMWR Recomm Rep. 2024;73(No. RR-4):1–126.
  2. Curtis KM, Jatlaoui TC, Tepper NK, Zapata LB, Horton LG, Jamieson DJ, Whiteman MK. U.S. Selected Practice Recommendations for Contraceptive Use, 2016MMWR. 2016;65(4):1–66.
  3. World Health Organization. Abortion care guideline. World Health Organization. Chapter 3. https://iris.who.int/handle/10665/349316. 2022. Accessed October 4, 2024.

 

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About the author

Geri D. Hewitt, MD, is chief of the Section of Obstetrics and Gynecology at Nationwide Children’s Hospital and a professor of Clinical Obstetrics in the Departments of Obstetrics and Gynecology and Pediatrics at The Ohio State University College of Medicine. Dr. Hewitt's primary interests are caring for the gynecologic and reproductive health needs for young girls as well as adolescents. Dr. Hewitt is an examiner for the American Board of Obstetrics and Gynecology. Dr. Hewitt is a Fellow of the American College of Obstetricians and Gynecologists and a co-editor for the Journal of Pediatric and Adolescent Gynecology Tips for Clinicians section.

Dr. Berlan is a physician in the Section of Adolescent Medicine at Nationwide Childcare’s Hospital and associate professor of Pediatrics at The Ohio State University College of Medicine.  She is a researcher, educator, clinician and advocate for young women’s reproductive health. As founder and director of the BC4Teens/Young Women’s Contraception Program at Nationwide Children’s, she leads the hospital’s diverse efforts in teen pregnancy prevention. Dr. Berlan is also an active participant in local efforts in public health to reduce infant mortality.