ABOG Complex Family Planning cheat sheet

Typical-use failure rates per 100 woman-years: implant 0.1, copper IUD 0.8, LNG-IUD 0.1–0.4, DMPA 4, combined hormonal contraception 7, male condom 13, withdrawal 20; perfect-use rates are lower.

Emergency contraception: copper IUD within 5 days is most effective; ulipristal 30 mg oral within 120 hours; levonorgestrel 1.5 mg within 72 hours, with lower efficacy near ovulation and at higher body weight.

Quick start: if pregnancy is reasonably excluded, start any method immediately; backup is needed for 7 days with combined hormonal contraception or DMPA, 2 days with progestin-only pills, and none with an IUD or implant.

WHO MEC category 4 for combined hormonal contraception includes migraine with aura, history of VTE, ischemic heart disease, stroke, breast cancer, severe hypertension, and smoking at age 35 or older with at least 15 cigarettes daily.

Postpartum: immediate postpartum LARC is safe; combined hormonal contraception is avoided before 21 days postpartum and for 21–42 days with VTE risk factors; progestin-only methods are preferred during lactation.

DMPA: return to fertility may take up to 10 months after the last injection; bone mineral density loss is largely reversible, and no absolute duration limit is required.

IUD complications: perforation occurs in about 1 per 1,000 insertions, expulsion in 2–10%, and pelvic infection risk is highest in the first 20 days; active purulent cervicitis or PID contraindicates insertion.

Enzyme-inducing drugs such as rifampin, carbamazepine, phenytoin, and topiramate at 200 mg/day or more can reduce combined pill and progestin-only pill efficacy; DMPA and copper IUD are unaffected.

Missed combined pills: if one pill is missed, take it and continue; if two or more consecutive pills are missed, use backup for 7 days and consider emergency contraception if unprotected intercourse occurred in the prior 5 days.

Medication abortion: mifepristone 200 mg orally followed 24–48 hours later by misoprostol 800 mcg buccal or vaginally; FDA-approved through 70 days, with evidence supporting use through 77 days.

Mifepristone is a progesterone receptor antagonist that causes decidual necrosis and cervical softening; misoprostol is a prostaglandin E1 analog that produces cervical ripening and uterine contractions.

Aspiration abortion is appropriate from early pregnancy through about 12–14 weeks; cervical preparation with misoprostol or osmotic dilators reduces the risk of uterine and cervical injury.

D&E for second-trimester abortion uses osmotic dilators with or without misoprostol; risks include perforation, cervical laceration, hemorrhage, and retained tissue.

Rh prophylaxis: give anti-D immune globulin 50 mcg before 12 weeks and 300 mcg after 12 weeks to Rh-negative, unsensitized patients undergoing abortion or pregnancy loss.

Prophylactic doxycycline 200 mg orally before surgical abortion reduces the risk of post-procedural pelvic infection.

Post-abortion LARC can be placed immediately; ovulation may return within 2 weeks, so contraception should be discussed before discharge.

Warning signs after abortion: fever of 38°C or higher, heavy bleeding soaking at least 2 pads per hour for 2 hours, severe pain, or foul discharge; evaluate for retained tissue, infection, or ectopic pregnancy.

Mifepristone is subject to an FDA risk evaluation and mitigation strategy; state gestational limits, waiting periods, and reporting requirements vary, so clinicians must verify local law.

Early pregnancy loss is a nonviable intrauterine pregnancy before 20 weeks; types include threatened, inevitable, incomplete, complete, missed, and septic.

Expectant management is reasonable for stable patients; misoprostol 800 mcg vaginally is effective medical management; manual or electric vacuum aspiration is definitive surgical management.

Septic abortion presents with fever, uterine tenderness, and purulent discharge; treatment requires broad-spectrum antibiotics and urgent uterine evacuation.

Ectopic pregnancy diagnosis uses serial hCG and transvaginal ultrasound; an intrauterine gestational sac should be visible when hCG exceeds about 3,500 mIU/mL, the discriminatory zone.

Methotrexate for ectopic pregnancy is an option when the patient is hemodynamically stable, the mass is unruptured and under 4 cm, there is no fetal cardiac activity, and hCG is under 5,000 mIU/mL.

After methotrexate, measure hCG on days 4 and 7; a decline of at least 15% between days 4 and 7 indicates adequate response, followed by weekly monitoring until hCG is undetectable.

Recurrent pregnancy loss is typically defined as two or more consecutive losses; evaluation includes karyotype, antiphospholipid antibodies, uterine imaging, and thyroid function.

After molar pregnancy evacuation, follow hCG to zero and use reliable contraception during surveillance to avoid pregnancy-related hCG confusion and reduce gestational trophoblastic neoplasia risk.

An interpregnancy interval shorter than 18 months is associated with preterm birth and low birth weight; postpartum contraception helps optimize timing.

WHO MEC categories: 1 means no restriction, 2 advantages outweigh risks, 3 risks usually outweigh advantages, and 4 represents unacceptable health risk for the condition.

Migraine with aura: combined hormonal contraception is category 4 because of ischemic stroke risk; progestin-only pills, DMPA, implant, and IUDs are generally category 1–2.

History of VTE or known thrombophilia: combined hormonal contraception is category 4; progestin-only methods and IUDs are generally acceptable.

SLE with positive antiphospholipid antibodies: combined hormonal contraception is category 4; copper IUD is category 1, and progestin-only methods are category 2–3.

Diabetes with vascular disease or end-organ damage: combined hormonal contraception is category 3 or 4; progestin-only methods and IUDs are generally preferred.

Epilepsy with enzyme-inducing anticonvulsants: combined pill and progestin-only pill efficacy may be reduced; DMPA and copper IUD are unaffected; combined hormonal contraception lowers lamotrigine levels.

Breast cancer: all hormonal contraception is category 4 during active disease; copper IUD is category 1 and is the preferred reversible option.

HIV: most contraceptive methods are safe; check interactions with antiretroviral drugs, and condoms reduce transmission.

Solid organ transplant: IUDs and progestin-only methods are often preferred; combined hormonal contraception may be category 3 or 4 because of VTE and infection risk, so coordinate with the transplant team.

The Hyde Amendment restricts federal Medicaid funding for abortion except in cases of rape, incest, or life endangerment.

Title X funds family planning services but prohibits abortion as a method of family planning; confidentiality protections apply, and parental consent is not required under Title X.

Dobbs v Jackson Women's Health Organization (2022) overturned Roe v Wade and returned abortion regulation to states, producing varied bans, gestational limits, and trigger laws.

Belmont principles are respect for persons, beneficence, and justice; IRB review and informed consent are required for human subjects research.

Reproductive justice asserts rights to have children, not have children, and parent children in safe environments, while addressing structural inequities.

Conscientious objection: clinicians may decline to provide abortion or contraception for religious or moral reasons but must provide referral and emergency care.

Randomized controlled trials minimize confounding; intention-to-treat analysis preserves randomization; cohort and case-control studies are observational designs.

Health disparities: unintended pregnancy and abortion rates are higher among low-income and minoritized populations; access barriers include cost, distance, and policy.

The ACA contraceptive mandate requires most private insurers to cover FDA-approved contraception without cost sharing, with religious and moral exemptions.