BACKGROUND

Long-acting reversible contraceptives (LARCs) are safe, effective and convenient post-abortal methods. However, there is concern that some LARCs may reduce the effectiveness of abortifacient drugs or result in other adverse outcomes.

OBJECTIVE AND RATIONALE

We undertook two systematic reviews to examine the early administration of LARCs in women undergoing medical abortion with mifepristone and misoprostol. (i) For women who are having a medical abortion and who plan to use a progestogen-only contraceptive implant or injectable, does administration of the contraception at the same time as mifepristone influence the efficacy of the abortion? (Implant/injectable review). (ii) For women who have had a medical abortion, how soon after expulsion of the products of conception is it safe to insert an intrauterine contraceptive device/system? (LNG-IUS/Cu-IUD review).

SEARCH METHODS

On 19 November 2018, we searched Embase Classic, Embase; Ovid MEDLINE(R) including Daily and Epub Ahead-of-Print, In-Process and Other Non-Indexed Citations; the Cochrane Library; Cinahl Plus; and Web of Science Core Collection. Eligible studies were randomised controlled trials (RCTs), in English from 1985 (Implant/injectable review) or 2007 (LNG-IUS/Cu-IUD review) onwards, conducted in women undergoing medical abortion with mifepristone and misoprostol and studying either (i) simultaneous administration of mifepristone and a progestogen-only contraceptive implant or injectable compared to administration >24 h after mifepristone, or (ii) immediate insertion of intrauterine contraception after expulsion of the products of conception compared to early insertion (≤7 days) or to delayed insertion (>7 days) or early compared to delayed insertion. One author assessed the risk of bias in the studies using the Cochrane Collaboration checklist for RCTs. All the outcomes were analysed as risk ratios and meta-analysed in Review Manager 5.3 using the Mantel–Haenszel statistical method and a fixed-effect model. The overall quality of the evidence was assessed using GRADE.

OUTCOMES

Two RCTs (n = 1027) showed lower ‘subsequent unintended pregnancy’ rates and higher ‘patient satisfaction’ rates, and no other differences, after simultaneous administration of mifepristone and the implant compared to delayed administration. One RCT (n = 461) showed higher ‘patient satisfaction’ rates after simultaneous administration than after delayed administration of mifepristone and the injectable, but no other differences between these interventions. Three RCTs (n = 536) found no differences other than higher copper IUC uptake after early compared to delayed insertion at ≤9 weeks of gestation and higher rates of IUC expulsion, continuation and uptake after immediate compared to delayed insertion at 9⁺¹–12⁺⁰ weeks of gestation and higher IUC continuation rates after immediate compared to delayed insertion at 12⁺¹–20⁺⁰ weeks of gestation. The quality of this evidence ranged from very low to high and was mainly compromised by low event rates, high attrition and no blinding.

WIDER IMPLICATIONS

The contraceptive implant or injectable should be offered on the day of taking mifepristone. Intrauterine methods of contraception should be offered as soon as possible after expulsion of the pregnancy.

中文翻译：

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药物流产后立即长效可逆性避孕：荟萃分析的系统评价

背景

长效可逆避孕药（LARCs）是安全，有效和方便的产后避孕方法。但是，令人担忧的是，一些LARC可能会降低流产药物的有效性或导致其他不良后果。

目的和理由

我们进行了两项系统的审查，以检查米非司酮和米索前列醇进行药物流产的妇女的早期服用LARC的情况。（i）对于正在进行药物流产并计划使用仅孕激素的避孕植入物或注射剂的妇女，与米非司酮同时服用避孕药会影响流产的功效吗？（植入/注射复查）。（ii）对于曾进行过药物流产的妇女，在排出受孕产品后多久可以安全地插入子宫内避孕装置/系统？（LNG-IUS / Cu-IUD审查）。

搜索方法

2018年11月19日，我们搜索了Embase Classic，Embase; Ovid MEDLINE（R），包括每日和Epub印刷前，处理中和其他非索引引文；科克伦图书馆；Cinahl Plus；和Web of Science核心合集。符合条件的研究是随机对照试验（RCT），分别于1985年（植入/注射审查）或2007年（LNG-IUS / Cu-IUD审查）以英语进行，该试验是在接受米非司酮和米索前列醇进行药物流产的妇女中进行的，其中一项研究（i）与米非司酮后24小时以上给药相比，同时给予米非司酮和仅孕激素的避孕植入物或注射剂；或（ii）与受孕早期药物（≤7天）相比，受孕产物排出后立即插入宫内避孕插入（> 7天）或比延迟插入早。一位作者使用Cochrane协作RCT清单评估了研究中偏倚的风险。使用Mantel–Haenszel统计方法和固定效应模型，所有结果均作为风险比进行了分析，并在Review Manager 5.3中进行了荟萃分析。证据的整体质量使用GRADE进行了评估。

结果

与延迟给药相比，米非司酮和植入物同时给药后，两项随机对照试验（n = 1027）显示出较低的“随后意外怀孕”率和较高的“患者满意度”，并且没有其他差异。一项随机对照试验（n = 461）显示，与米非司酮和注射剂延迟给药相比，同时给药后的“患者满意度”更高，但这些干预措施之间没有其他差异。三个RCT（n = 536）发现，与妊娠≤9周时延迟插入相比，早期铜IUC摄取更高，立即延迟后与9 ⁺¹ –12延迟插入相比，IUC排出，持续和摄取率更高。⁺⁰与在妊娠12 ⁺¹ –20 ⁺⁰周时延迟插入相比，立即妊娠后3周的妊娠和更高的IUC持续率。该证据的质量从非常低到很高不等，主要是由于低事件发生率，高损耗和无致盲性而受到损害。

暗示

服用米非司酮当天应提供避孕药植入物或注射剂。驱逐妊娠后应尽快提供宫内避孕方法。