National Guideline Alliance, The Royal College of Obstetricians and Gynaecologists, London, SE1 1SZ, UK.
Department of Gynaecology, Royal Cornwall Hospitals NHS Trust, Truro, TR1 3LQ, UK.
Hum Reprod Update. 2020 Feb 28;26(2):141-160. doi: 10.1093/humupd/dmz040.
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.
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).
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.
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.
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.
长效可逆避孕方法（LARC）是安全、有效且方便的流产后避孕方法。然而，人们担心某些 LARC 可能会降低流产药物的效果，或导致其他不良后果。
我们进行了两项系统评价，以检查米非司酮和米索前列醇药物流产后早期使用 LARC 的情况。（i）对于正在接受药物流产且计划使用孕激素避孕药具（植入物或注射剂）的女性，在与米非司酮同时使用避孕措施会影响流产效果吗？（植入物/注射剂评价）。（ii）对于已经进行了药物流产的女性，在排出妊娠产物后多久可以安全地插入宫内节育器/系统？（LNG-IUS/Cu-IUD 评价）。
2018 年 11 月 19 日，我们检索了 Embase Classic、Embase、Ovid MEDLINE（包括每日和提前在线印刷、处理中和其他非索引引文）、Cochrane 图书馆、 Cinahl Plus 和 Web of Science 核心合集。合格的研究为随机对照试验（RCT），英语文献为 1985 年（植入物/注射剂评价）或 2007 年（LNG-IUS/Cu-IUD 评价）以后发表的，在使用米非司酮和米索前列醇进行药物流产的女性中进行，研究对象为（i）米非司酮与孕激素避孕药具同时使用与米非司酮给药后 >24 小时使用相比，或（ii）妊娠产物排出后立即放置宫内节育器与早期放置（≤7 天）或延迟放置（>7 天）或早期放置与延迟放置相比。一位作者使用 Cochrane 协作组对 RCT 的偏倚风险评估检查表评估了研究的偏倚风险。所有结局均采用 Review Manager 5.3 软件分析，使用 Mantel-Haenszel 统计方法和固定效应模型进行风险比分析和荟萃分析。使用 GRADE 评估证据的总体质量。
两项 RCT（n=1027）显示，同时使用米非司酮和植入物与延迟使用相比，“后续非意愿妊娠”发生率较低，“患者满意度”较高，其他方面无差异。一项 RCT（n=461）显示，同时使用米非司酮和注射剂的患者满意度高于延迟使用，其他方面无差异。三项 RCT（n=536）发现，在妊娠 9 周以内，早期与延迟放置相比，铜 IUC 使用率更高，IUC 脱落、继续和使用率更高，9+1-12+0 周妊娠时即刻与延迟放置相比，IUC 继续使用率更高，12+1-20+0 周妊娠时即刻与延迟放置相比，IUC 继续率更高，其他方面无差异。该证据质量为极低到高，主要受低事件率、高失访率和无盲法影响。
避孕药具应在服用米非司酮当天提供。妊娠产物排出后应尽快提供宫内节育器避孕方法。
