AFJOG

African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 2 | 2025 | 31 GUIDELINES after delivery and up to 48 hours in the postpartum period. Patients should be counselled that the risk of perforation and expulsion is relatively high especially after later insertion. An IUCD is contra-indicated if there has been prolonged rupture of membranes; chorioamnionitis or postpartum haemorrhage. Women should be counselled that the device could be expelled without them realising and therefore it is important to confirm the device placement at the 6 week visit. They should seek medical assistance for any symptom suggesting infection, heavy bleeding or expulsion. Breast-feeding patients should choose progestogen-only pills over combinations. Combined oral contraceptives can be started after three weeks in non-breast-feeding women without risks for venous thromboembolism. Lactational amenorrhoea is effective, provided that breastfeeding is exclusive, the mother has amenorrhoea, and the baby is less than 6 months old. Emergency Contraception The copper IUD is the first choice emergency contraceptive as it is the most effective method, can be used up to 120 hours after unprotected sexual intercourse (UPSI) and provides ongoing contraception for five years or longer. The levonorgestrel single dose tablet available as Escapelle ® is 1.5mg tablet taken immediately up to 72 hours after unprotected sexual intercourse (UPSI). It has been used up to 96 hours, but contraceptive effectiveness decreases significantly. It will not prevent ovulation if taken after the onset of the LH surge. LNG may also be used in 2 divided doses i.e. 0.75mg 12 hourly for 24 hours. The selective progestogen receptor modulator ulipristal acetate, Ella ® , inhibits ovulation for 5 days at a dose of 30mg immediately and is effective up to 120 hours after UPSI because it still inhibits ovulation after onset of the LH surge. It is not effective after the LH peak, meaning that it is important to ascertain how close to ovulation the UPSI was. The Yuzpe method consist of two tablets high dose combined oral contraceptives taken immediately but within 72 hours of UPSI, followed by another two after 12 hours. The method is no longer recommended due to the high dose of estrogen and the side effects of nausea and vomiting, but can be used in the absence of other available methods. Menstruation may be delayed when using emergency contraception, but up to 75% of women taking UA will experience their period at the normal time. Deep or Difficult Implant removals Implants for removal that cannot be palpated may be removed under ultrasound guidance ideally using a high frequency linear probe 10 – 18 MHz; abdominal and vaginal probes have also been used successfully. (9) . Contraception in the perimenopause During the peri-menopause the small remaining risk for pregnancy must be balanced with the risks, costs and inconvenience of the contraceptive hormone dosage in the older woman. Menopausal hormone therapy (MHT) does not protect against pregnancy. Older age, menopausal symptoms and longer period of amenorrhoea all lower the chances of remaining fertility. After the age of 50 years, many women will have co- morbidities or risk factors that make combined oral contraceptives (cardiovascular risks) and injectables (bone density risks) undesirable. FSH-levels cannot be interpreted in women using these two methods, but can be done on a yearly basis after interrupting COC’s for 8 days, to determine ovarian function. Fertility after age 55 years is very uncommon, so most women can safely stop contraceptives or change to MHT. LNG IUS, progestogen only tablets and implants all allow the use of FSH levels to ascertain ovarian failure, but are all considered safe to continue also after menopause. LNG IUS has a longer effective lifespan of up to 10 years in women >45 years. (10) Risk of HIV acquisition Findings from observational trials suggested an elevated risk of HIV acquisition among women at high risk using progestogen-only injectable contraceptives. (8) The WHO subsequently conducted a randomised clinical multicentre study with sites in South Africa, eSwatini, Zambia and Kenya, called the ECHO trial, randomising women to either DMPA, Levonorgestrel implant or copper IUD. The study showed an equal risk of HIV acquisition of 4% across all methods without any significant difference in HIV acquisition. (11) Following this evidence, injectables are categorised as MEC category 1, and considered safe regarding HIV-acquisition. (12) DISCLAIMER: This document is intended to guide clinical care without changing the responsibility of the health care team or the patient. It never replaces clinical judgement and individualised care. Guidelines are time sensitive and the authors welcome any contributions which should be sent to the SASOG secretariat. ACKNOWLEDGEMENT: Copyright of BetterGyn TM and the South African Society of Obstetricians and Gynaecologists and published with permission. BetterGyn TM is an official trademark of SASOG and a programme aimed at improving clinical care in Gynaecology in South Africa. Developed and endorsed by SASOG as part of the BetterGyn ® programme. REFERENCES ± § Ã Ã Ã _ ¦ _ ® ¦