Depo-Provera Administration in Ped ED

In the past we have discussed the administration of chronic medications (ex, Controller Meds for Asthma) and vaccinations that previously were felt to belong only in the Primary Care Setting. Clearly, the patient’s location matters less than what care she or he needs. There is expertise in the Primary Care realm that I do not possess… just ask my sister… but there are also issues and care that we in the ED should be more comfortable with so that we can optimize care for our patients. While many may think we need to “stay in our lane,” our lane is obviously quite broad (ex, Firearm Safety). This week, one of our STELLAR Pediatric EM Fellows, Dr. Nikki Richardson educated me about an aspect of care that I need to become more comfortable with. Here is what she taught me about Depo-Provera Administration in the Ped ED: (btw, this is the first Morsel ever authored by someone other than me — thank you Dr. Richardson!)

Birth Control from the ED: This is our Realm!

Adolescents use the Emergency Department as their Primary Care 

• Adolescents in the US under-utilize primary care services and rely more heavily on ED services. 

• Older adolescents are overrepresented in their use of ED services [Ziv, 1998]
  • Adolescents with higher levels of risky sexual behavior are more likely to report the ED as their usual source of care. [Wilson, 2000]

• Risky sexual behavior without protection = pregnancy 
  • 1/3 of adolescent females presenting to the pediatric ED were either pregnant or could be expected to become pregnant within a year. [Chernick, 2011]

• Adolescents are interested in birth control from the ED
  • ½ patients surveyed believe ED doctors should discuss pregnancy prevention. [Cernick, 2011]
  • ¼ were interested in starting birth control from the ED. [Chernick, 2011]

Adolescents Need Better Access to Intermediate and Long-Acting Contraception

• When compared with older women, adolescents have higher failure rates with “typical use”. [Rosenstock, 2012]
  • Contraceptive failure for short-acting methods was 20 times higher than for long-acting methods. [Truehart, 2015]
  • Females less than 21 years old who use short acting methods are Twice as likely to experience unintended pregnancy. [Truehart, 2015]

• Failure rates of short-acting methods are 9% in the general population, but for teenagers this can be as high as 30-38%. [Trussell, 2011]

Better Contraception Option from the Ped ED

Depo-Provera: Basics

• Depo-Provera (depot medroxyprogesterone acetate, DMPA) is an intermediate acting birth control method that is easily administered as an IM injection from ANY healthcare setting and protects from pregnancy for 3 months.  

• Adverse effects include:
  • Irregular bleeding, which dissipates with continued use [Truehart, 2015]
  • Possibility of weight gain 
    • Although there is reassuring evidence that most methods of hormonal contraception are not associated with weight gain, conflicting information exists with regards to DMPA. [Truehart, 2015; Vickery, 2013]
    • Despite the possible risk of weight gain, there is no contraindication to use in overweight or obese adolescents. [Truehart, 2015]

• Contraindications to use include pregnancy, prior CVA, uncontrolled diabetes, lupus with antiphospholipid antibody syndrome, and significant liver disease. [Truehart, 2015]

Depo-Provera Prescribing from the ED: How-to

• The Quick Start method allows initiation of hormonal contraception at the time the patient seeks care, regardless of where they are in their menstrual cycle. [Westhoff, 2002] 

• The Quick Start Method is listed in the evidence-based clinical practices for adolescent clients in the CDC and Prevention Office of Adolescent Health teen pregnancy prevention community-wide initiatives of 2011. [CDC, 2015]

• Steps
  • Step 1: Preform a thorough sexual history
  • Step 2: Counsel on options including DMPA
    • Most states do not require parental consent for initiation of birth control, sexual health assessment and reproductive counseling.
    • For your states specific laws/policies see – Guttmacher.org.
  • Step 3: Obtain UPT
  • Step 4: If UPT negative, administer Depo-Provera 
  • Step 5: Post administration counseling
    • Back-up method needed for 7 days 
      • It takes 7 days to reliably change cervical mucus. [Petta, 1998]
      • In a study of 402 patients who became pregnant while using DMPA for pregnancy prevention, 45% became pregnant after the injection. [Borgotta, 2002]
    • Repeat UPT in 2-4 weeks 
      • Repeating UPT is important since a very early pregnancy may have been missed on first test. [Balkus, 2005]
    • Follow-Up: Patient needs repeat injection in 10-13 weeks.

Moral of the Morsel

• This is our lane. Adolescent patients often rely on us in the ED as the source of their primary care.
• Taking a pill every day is difficult for everyone… especially teenagers!
• It is safe and effective! … and Depo-Provera can be administered from the emergency department.
• “You get a UPT! You get a UPT! You get a UPT!” Obtain a UPT prior to administration.
• Consider, Counsel, UPT, Administrate, and Follow-up. That is it. Repeat UPT in 2-4 weeks and repeat injection in 10-13 weeks… hopefully in the Primary Care Doctor’s office.

References:

Ziv A, Boulet JR, Slap GB. Emergency Department Utilization by Adolescents in the United States. Pediatrics. 1998;101(6):987–994. doi: 10.1542/peds.101.6.987.

Wilson KM, Klein JD. Adolescents who use the emergency department as their usual source of care. Arch Pediatr Adolesc Med. 2000;154(4):361–5. 

Chernick L, Kharbanda EO, Santelli J, Dayan P. Identifying adolescent females at high risk of pregnancy in a pediatric emergency department. J Adolesc Health. 2012;51(2):171–8. doi: 10.1016/j.jadohealth.2011.11.023

Trussell J. Contraceptive failure in the United States. Contraception. 2011;83:397–404.

Rosenstock JR, Peipert JF, Madden T, et al. Continuation of reversible contraception in teenagers and young women. Obstet Gynecol. 2012;120:1298–1305

Truehart A, Whitaker A. Contraception for the Adolescent Patient. Obstetrical and Gynecological Survey. 2015;70(4):263-273

Vickery Z, Madden T, Zhao Q, et al. Weight change at 12 months in users of three progestin-only contraceptive methods. Contraception. 2013;88:503–508

Westhoff C, Heartwell S, Edwards S, et al. Initiation of oral contraceptives using a quick start compared with a conventional start: A randomized controlled trial. Obstet Gynecol 2007;109:1270e6.

Centers for Disease Control and Prevention. Teen pregnancy prevention 2015. Accessed May 17, 2021. Available at, http://www.cdc.gov/ teenpregnancy/prevent-teen-pregnancy/index.htm.

Petta CA, Faundes A, Dunson TR, et al. Timing of onset of contraceptive effectiveness in Depo-Provera users: Part I. Changes in cervical mucus. Fertil Steril 1998;69:252 – 7

Balkus J, Miller L. Same-day administration of depot-medroxyprogesterone acetate injection: a retrospective chart review.Contraception, 2005; 71:395-398

Borgatta L, Murthy A, Chuang C, Beardsley L, Burnhill M. Pregnancies diagnosed during Depo-Provera use. Contraception 2002;66:169 – 72.