What are the next steps for a patient who is 6 days late for their contraceptive (Depot Medroxyprogesterone Acetate) injection?

From the Guidelines

If a patient is 6 days late for their contraceptive injection, they should receive the injection immediately if pregnancy can be reasonably ruled out, as the guidelines suggest proceeding with the injection if it is less than 2 weeks late 1. When a patient presents 6 days past their scheduled contraceptive injection, the primary concern is to minimize the risk of unintended pregnancy while ensuring the patient's safety and maintaining the efficacy of the contraceptive method.

• The patient should undergo a pregnancy test before administering the injection to confirm they are not pregnant.
• No backup contraception is needed if the injection is less than 7 days late, but the patient should be advised on emergency contraception options like levonorgestrel (Plan B) or ulipristal acetate (ella) if unprotected intercourse occurred during this period.
• The reason for this approach is that DMPA (Depo-Provera) typically maintains contraceptive effectiveness for about 13-14 weeks despite the standard 12-week dosing schedule, providing a small buffer for slightly delayed injections, as supported by the guidelines from the CDC 1.
• Schedule the next injection based on this current administration date, not the originally planned date, to maintain the contraceptive efficacy and minimize the risk of pregnancy. Key considerations include:
• Ruling out pregnancy before administering the injection
• Advising on emergency contraception if necessary
• Maintaining the standard dosing schedule for future injections
• Ensuring patient understanding of the risks and benefits associated with delayed injections, as outlined in the CDC recommendations 1.

From the FDA Drug Label

To ensure the patient is not pregnant at the time of the first injection, the first injection MUST be given ONLY during the first 5 days of a normal menstrual period; ONLY within the first 5-days postpartum if not breast-feeding; and if exclusively breast-feeding, ONLY at the sixth postpartum week If the time interval between injections is greater than 13 weeks, the physician should determine that the patient is not pregnant before administering the drug.

The patient is 6 days late for the contraceptive injection.

• The time interval between injections is greater than 13 weeks is not applicable in this case, but the patient is late.
• Before administering the next dose, the physician should determine that the patient is not pregnant. The FDA drug label does not provide specific guidance for a 6-day delay, but given the patient is late, a pregnancy test should be performed before administering the next dose to ensure the patient is not pregnant. 2

From the Research

Proceeding with a Late Contraceptive Injection

If a patient is 6 days late for their contraceptive injection, the following steps can be taken:

• Administer the injection as soon as possible, as the effectiveness of the contraceptive may be reduced if the patient is already pregnant 3.
• Consider the patient's menstrual cycle and ovulation status, as the injection may not be effective if ovulation has already occurred 3.
• Inform the patient about the potential risks and benefits of the injection, including the possibility of ovulatory disruption or dysfunction 3.

Factors to Consider

When deciding how to proceed with a late contraceptive injection, the following factors should be considered:

• The patient's medical history and any potential contraindications for the injection 4, 5.
• The patient's previous experience with contraceptive methods and any potential side effects 6, 7.
• The patient's lifestyle and preferences, including their ability to adhere to a regular injection schedule 6, 7.

Potential Consequences

If the patient is 6 days late for their contraceptive injection, there is a risk of:

• Reduced effectiveness of the contraceptive, potentially leading to unintended pregnancy 3.
• Ovulatory disruption or dysfunction, which may affect the patient's menstrual cycle and fertility 3.
• Increased risk of side effects, such as nausea, dizziness, and fatigue, particularly with the use of depot medroxyprogesterone acetate (DMPA) 7.