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Acitretin exposure during the post-treatment pregnancy-prevention interval — DFSRH MCQ

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HardTeratogenicityAcitretin exposure during the post-treatment pregnancy-prevention intervalDFSRH

A 30-year-old woman attends on 19 August 2026 requesting emergency contraception. She completed a course of acitretin for severe psoriasis on 17 October 2024. She has since used a levonorgestrel 30 microgram progestogen-only pill but missed two consecutive pills and had unprotected sexual intercourse 86 hours ago. There was no other intercourse during the preceding 5 weeks. A sensitive urine pregnancy test is negative. She has no contraindication to intrauterine contraception, her STI risk is low, and she would accept an intrauterine device. She plans to stop contraception in October 2026 because this will be 2 years after stopping acitretin. She has had no alcohol since starting acitretin. Which management plan best addresses both her immediate and ongoing pregnancy risk?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Insert a copper intrauterine device today and retain it until at least 17 October 2027, with pregnancy-prevention follow-up

Explanation lettering: D = shown as A · A = shown as D

The copper intrauterine device is the most effective emergency contraceptive and can be inserted within 5 days of the first unprotected intercourse following missed progestogen-only pills. It also immediately provides user-independent, highly effective ongoing contraception. Acitretin requires effective contraception for the full 3 years after cessation, irrespective of amenorrhoea or alcohol avoidance; this interval ends on 17 October 2027, not in October 2026. Her low-dose levonorgestrel pill is additionally unsuitable within the acitretin pregnancy-prevention framework because reduced contraceptive effect has been reported. B is a reasonable oral fallback if a copper device is declined, but ulipristal is less effective than copper emergency contraception and recently taken progestogen may theoretically reduce its efficacy. C permits immediate implant initiation and may be considered if the copper device is declined; however, levonorgestrel emergency contraception is less effective than a copper device and its use at 86 hours is off-label. D provides highly effective ongoing contraception but the levonorgestrel intrauterine system is not the recommended intrauterine method for emergency contraception in current FSRH guidance. E addresses future risk but not the pregnancy risk from intercourse 86 hours earlier; a negative test today cannot exclude that conception. Pregnancy-prevention follow-up, including testing as specified by the acitretin programme, should continue for 3 years after treatment.

Reference: FSRH Guideline: Emergency Contraception (March 2017, amended April 2026) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-guideline-emergency-contraception03dec2020-amendedjuly2023-11jul.pdf Acitretin 25 mg Capsules: Summary of Product Characteristics (Text revised 28 August 2024) — https://www.medicines.org.uk/emc/product/10292/smpc FSRH CEU Statement: Contraception for women using known teratogenic drugs or drugs with potential teratogenic effects (14 February 2018) — https://www.fsrh.org/Common/Uploaded%20files/documents/teratogenic-medication-and-contraception-fsrh-ceu-statement-february-2018.pdf