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Secured aneurysmal subarachnoid haemorrhage with ongoing dual antiplatelet therapy — DFSRH MCQ

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HardSubarachnoid HaemorrhageSecured aneurysmal subarachnoid haemorrhage with ongoing dual antiplatelet therapyDFSRH

A 36-year-old woman attends a specialist sexual and reproductive health clinic 10 weeks after an aneurysmal subarachnoid haemorrhage. A ruptured posterior communicating artery aneurysm was treated by stent-assisted coiling; follow-up angiography confirms complete occlusion, and she has no neurological deficit. She takes aspirin 75 mg and clopidogrel 75 mg daily because of the intracranial stent, with dual antiplatelet therapy planned for a further 4 months. Before the haemorrhage, she used a combined oral contraceptive containing ethinylestradiol and levonorgestrel, partly to manage longstanding heavy menstrual bleeding. This was stopped on admission. Her first subsequent menstruation lasted 9 days with flooding. Haemoglobin is 101 g/L and ferritin 6 micrograms/L. Pelvic ultrasonography shows no pathology and a normal uterine cavity. She has had no sexual intercourse since the haemorrhage, and pregnancy testing is negative. She wants highly effective, user-independent reversible contraception and would welcome substantially reduced menstrual bleeding. She accepts intrauterine contraception. There is no pelvic infection or other contraindication to insertion. Which is the most appropriate contraceptive plan?

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Correct answer: E — Insert a 52 mg levonorgestrel intrauterine device now without interrupting dual antiplatelet therapy

A subarachnoid haemorrhage is a cerebrovascular accident: securing the culprit aneurysm does not remove the history of stroke for contraceptive eligibility. Combined hormonal contraception is therefore UKMEC 4 and should not be restarted. For someone with a history of stroke, initiation of an LNG-IUD is UKMEC 2, whereas DMPA is UKMEC 3. The 52 mg LNG-IUD is highly effective and directly addresses her heavy bleeding and iron-deficiency anaemia, which may otherwise be aggravated by dual antiplatelet therapy. Although a copper IUD is UKMEC 1, it can increase menstrual blood loss and is therefore inferior in this specific case. Antiplatelet treatment should not routinely be withheld for intrauterine insertion: the small procedural bleeding risk is outweighed by the potentially serious thrombotic risk of interrupting treatment for an intracranial stent. Insertion should be undertaken by an experienced clinician with measures to minimise trauma, haemostatic equipment available, assessment for bleeding before discharge and avoidance of peri-procedural NSAIDs. A progestogen-only pill is UKMEC 2 for initiation after stroke and would be a reasonable bridge if insertion had to be delayed, but antiplatelet therapy alone is not a reason for deferral. DMPA is less appropriate because its UKMEC 3 classification requires the absence or unacceptability of more suitable methods.

Reference: FSRH Guideline: Intrauterine Contraception (March 2023, amended January 2025) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-clinical-guideline-intrauterine-contraception-mar-23-amended.pdf FSRH Guideline: Intrauterine Contraception, Figure 1 (March 2023, amended January 2025) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-clinical-guideline-intrauterine-contraception-mar-23-amended.pdf UK Medical Eligibility Criteria for Contraceptive Use (April 2016, amended September 2019) — https://www.fsrh.org/Common/Uploaded%20files/Standards-and-Guidance/fsrh-ukmec-full-book-2019.pdf