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Contraception Corner

Pregnancy Testing: A "Teachable Moment"

Miriam Zieman, MD; Robert A. Hatcher, MD, MPH

Pregnancy testing is an important component of contraceptive care, and there are many reasons to encourage the early diagnosis of pregnancy. If a woman wishes to continue her pregnancy, timely measures can be taken to ensure a healthy outcome. If a woman wishes to terminate her pregnancy, early diagnosis allows for more options, including medical abortion. If a woman is found not to be pregnant, pregnancy testing provides an important opportunity to discuss preconceptional care or more effective contraception, depending on her immediate fertility plans.

PROCEDURE

The most common office pregnancy tests are urine immunometric assays that are specific for the β subunit of human chorionic gonadotropin (β-hCG). These tests provide accurate qualitative (positive or negative) test results for hCG levels ranging from 5 to 50 mIU/mL, depending on the specific kit. Most of these tests, whether urine or serum, can detect pregnancy 7 to 10 days after fertilization (ie, 3 to 4 days after implantation), which may be several days before the next menstrual period is due.¹ Shortly after implantation, levels of β-hCG may be too low to detect, especially in a dilute urine specimen. This may lead to a false-negative result. A false-negative result is much more likely than a false-positive pregnancy test result, which is likely to be due to laboratory errors. Home pregnancy tests are more subject to error due to the inexperience of the user and, in some cases, lower test sensitivity. If the clinician suspects that a test result is false, a serum radioimmunoassay pregnancy test may be performed.¹

Pregnancy Test Negative: A "Teachable Moment"6 A negative pregnancy test result for a woman who does not wish to become pregnant provides the clinician with an excellent "teachable moment." This is the time to discuss what would be the best method of contraception for her as well as discuss emergency contraceptive pills (ECPs), which could be used in the event of unprotected intercourse. The clinician should acknowledge the patient's worry over the possibility of pregnancy, and take the opportunity to emphasize certain points: If the patient hasn't been using contraception, this is her "wake-up call." This is the time to discuss the most appropriate methods of contraception for her. The patient may wish to consider abstinence. If abstinence is not a possibility, she should be urged to use contraception unless she wants to become pregnant, and a contraceptive method should be provided at that visit. It usually is not necessary to perform a pelvic examination first. The patient should be informed about ECPs and possibly emergency intrauterine device insertion. The patient should be advised against trying to become pregnant just to test her fertility. The patient should be urged not to take such chances in the future, and not to engage in intercourse without adequate protection against both unwanted/unintended pregnancy and infection. The patient should be screened for possible sexual abuse and/or domestic violence. The patient should be cautioned that a negative urine pregnancy test result does not eliminate the possibility of pregnancy that may result from acts of intercourse in the past 2 weeks. The patient should be provided with ECPs to use in the event of an act of unprotected intercourse; advance provision is highly effective. A negative pregnancy test result for a woman who wishes to become pregnant provides the clinician with an equally important "teachable moment." Most women are not familiar with the importance of preconceptional care and do not appreciate all the steps that they can take before getting pregnant to optimize the outcome of their pregnancies. The negative pregnancy test gives the woman a second chance to prepare for a more healthy pregnancy. It is important for all reproductive-aged women who are sexually active to take folic acid daily. Some women with negative pregnancy test results may have been attempting to become pregnant for extended periods of time and would benefit from evaluation of possible infertility.

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PATIENT COUNSELING

A negative pregnancy test result for a woman who does not want to become pregnant is a big relief, but it is also an important opportunity for targeted counseling messages (see "Pregnancy Test Negative: A 'Teachable Moment'"). The most important step is to work with the patient to decide upon an appropriate form of contraception for the patient, and ensure that it is provided for her to take home. An immediate pelvic examination is not required for most methods, so there need be no delay in supplying the patient.² Of course, if a patient has had unprotected intercourse in the last 5 days, discussion of emergency contraception (EC) is the standard of care.

Two studies of women starting oral contraceptives (OCs) showed that it is safe and acceptable to initiate use on any day of the menstrual cycle ("quick start"); patients do not need to wait until the next menstrual cycle.^3,4 Condoms must be used for at least the next 7 days if women are given quick start OCs. A repeat pregnancy test in 2 to 3 weeks may be helpful if there are any questions about her situation. The quick start approach is now under study in a large, multicenter trial. Emergency contraception can be provided with progestin-only pills (levonorgestrel, 0.75 mg; [Plan B]), varying doses of conventional OCs, or, in some select cases, with insertion of a copper intrauterine device. Even women who have no immediate need for EC can be educated about EC, and may be provided with a prescription or a pack of EC pills (ECPs) to be used if the need arises in the future. Finally, it is essential to emphasize the need for protection against sexually transmitted infections.

A positive pregnancy test result for a woman who does not wish to become pregnant requires sensitive counseling about all of her options (see "Pregnancy Test Positive: A 'Teachable Moment'"). Many women will need time to decide what to do, along with immediate health advice should they decide to continue with the pregnancy. Specifically, while deciding, they should start taking folic acid and stop drinking alcohol, smoking, and using recreational drugs. If they are using prescription medications or have a chronic medical problem, a review of medications is advisable. Continued condom use is advisable if there is any risk of infection.

Pregnancy Test Positive: A "Teachable Moment"6 The pregnancy test result is positive, and the patient wishes to continue the pregnancy. Regardless of whether the pregnancy was planned, this still affords the clinician a "teachable moment." All of the woman's options should be presented, including adoption. The health care provider should use the opportunity to take immediate measures to help ensure a healthy outcome for mother and fetus: The patient should start taking folic acid (0.4 mg/d), preferably in full-spectrum prenatal vitamins. The clinician can supply her with a starter pack, or she can buy them on the way home. All reproductive-aged women should use folic-acid supplementation, at least when they are preparing for pregnancy. The patient should stop smoking immediately; the clinician should be prepared to provide her with aids for quitting and referral to local programs. The patient should stop drinking alcohol and using illicit drugs, again with referral to local programs if necessary. The patient should find a clinician to help follow her throughout her pregnancy, starting as soon as possible. The clinician should discuss all medications and supplements that the patient is using. The patient should be advised to use condoms if she is at any risk for human immunodeficiency virus or other sexually transmitted diseases. If the patient does not wish to continue her pregnancy, the health care provider should discuss pregnancy termination options with her or refer her to an appropriate facility. The possibility of giving the baby up for adoption can also be explored. If the patient is undecided about continuing the pregnancy, she should be provided with literature about termination options and adoption, and perhaps referred for further counseling. The need for a timely decision about termination should be emphasized, along with encouraging a safer and healthy life-style in the meantime. A discussion about the need for effective contraception after pregnancy can be particularly important.

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CONCLUSION

For most women—regardless of whether or not they wish to become pregnant—a pregnancy test represents a "watershed." The health care provider should never fail to take advantage of the patient's heightened motivation and awareness to help her improve her life-style, promote healthier practices, and plan her pregnancies.

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References

1. Hatcher RA, Trussell J, Stewart F, et al, eds. Contraceptive Technology. 18th ed. New York, NY: Ardent Media, 2004.
2. Stewart FH, Harper CC, Ellertson CE, Grimes DA, Sawaya GF, Trussell J. Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs evidence. JAMA. 2001;285(17):2232-2239.
3. Westhoff C, Kerns J, Morroni C, Cushman LF, Tiezzi L, Murphy PA. Quick start: novel oral contraceptive initiation method. Contraception. 2002;66(3):141-145.
4. Lara-Torre E, Schroeder B. Adolescent compliance and side effects with Quick Start initiation of oral contraceptive pills. Contraception. 2002;66(2):81-85.
5. Westhoff CL, Robilotto CM, Richmond AM, Cushman LF, Kalmuss DS. Three-month continuation rates after immediate initiation of oral contraceptives. Obstet Gynecol. 2004;103(4): 14S.
6. Hatcher RA, Zieman M, Cwiak C, et al, eds. A Pocket Guide to Managing Contraception. 7th ed. Tiger, Ga: The Bridging the Gap Foundation; 2004: 26.

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