A 34-year-old woman attends the surgical admission unit as she is scheduled to undergo female sterilisation today. She reports she has been using the combined oral contraceptive pill sporadically and does not use barrier contraception regularly. She has had sex in the past 2 weeks and her last menstrual period was 2 weeks ago. She has irregular cycles lasting between 25 and 32 d.

What is the next best step in her management?

Options:
explanation: An ultrasound would not be able to reliably detect pregnancy in its early stages. Before sterilisation, patients are advised to be on effective contraceptive for a month to minimise the risk of pregnancy at the time of the procedure, which can lead to ectopics occurring. This patient has not been taking effective contraception and has had sex recently; thus, her procedure should be cancelled.
name: Ultrasound to assess for pregnancy and, if negative, proceed
label: e
answer: no
explanation: Before sterilisation, patients are advised to be on effective contraceptive for a month to minimise the risk of pregnancy at the time of the procedure, which can lead to ectopics occurring. This patient has not been taking effective contraception and has had sex recently; thus, her procedure should be cancelled. Pregnancy tests may be negative in the very early stages of a pregnancy and as such a negative pregnancy test on the day of the procedure is not reliable enough to enable the operation to proceed. This should be explained to the patient and suitable contraception offered; in this case, due to issues with taking oral contraception or barrier methods previously, a LARC may be the best option but this is a conversation to be had with the patient. Levonelle is an emergency contraceptive medication, which is provided within 3 d of unprotected intercourse to prevent pregnancy; there is nothing in the question to suggest the patient wants emergency contraception, and even if she did this would not be an option available to her since her unprotected intercourse was 2 weeks ago. If Levonelle were an option, you would still not proceed with the procedure due to the subsequent risk of pregnancy still being relatively too high and you would postpone until the patient has been taking contraception for a month.
.
name: Give levonorgestrel (Levonelle) and proceed
label: d
answer: no
explanation: Before sterilisation patients are advised to be on effective contraceptive for a month to minimise the risk of pregnancy at the time of the procedure, which can lead to ectopics occurring. Pregnancy tests may be negative in the very early stages of a pregnancy and as such a negative pregnancy test on the day of the procedure is not reliable enough to enable the operation to proceed. This patient has not been taking effective contraception and has had sex recently; thus, her procedure should be cancelled.
name: Perform a pregnancy test and, if negative, proceed
label: c
answer: no
explanation: Before sterilisation, patients are advised to be on effective contraceptive for a month to minimise the risk of pregnancy at the time of the procedure, which can lead to ectopics occurring. This patient has not been taking effective contraception and has had sex recently; thus, her procedure should be cancelled. Pregnancy tests may be negative in the very early stages of a pregnancy and as such a negative pregnancy test on the day of the procedure is not reliable enough to enable the operation to proceed. This should be explained to the patient and suitable contraception offered; in this case, due to issues with taking oral contraception or barrier methods previously, a long-acting reversible contraception (LARC) may be the best option but this is a conversation to be had with the patient.
name: Postpone sterilisation
label: a
answer: yes
explanation: Before sterilisation, patients are advised to be on effective contraceptive for a month to minimise the risk of pregnancy at the time of the procedure, which can lead to ectopics occurring. This patient has not been taking effective contraception and has had sex recently; thus, her procedure should be cancelled. Pregnancy tests may be negative in the very early stages of a pregnancy and as such a negative pregnancy test on the day of the procedure is not reliable enough to enable the operation to proceed. This should be explained to the patient and suitable contraception offered; in this case, due to issues with taking oral contraception or barrier methods previously, a LARC may be the best option but this is a conversation to be had with the patient.
name: Proceed with sterilisation
label: b
answer: no

Correct answer: a


Learning point: Prior to female sterilisation, ensure effective contraception is used for at least one month to reduce the risk of unintended pregnancy, a contraindication for sterilsation.