Emergency Contraception

WOMEN REQUESTS  EMERGENCY CONTRACEPTION-Initial assessment and Indications

Reassure about confidentiality UPSI → when and how many episodes time elapsed ( approx hrs ) Check if emergency contraception is indicated Exclude pregnancy LMP STI- risk assessment Assess risk of abuse , rape and non-consensual sex Follow up ( for eg what happens if she vomits after taking hormonal emergency ) Offer regular method of contraception

Check if on any medications – may interact with hormonal contraception ( eg Liver enzyme inducing drugs as rifampicin , phenytoin and carbamezapine )  Breastfeeding - ○ Cu-IUD is suitable from 4 weeks or more post-partum ○ Levonergestrel can be taken- advice to take immediately after breastfeeding and avoid nursing for 8 hrs following that  ( minimize exposure to baby ) ○ Avoid breastfeeding for 1 week after taking ulipristal  acetate

Levonorgestrel- Precise mechanism not understood but possibly works by inhibition of ovulation To take LNG as soon as possible after UPSI Pregnancy occurring after LNG failure are not associated with any major congenital malformations or adverse outcomes Can be used more than once in a cycle ( may disturb menstrual cycle- manufacturer does not recommend ) If UPSI occurs within 12 hrs after taking LNG- further EC is not required .Oral 1.5 mg single tablet taken within  72 hrs of UPSI or contraceptive failure .Nausea and vomiting- if ♀ vomits within 2 hrs →take another dose as soon as possible and consider also taking an anti-emetic Menstrual irregularities  ( delay of menses by > 7 days , irregular bleeding , spotting ) Dizziness Diarrhoea Breast tenderness. Not 100 % effective so if period is delayed more than 5-7 days late or bleeding is lighter than usual- do a pregnancy test Risk of ectopic pregnancy is very small ( but if severe abdominal pain after taking LNG- seek help ) Next period might be different ○ early mild bleeding may be due to LNG ( may not be start of next menstrual cycle ie should not regard this time as safe for UPSI ) ○ most ♀ next period will be on time Does not provide contraceptive cover for rest of cycle

Ulipristal acetate ( UPA ) 0Selective progesterone-receptor modulator Primary action thought to be inhibition or delay of ovulation Can be taken any time of cycle Not advisable to take UPA more than once in a cycle If UPSI occurs in the same cycle in which UPA has been taken →LNG can be taken ( outside product license ) Contraindicated in pregnancy .Single dose 3 mg tablet within  120 hrs ( 5 days ) of UPSI or contraceptive failure. Vomiting , nausea , abdominal pain , discomfort Mood disorders , headache , dizziness Fatigue , myalgia and back pain Breast tenderness , pelvic pain , dysmenorrhoe. Not 100 % effective-Pregnancy test – if next period is > 7 days late or abnormal bleeding in her next period Vomiting within 3 hrs →take a 2nd dose ASAP Ectopic pregnancy→ risk is small Early mild bleeding or spotting may be due to UPA ( may not be start of next cycle- should not regard this time safe for UPSI ) Most ♀ will have a normal period at the expected time If ♀ becomes pregnant after UPA use →evidence on outcome of pregnancies exposed to UPA is very limited , however there have been no associated adverse outcomes with the small number of pregnancies that have been reported to date

Copper intrauterine device ( Cu IUD )-Copper is toxic to the ovum and sperm Effective immediately after insertion and works primarily by inhibiting fertilization Alterations in the copper content of cervical mucus may inhibit penetration by sperm and inflammatory reactions within the endometrium may prevent implantation .Upto 120 hrs after the 1st episode of UPSI in a cycle or Up to 5 days after the earliest expected date of ovulation .Pelvic infections – small risk of pelvic infections in the 20 days following the insertion of Cu-IUCD After 20 days the risk is same for non-IUD using women Uterine perforation- rare (2 per 1000 insertions ) Pain-during or after the IUD insertion Expulsion- risk around 1 in 20 , ↑ common in the 1st year especially within 1st 3 months Bleeding- spotting , light bleeding , or heavy  ( and prolonged ) bleeding are common in the 1st 3-6 months. Pregnancy test if – next period > than 4-5 days late , if bleeding lighter than usual , or if she feels that she might be pregnant Check regularly that the IUD is in place Removal- to attend either in 1st few days after the onset of menstruation or abstain from UPSI for atleast 7 days before remomval If pregnancy desired-the IUD can be removed anytime F/U appt →after her next peiod 9 or 3-6 weeks after insertion ) to exclude infection , perforation , expulsion