Emeregency Contraception Flashcards by Saarrah Mohammed

What is emergency contraception?

This is the intervention aimed in preventing unintended pregnancy after unprotected sexual intercourse or potential contraceptive failure.

How well did you know this?

Not at all

Perfectly

When is emergency contraception used and why?

1.when the patient has a natural cycle and no contraception has been used:
-in this case we need to determine how at risk the patient is at potential pregnancy and what method would be most appropriate.
-if in doubt we always supply

When there is incorrect use or potential failure in the hormonal contraception that is used:
-this contraception failure and it needs consideration of the type of contraception that is used and inform of the incorrect use of that method of contraception e.g. the missed pill rules
From 21 days after childbirth unless all LAM criteria is met
From day 5 after miscarriage,abortion or ectopic pregnancy

How well did you know this?

Not at all

Perfectly

What is the menstrual cycle length?

-the first day of menstruation (period ) is day one of the cycle
-the menstrual cycle is the time front he first day of menstruation up to the day before the next menstruation, the averaged cycle is around 28 days, but can vary from 21-40 days.
-THIS IS IMPORTANT TO HELP DETERMINE THE EXPECTED TIME FOR OVULATION.

How well did you know this?

Not at all

Perfectly

How does oral emergency contraception work?

Works by delaying and slowing down ovulation.
If emergency contraception is taken after it is ineffective.

How well did you know this?

Not at all

Perfectly

When does ovulation occur?

Occurs 14 days before menstruation (period) starts

How well did you know this?

Not at all

Perfectly

How do we calculate the estimated ovulation time?

We woke of the patients predicated ovulation by determine the length of their cycle subtracting 14 off that .
-if the patient has an irregular cycle then calculate the likely ovulation date using the shortest cycle in the past 12 months.

How well did you know this?

Not at all

Perfectly

What is the fertile period?

This is the most likely time for a likely to be at her most fertile state to get pregnant.
-this however, only occurs for a short amount of time
-it occurs near to ovulation
-a women is said to be most fertile the 5 days leading up to and including th estimated ovulation day ( 6 days)

How well did you know this?

Not at all

Perfectly

When is the follicle stimulating hormone the highest?

This is around day 14 ovulation

How well did you know this?

Not at all

Perfectly

How long are sperm viable after UPSI?

5 days

How well did you know this?

Not at all

Perfectly

What happens if sperm is still present and ovulation occurs?

If ovulation occurs within the 5 days which sperm are present for then there is a potential risk of pregnancy
-once released an unfertilised egg can survive for 12-24 hours

How well did you know this?

Not at all

Perfectly

What methods are available for emergency contraception?

Ulipristal (ellaOne)

Levonorgestrel (levonlle)

Copper IUD

How well did you know this?

Not at all

Perfectly

What is the most effective method of emergency contraception?

COPPER IUD (more than 99% effective)
-it is effective during and after ovulation when oral emergency contraception will not work.

How well did you know this?

Not at all

Perfectly

What is the mechanism of action of Copper IUD?

It has pre and post fertilisation mechanisms of action:
-it is spermicidal and toxic to the ovum and thus prevents fertilisation
-if fertilisation does occur, the copper IUD causes a local endometrial inflammatory reaction which prevents implantation

How well did you know this?

Not at all

Perfectly

When can the copper IUD be inserted?

-up to 5 days (120 hours) after the first UPSI
Or
-up to 5 days after the earliest estimated day of ovulation (before the process of implantation has begun)

How well did you know this?

Not at all

Perfectly

What are the contraindications of Copper IUD contraception?

-ovarian
-acute pelvic infection
-gynaecological cancers e.g. cervical
-undiagnosed vaginal bleeding
-pregnancy
-can’t be used until 4 weeks postpartum

How well did you know this?

Not at all

Perfectly

How does levonorgestrel work?

The mechanism of action of levonorgestrel is that it delays the follicular development when administrated before the level of LH increases.

How well did you know this?

Not at all

Perfectly

Up to how many hours can levonorgestrel be taken before?

72 hours after UPSI (3 days)

How well did you know this?

Not at all

Perfectly

When does the levonorgestrel become ineffective and what would we give in replacement and why?

When the level of leutonising hormone begins to rise this is because this hormone tells the ovaries to release an egg making the female more likely to get pregnant.

We would give ullipristal

How well did you know this?

Not at all

Perfectly

What are the indications of levonogestrel ?

Had UPSI with compromised contraception within the previous 72 hours

Have had levonorgestrel but vomited within three hours of administration and are still within 72 hours of UPSI

How does ullipristal work?

It is a selective progesterone receptor modulator
-it inhibits follicular rupture even after the level of luteinizing hormone starts to increase.
-so essentially it inhibits the release of an egg despite the increase in LH.

How long does ullipristal have until it begins to be ineffective?

5 days (120 hours)
-this is the first choice if the UPSI occurred during the fertile period
-delays the follicular rupture for up to 5 days

What key information should the patient be aware of if after taking ullipristal?

-cannot start or redstart contraception until five days after taking ullipristal
-it may be less effective on those patients that have had the progesterone in the pre feeding 7 days

What is the only contraceptive that works after the ovulation stage and how does it do so ?

Copper IUD
-if an egg is already fertilised, the copper IUD can still stop pregnancy by preventing implantation.

Which contraceptive can you use for under 16s?

Ullipristal

The time has elapsed since UPSI ?

72 hours - Levo 120 hours -ullipristal 7 days for copper IUD

When do you consider the Fraser competency and safeguarding?

From the ages of 13-14

What to consider when supplying to a patient under 16?

-non consensual intercourse -child protection -vulnerable adults -PGDs are in place in many community pharmacies for the supply of both levo and ulipristal to patients over 13 years old. -greaser competency must always be assessed in a supply made to a patient under 16

What is Fraser guidance?

Relating to contraception: -the Young person understands the advice they have been given -the young person cannot be convinced to involve parents or to allow the medical practitioner to do so on their behalf - the young persons best interests require contraceptive advice, treatment or supplies to be given without parental consent

What should be considered before giving emergency contraception and give the 2 types that can be used and what effect they pose ?

TIME SINCE LAST UPSI -it should be offered as soon as possible after UPSI LEVONORGESTREL: -licensed for use within 72 hours( 3 days) -the efficacy of this etc declines over time -up to 12 hours 95% effective -25-48 85% effective -49-72 58% effective ULIPRISTAL: -is effective for up to 120 hours (5 days) after UPSI -remains effective up until 120 hours -it is more effective around the time of ovulation

What else should be considered?

1. What was the date of the last menstrual period 2.what is the usual cycle length 3. Is ovulation likely to have taken place within the cycle?

If a patient is taking a COC, when is EC needed if contraception is missed?

What considerations are needed to be thought about in terms of breast feeding and emergency contraception (levonorgestrel) ?

Levonorgestrel has no adverse effects on breastfeeding on their infants, if however the patient is worried, suggest to take the EC immediately after breast feeding and avoid nursing for at least 8 hours, which means this level will drop by the next feed.

Why is ulipristal not suitable for women breast feeding and what advice should be given?

It is not suitable for women who are breastfeeding, they should express and discard milk for 7 days after they have had ulipristal.

What considerations need to be made regarding the patients BMI when giving out levonorgestrel ?

-the effectiveness of the EC can be reduced in women who are weighed over 70kg or have a bmi of over 26 -patients who are overweight should be informed of this risk and potentially discuss alternatives, could give ULIPRISTAL as it seems to be unaffected by BMI.

If a patient is overweight what should we give in terms of oral EC?

Give a single dose of ULIPRISTAL 3mg Or Give a double dose (3mg) of levonorgestrel (otc doesn’t allow to be supplied and would need to be off label and referred)

In what sorts of patients should levonorgestrel NOT be used?

-severe liver dysfunction -patients at risk of ectopic pregnancy -inflammation of fallopian tubes -reduced efficacy with people suffering with severe malabsorption -acute polyhyria

When should ULIPRISTAL NOT be used?

In patients with: -severe asthma who are on oral glucocorticoids -severe liver impairment

What medication can cause a decrease in the efficacy of EC?

ENZYME INDUCING DRUGS both ulipristal and levonorgestrel. -phenytoin -carbamazepine -phenobarbital -rifamipicin

What do enzyme inducing drugs do if taken with EC?

They decrease the efficacy of the contraceptive this meaning it is not working at its fullest potential.

What is advices if a workmen is taking enzyme inducing drugs in the past 4 weeks ?

Give CU-IUD Or if I tolerated give Double dose of levonorgestrel , ULIPRISTAL is not recommended if the patient has had an enzyme inducing drug 4 weeks prior

When can a patient restart regular contraception after taking ulipristal?

5 days for hormonal contraception And 12 days for combined

When can a patient restart contraception after levonorgestrel?

It can be taken immediately after

How does progesterone affect ulipristal?

If progesterone is taken within the 120 hours then the efficacy of ulipristal to essentially delay ovulation is reduced. I.e. if they have missed pills.

What would you give instead of ulipristal if the patient has taken progestrogen?

Give levonorgestrel instead, if the patient has had progestrogen 7 days prior

What happens if the patient is to vomit within 3 hours of taking the EC?

Another tablet should be given as soon as possible Both tablets can be taken with or without food

What advice would you give the patient regarding cycle disruption?

-advise that her menstrual cycle may be altered, the next period could be early or late, if it is delayed for more than 7 days suggest to take a pregnancy test.