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Y4 - GOSH > Emergency Contraception > Flashcards

Emergency Contraception Flashcards

1
Q

When is emergency contraception used?

A
  • used after episodes of UPSI
  • this includes damaged condoms / missed pills
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2
Q

What is meant by “established pregnancy”?

How do EC methods interfere with this?

A
  • established pregnancy is defined at implantation
  • this occurs between day 6 and 12 post-fertilisation
  • EC methods are NOT abortifacient as they work prior to implantation
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3
Q

What is the definition of post-coital contraception?

A

an intervention to stop pregnancy within 120 hours of fertilisation (5 days)

this is before implantation has occurred and pregnancy is “established”

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3
Q

What is the definition of post-coital contraception?

A

an intervention to stop pregnancy within 120 hours of fertilisation (5 days)

this is before implantation has occurred and pregnancy is “established”

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4
Q

How can the menstrual cycle be divided into 2 halves?

A

proliferative / follicular phase:

  • this is the first half of the cycle that is oestrogen driven
  • it can vary in length

luteal / secretory phase:

  • this is the second half that is progesterone driven
  • it is ALWAYS 14 days in length
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5
Q

How can the timing of ovulation be calculated?

How long does the ovum survive for?

A
  • the timing of ovulation is cycle length minus 14 days
  • the ovum survives for 12-24 hours
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6
Q

What is the survival of sperm like?

A
  • the survival of sperm is 7 days
  • traditional / conservative views stated 1-2 days
  • it is more likely to be around 5 days
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7
Q

Why is a pregnancy test not always relevant when considering EC?

A
  • a pregnancy test is not reliable until after 3 weeks
  • patients may be advised to re-perform one in 3 weeks despite EC
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8
Q

What are the 3 most important areas to cover in an EC history?

A

LMP / cycle length:

  • to calculate date of ovulation

(if someone has irregular cycles, minus 14 from the shortest cycle they have had)

timing of UPSI:

  • the most recent and all UPSI in this cycle

potential contraceptive failure:

  • e.g. missed pills / condom accident
  • potential medication interactions
    • antituberculosis
    • antiretroviral
    • antiepileptic
    • St John’s Wort
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9
Q

What are the 4 indications for EC?

A
  • UPSI on any day of a natural menstrual cycle
  • UPSI from day 21 post childbirth
  • UPSI from day 5 after abortion, miscarriage or ectopic pregnancy
  • regular contraception has been compromised / used incorrectly
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10
Q

At what points in the cycle is someone most fertile?

A
  • most fertile at / around the time of ovulation
  • the pregnancy risk is negligible on day 1-3
  • and the risk is very low 48 hours after ovulation due to demise of the ovary
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11
Q

What are the 3 options for emergency contraception?

A

levonorgestrel 1500mcg:

  • must be taken within 72 hours of UPSI
  • e.g. Levonelle / Upostelle

ulipristal acetate 30mg:

  • must be taken within 120 hours of UPSI
  • e.g. EllaOne

copper coil:

  • can be inserted within 5 days of UPSI
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12
Q

When must levonorgestrel be taken to be effective?

A

within 72 hours of UPSI

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13
Q

When must ulipristal acetate be taken to be effective?

A

within 120 hours of UPSI

  • this is more powerful / effective than levonorgestrel
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14
Q

What is the most effective method of EC?

A

copper IUD

  • this is not affected by BMI, enzyme-inducing drugs or malabsorption
  • it also provides ongoing contraception
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15
Q

At what points during the menstrual cycle is EC offered?

A
  • it is offered at ANY time during the cycle
  • it is unlikely to be effective if ovulation has already occurred
  • the woman should be advised to take a pregnancy test in 3 weeks / if her period is delayed
16
Q

What is levonorgestrel and how does it work?

A
  • it is a progestogen
  • it works by preventing / delaying ovulation by suppressing the LH surge for up to 5 days

(it is not effective if the LH surge has already occurred, but fertility is reduced after demise of the ovum anyway)

  • it is not harmful in pregnancy if this does occur
17
Q

When can contraception be started following levonorgestrel?

A
  • COCP or POP can be started immediately
  • condoms should be used for 7 days after starting COCP
  • condoms should be used for 2 days after starting POP
18
Q

What is the dose of levonorgestrel that is given?

A
  • 1.5mg as a single dose
  • 3mg as a single dose if BMI > 26** or **> 70kg

(double dose is also given with enzyme-inducing drugs but this is off licence)

19
Q

What is done if vomiting occurs after levonorgestrel?

A
  • the dose must be repeated if vomiting occurs within 3 hours
  • nausea & vomiting are common side effects
20
Q

What are the other side effects associated with levonorgestrel?

A
  • spotting / changes to next menstrual period
  • diarrhoea
  • breast tenderness
  • dizziness
  • depressed mood
21
Q

How does levonorgestrel affect breast feeding?

A
  • it is NOT harmful in breastfeeding, so this can continue
  • it is advised to avoid breast feeding for 8 hours after taking the dose
22
Q

How does ulipristal work?

A
  • it is a selective progesterone receptor modulator (SPRM)
  • it suppresses the LH surge, but more powerfully than levonorgestrel
  • it prevents / delays ovulation
23
Q

What advice is given around starting contraception after ulipristal?

A

!! WAIT 5 DAYS !!

  • when starting COCP, use condoms for initial 7 days
  • when starting POP, use condoms for initial 2 days
24
Q

What dose of ulipristal is given?

A
  • a single dose of 30mg
  • unlike levonorgestrel, this dose CANNOT be doubled
25
Q

What are the limitations to the use of ulipristal?

A
  • as the dose cannot be doubled, it cannot be used with enzyme-inducers
  • it is not known whether UPA or LNG is more effective when BMI > 30** or **weight > 85kg
  • breast-feeding must be avoided for 1 week after use
26
Q

What are the contraindications to ulipristal?

A

severe asthma

27
Q

What should happen if vomiting occurs after taking ulipristal?

A

if vomiting occurs within 3 hours, the dose must be repeated

28
Q

What are the other side effects associated with ulipristal?

A
  • breast tenderness
  • N&V
  • back pain
  • mood changes
  • spotting / changes to next menstrual period
  • headache / dizziness
  • abdominal / pelvic pain
29
Q

What are the significant drug interactions associated with ulipristal?

A

UPA is less effective if:

  • progestogens have been taken in the 7 days prior
  • progestogens are taken in the 5 days following
  • enzyme inducers
30
Q

When is UPA used?

A

if patient presents 72-120 hours post-UPSI and does not want an IUD

31
Q

When is the IUD used as emergency contraception?

A
  • it can be fitted up to 5 days after UPSI

OR

  • within 5 days of earliest calculated day of ovulation
    • this is 14 days before the cycle ends
    • e.g. day 12 for a 26 day cycle
  • it is recommended when there have been multiple episodes of UPSI within the last few days
32
Q

Why is the copper IUD the first line for EC?

A
  • it is 99% effective
  • it can be used for ongoing contraception
  • it is toxic to the ovum + sperm and inhibits implantation
33
Q

How long should the copper IUD be kept in for if it is not wanted for contraception?

A
  • it needs to be kept in until at least the next period
  • after this, it can be removed
34
Q

What is the major side effect associated with the copper IUD?

A
  • insertion can lead to pelvic inflammatory disease
  • this is more likely in women who are high risk for STIs
35
Q

What are the disadvantages to copper-IUD fitting?

A
  • periods can become longer, heavier + painful
  • there is a risk of perforation
  • there is a risk of expulsion
  • there is an increased risk of ectopic pregnancy
36
Q

When is insertion of a Cu-IUD strongly encouraged?

A
  • around the time of ovulation, the chance of pregnancy from a single act of UPSI is 30%
  • after ovulation has occurred, levonorgestrel + ulipristal are less likely to be effective
  • the IUD will still work to be toxic to the sperm / ovum
37
Q

Why can the Cu-IUD only be inserted up to 5 days after UPSI?

A
  • the earliest date of implantation is 6 days after ovulation
  • the IUD must be inserted prior to implantation occurring

Y4 - GOSH (62 decks)

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