Emergency Contraception Flashcards
What is the most effective emergency contraception
Copper intrauterine device Cu-IUD
Following an episode of UPSI or incorrect contraceptive use what two other concerns should be considered
- Sexually transmitted infection
- Ongoing contraception
Which days in a cycle is conception extremely unlikely
First 3 days of a cycle
What is the risk of pregnancy following a single episode of UPSI during her fertile period
30%
What is the chance that a single UPSI will occur during the woman’s fertile period
25% chance
What is considered the woman’s fertile period
6 days up to and including the day of ovulation
Why should EC be offered following UPSI on any day in a woman’s natural cycle
Estimating the fertile period using cycle length and date of last menstrual period may be imprecise and unreliable
Which days of the cycle does the uterine lining thicken
Days 6-10
What days does ovulation usually occur
Days 11-18 (14 days prior to the next menstruation)
On what day post partum should EC be offered for UPSI on or after this day
Day 21 post partum (unless lactational amenorrhoea conditions fully met)
If there has been UPSI in the 28 days following use of liver enzyme inducing drugs, what can be used for EC
- cu-IUD
- Double dose (3mg) of LNG-EC
UPA-EC not recommended in this situation
EC should be offered for UPSI from day — after abortion, miscarriage, ectopic pregnancy or uterine evacuation for gestational trophoblastic disease
5
If a woman is referred on for fitting of Cu-IUD for EC what should be given at the time of referral
Oral EC should be given in case the Cu-IUD cannot be inserted or woman changes her mind
How many hours after UPSI is ulipristal acetate (UPA-EC) effective for
120 hours (5 days)
How many hours after UPSI is levonorgestrel EC licensed to be given
Up to 72 hours after UPSI
Evidence suggests it is ineffective if taken more than 96 hours (4days) after UPSI
Is UPA or LNG more effective as EC
UPA-EC
When is oral EC ineffective
After ovulation
LNG ineffective if on or recently finished (28d) liver enzyme inducing drugs
Which ECs effectiveness may be reduced by increased BMI
Oral EC in particular LNG-EC
What should not be taken in the 5 days after taking UPA-EC
Progesterone as it reduces the effectiveness of the EC
The effectiveness of UPA-EC could theoretically be reduced if a woman has taken progesterone in the — days prior to taking UPA-EC
7 days prior
Which method of EC is contraindicated for women who have severe asthma controlled by oral glucocorticoids
UPA-EC
What are the contraindications for Cu-IUD EC (4)
Same as for routine IUD insertion:
1. <28 days post partum
2. Uterine anatomical distortion
3. Active pelvic infection
4. Wilson’s or copper allergy
5. Undiagnosed uterine bleeding
6. Endometrial or cervical cancer
7. Currently pregnant
8. Trophoblastic disease
9. Post septic abortion
10. Puerperal sepsis
breastfeeding women - Oral EC - what advice would you give
UPA-EC pump and dump for 7 days
LNG-EC available limited evidence indicates no adverse effects on breastfeeding or their infants
When does the egg usually reach the uterus after ovulation
Usually around the sixth day
What are the mechanism of action of the copper IUD (2)
- Toxic to sperm and egg inhibit fertilisation
- Endometrial inflammatory reaction preventing implantation
Which is the only method of emergency contraception that is effective after ovulation
Copper IUD
When can the copper IUD be used for emergency contraception
Within 5 days of the first UPSI in a cycle or within 5 days of the earliest estimated date of ovulation
Why can copper IUD be used within the 5 days of earliest estimate date of ovulation
This would be before the earliest expected implantation allowing it to impede implantation of any fertilised egg
What is the effect of Copper ions on sperm and ovum
Direct effect on ovum motility and survival
Secondary effect on endometrium to impede implantation and increase sperm phagocytosis
What do you need to use to calculate the latest day in a women’s cycle when an IUD can be used for EV
The shorted normal cycle length
Assuming the patient has regular cycles and knowledge of her last menstrual period
For a 26 day cycle on which day is the last day that an cuIUD can be fitted for emergency contraception
Day 17
For a 28 day cycle when is the latest day an cuIUD can be fitted for EM contraception
Day 19
For a 30 day cycle when is the latest day an cuIUD can be fitted for EM contraception
Day 21
For a 32 day cycle when is the latest day an cuIUD can be fitted for EM contraception
Day 23
When can cuIUD be fitted for em contraception
Whichever is later out of…
Up to 5 days after the first UPSI
Or up to 5 days after earliest ovulation date expected
UPA-EC Could be potentially less effective with a BMI >__ or >__kg
BMI >30 or >85kg
When should a double dose (3mg) of LNG-EC be considered
- After liver enzyme inducing drug use
- BMI>26 or weight >70
When is LNG effective for EM contraception
Effective if administered up to the start of the LH surge (36hrs before ovulation)
How does LNG work for Emergency contraception (EC)
Delaying ovulation
How does UPA-EC work for EC
Slaying ovulation for at least 5 days until sperm are no longer viable
When is UPA-EM effective in the cycle
If administered during the LH surge but cannot inhibit ovulation if taken after the LH peak
What are the side effects of Oral EC
- Headaches nausea dysmenorrhea reported 10%
- vomiting
- Menstrual disturbances
- after UPA 75% of women had their next period at or within 7 days of the expected time
- a small number we’re >7 d early
- 20% were > 7 d late
- 4% were > 20 days late
Within what time scale is vomiting and issue after taking oral EC and a further dose needed
Within 3hrs of taking oral EC
When should a pregnancy test be performed following EC
If menses are delayed more than 7 days
Is ectopic pregnancy risk increased with UPA EC if pregnancy is not prevented
No higher risk than general population risk
Is there a higher risk of ectopics with LNG EM that has failed to preven pregnancy
Yes however the numbers are small and overall use of LNG reduces the chance by reducing the chance of pregnancy in the first place
Is long term fertility affected by EC
No
No evidence of adverse pregnancy outcomes or fetal anomaly despite oral EC too
What is the percentage chance of pregnancy using IUD for EC
<0.1%
What is the percentage chance of pregnancy using UPA-EC
1-2% overall pregnancy rate. This does NOT mean that a woman who has taken UPA-EC after UPSI just prior to ovulation has a 1-2% chance of pregnancy
What is the percentage chance of pregnancy using LNG-EC
Overall pregnancy rate of 0.6-2.6%
Which oral EC is significantly more effective when taken 0-120hrs after UPSI
UPA-EC
Porphyria carries a UKMEC 2 for which method of EC
LNG-EC may be linked to an acute attack as it is a progestogen that can pracipitate this. However, naturism fluctuations in oestrogen and progestogen appear to be associated with acute attacks rather than exogenous hormones
Asthma on oral glucocorticoids means which method of EC should be avoided
UPA-EC as it has an anti-glucocorticoid effect therefore it should be avoided for severe asthma controlled by oral steroids
Hepatic impairment causes an issue for which EC
UPA in the SPC advises it should be avoided but faculty guidance advises pregnancy poses a significant risk and thus UPA 30mg is acceptable
Do CYP450 enzyme inducing drugs cause an issue for LNG-EC
Yes - reduce effectiveness and double dose recommended 3mg but effectiveness of this is not known
Drugs that increase gastric pH can they effect the efficacy of EC
It is not known if UPA effectiveness is reduced
Menstrual disturbance after UPA-EC what percentage of women had their next period at or within 7 days of the expected time?
75%
Menstrual disturbance after UPA-EC what percentage of women had their next period > 7 days late of the expected time?
20%
4% of women were how many days late after taking UPA-EC
20 days
How many were more than 7 days early after taking UPA-EC
A small number 1%
What might happen with EC oral is there is malabsorption or small bowel resection?
Reduced absorption and less effective
At what weight or BMI is the LMG-EC thought to be less effective
> 70kg or BMI >26 double dose recommended but not known if this is more effective
At what weight or bmi is UPA-EC thought to be less effective
> 85kg BMI >30
Can a Cu-IUD be inserted when there is known chlamydia infection
Yes if asymptomatic only, give abx at time of insertion or sooner if possible
If there is chlamydia or gonorrhoea infection can cu-IUD be fitted for EC
Not is symptomatic chlamydia, not with any gonorrhoea. Complete abx first
Postpartum when can cu-IUD be used for EC
Not between 48hrs-28 days after delivery due to increased risk of expulsion or perforation
Can UPA-EC be used in breastfeeding mums
Yes but it is excreted and safety not known so advise is to pump and dump for 1 week after taking it
What is the risk of perforation with cu-IUD insertion for breastfeeding mother <9 month’s (36wks) postpartum >28days
1 in 200 risk (5.6 in 1000)
What is the risk of perforation with cu-IUD insertion for breastfeeding mother >9 month’s (36wks) postpartum
1.6 per 1000 (1:700)
What is the risk of perforation with cu-IUD insertion for non breastfeeding mother <9 month’s (36wks)
1.7 per 1000 (1:700)
What is the risk of perforation with cu-IUD insertion for non breastfeeding mother >9 month’s (36wks) postpartum
EURAS-IUD study
0.7 per 1000 (less than 1 in a 1000)
If a women is over 50 does she need EC
Not if she is amenorrhoeic for 1 year and not caused by hormone contraction or HRT
How many years does a women need to be amenorrhoic for to not need EC <50yrs
2 years amenorrhoea and not due to hormonal therapy
Can oral EC be repeated if there are more UPSI in the same cycle
Yes but don’t give LNG if less than 7 days after UPA and don’t give UPA if LNG was taken up to 7 days ago
What safety questions should be asked when someone asks for EC (4)
Was it consensual
Drugs or alcohol involved
Learning disabilities ?valid consent
Domestic violence - may not be able to use ongoing contraception but may not report the sex as non-consensual
Do you have to pay for EC
No Although some pharmacies charge
Apart from GP pharmacy & SH clinics where can you get oral EC
School nurses
Emergency dept
NHS walk in
Minor injury units
Online pharmacies
What advice should you give following EC (7)
- If vomits within 3hrs of oral EC she will need to return for a further dose
- Her next period may be early or late
- Urine pregnancy test at 21days post UPSI (unless normal menstrual bleed)
- If Oral EC fails it is not thought to be harmful to pregnancy
- Return if further UPSI
- Further contraception advice
- Full STI screen and sexual history - when and how to get tested
