Emergency_Contraception_Flashcards

Question

A 23-year-old university student presents to her GP four days after having unprotected sexual intercourse with her new boyfriend. She does not intend to start a family in the next five years. She has a history of anxiety and asthma. She is not taking any medication, but she wishes to begin regular contraception. What is the most appropriate emergency contraception for this patient? Contraceptive implant Copper intrauterine device Oral levonorgestrel Oral ulipristal (EllaOne) Progesterone intrauterine system (Mirena)

Answer 1

The copper intrauterine device can be inserted for emergency contraception within 5 days after the first unprotected sexual intercourse in a cycle, or within 5 days of the earliest estimated date of ovulation, whichever is later Important for meLess important This patient does not wish to start a family in the next five years and, therefore, does not wish to become pregnant. She, thus, requires emergency contraception. There are two methods of emergency hormonal contraception: levonorgestrel and ulipristal, both of which are oral progesterone receptor modulators. The only non-hormonal option is copper intrauterine device (IUD), also referred to as the copper coil. Copper intrauterine device is the correct answer. This is the most effective method of emergency contraception. It is recommended for women who can have it inserted within five days of unprotected sexual intercourse (UPSI) or up to five days after their estimated ovulation date, whichever comes later. In this scenario, the patient presents four days following UPSI, thus meeting the criteria for IUD insertion. Given that this woman does not wish to start a family in the next five years, it would be appropriate to discuss contraception methods. The IUD can be left in situ to provide long-term contraception following its use as an emergency contraception. Contraceptive implant is incorrect. It is not indicated for use as an emergency contraceptive but rather serves as a long-term method of contraception. Therefore, it would not be useful for this patient who requires emergency contraception. Oral levonorgestrel is incorrect. Ideally, it should be taken as soon as possible, as efficacy decreases with time. It can be taken up to 72 hours after UPSI. Therefore, too much time has lapsed since this patient had UPSI. Furthermore, it cannot be used as long-term contraception as it is a one-off tablet. Therefore, it is not the most appropriate option for this patient. Oral ulipristal (EllaOne) is incorrect. It can be used within a five-day window following UPSI; however, caution must be exercised in patients with a history of asthma. Like levonorgestrel, ulipristal cannot provide sustained contraceptive coverage due to its single-use design. Therefore, it is not the most appropriate option for this patient, who would ideally like long-term contraception as well. Progesterone intrauterine system (Mirena) is incorrect. It is not indicated for use as an emergency contraceptive but instead serves as a long-term method of contraception. Therefore, it would not be helpful for this patient who requires emergency contraception.

Answer 2

Copper intrauterine device The copper intrauterine device can be inserted for emergency contraception within 5 days after the first unprotected sexual intercourse in a cycle, or within 5 days of the earliest estimated date of ovulation, whichever is later Of the options listed here, the only suitable method for this patient is the copper intrauterine device (IUD). As well as being an effective form of regular contraception, it can be used as a form of emergency contraception if inserted within 5 days of unprotected sexual intercourse. Alternatively, if presenting after more than 5 days, it may be fitted up to 5 days after the likely ovulation date. As this patient has a regular 28-day cycle, her ovulation would be expected to occur at day 14. She is currently at day 17 and so within the 5-day window for fitting of the IUD. Levonorgestrel is a tablet commonly used for emergency contraception. It must be taken within 72 hours of unprotected sexual intercourse, however, and so would not be suitable in this instance. The Mirena intrauterine system is a hormonal device fitted in the uterus that acts as an extremely effective form of regular contraception. It is generally more popular than the copper device nowadays, due to generally reducing bleeding/stopping periods altogether, rather than increasing the heaviness of bleeding as the copper device does. However, unlike the copper device, it cannot be used as emergency contraception. Norethisterone is a drug used to control dysfunctional uterine bleeding and also to delay periods. It is not used as emergency contraception. Ulipristal is an alternative tablet to levonorgestrel and can be taken up to 5 days after unprotected sexual intercourse. Given that this patient is presenting 7 days later, this is not a suitable option.

Answer 3

Intrauterine device A copper IUD is the most effective method of emergency contraception and should be offered to all women A copper intrauterine device (IUD) is the most effective method of emergency contraception, and should be offered first-line to all women who have experienced unprotected sexual intercourse (UPSI). The IUD can be offered for up to 5 days after the UPSI, or up to 5 days after the earliest estimated date of ovulation. The combined oral contraceptive pill is incorrect. This cannot be used as emergency contraception. The intrauterine system is incorrect. This cannot be used as emergency contraception. Levonorgestrel is incorrect. Although levonorgestrel can be prescribed as emergency contraception, it must be offered within 72 hours of the UPSI. This patient has presented 4 days after the UPSI, so levonorgestrel is not an option. Regardless, the IUD is more effective than levonorgestrel and so should be offered first-line, even if presenting within 72 hours of the UPSI. Ulipristal acetate is incorrect. This drug can be prescribed as emergency contraception within 5 days of the UPSI. However, the IUD is more effective and so should be offered first-line. Furthermore, caution should be used when prescribing ulipristal acetate to those with severe asthma.

Answer 4

Prescribe ulipristal Levonorgestrel must be taken within 72 hours of UPSI The correct answer is to prescribe ulipristal. This patient is inquiring about emergency contraception for unprotected sexual intercourse that happened 96 hours ago. Ulipristal (a selective progesterone receptor modulator) can be prescribed up to 120 hours following the intercourse. It is thought to work by inhibiting ovulation. This is the only option between the proposed one that can be administered in the current timeframe and does not involve the administration of invasive contraception. Insertion of an intrauterine device is inappropriate as the patient declined an offer of invasive contraception. A copper device can be inserted to prevent pregnancy up to five days following unprotected intercourse, but it has to be left in situ at least until the next period. Since she has no contraindication for taking ulipristal, this option is inappropriate as it goes against the wish of the patient. Insert of an intrauterine system is inappropriate as this option is not used for emergency contraception. Even if the medication contained in this option is levonorgestrel, it cannot be used as emergency contraception in this form. Prescription of levonorgestrel is inappropriate as this medication is effective for emergency contraception only up to 72 hours following the unprotected intercourse. This patient reports the intercourse happening 96 hours ago making the option incorrect. Prescription of mifepristone is inappropriate as this drug is not licensed for emergency contraception. This drug is a prostaglandin analogue that causes uterine contractions. It is used in combination with misoprostol to terminate pregnancies.

Answer 5

ellaOne (ulipristal acetate) pill The only two methods on this list that can be used as emergency contraception are ellaOne (ulipristal acetate 30mg) and Levonelle (levonorgestrel 1.5mg). The other three options can provide routine but not emergency contraception, so whilst they may be useful in the longer term they do not address the immediate problem. Levonelle is most effective if taken within 72 hours of unprotected intercourse (it may be used until 96 hours but its effectiveness decreases over time) and can be used more than once during a menstrual cycle. ellaOne (ulipristal acetate) is effective if taken within 120 hours of unprotected intercourse. Previously it was advised that ulipristal could only be used once during a menstrual cycle. However, this guidance has now changed. Please see the link for more details. The copper intrauterine device would be a viable alternative but did not appear on the list of options. (BNF 2015)

Answer 6

**Arrange for copper coil (IUD) insertion** A copper IUD is the most effective method of emergency contraception and should be offered to all women This patient is presenting approximately 72 hours following an episode of unprotected intercourse and would like the most effective form of contraception. The most appropriate action is to arrange for copper coil (IUD) insertion. The IUD is effective in preventing pregnancy for up to five days (120 hours) following unprotected intercourse (if not yet ovulated) or up to five days following ovulation and acts to prevent fertilisation or implantation respectively. If there are concerns about the presence of sexually transmitted diseases, antibiotics can be given concurrently. Advise she has missed the window for emergency contraception is incorrect. Both the copper coil (first-line) and ulipristal acetate are licensed for emergency contraception up to five days (120 hours) following intercourse, whilst levonorgestrel emergency contraception can be taken up to 72 hours post-coitus. Prescribe levonorgestrel emergency contraception is incorrect. Levonorgestrel efficacy is greatest when taken within 12 hours, and no later than 72 hours, post-intercourse. Efficacy decreases with time and is minimally effective if ovulation has occurred. This patient is presenting 72 hours following intercourse and with her last menstrual period 14 days ago it is possible that she has already ovulated. A copper coil (IUD) insertion would therefore be a more appropriate choice. Prescribe ulipristal acetate emergency contraception is incorrect. Whilst ulipristal acetate may be taken up to 120 hours post-intercourse, its efficacy decreases with time. Additionally, the main mechanism of action is to prevent ovulation and therefore efficacy decreases if ovulation has occurred. In this case, a copper coil would be more appropriate. Start the combined oral contraceptive pill is incorrect. Whilst the discussion of contraceptive choices going forward is appropriate in this consultation, this will not address the patient's presenting concern.