Week 2 - G - Quick start contraception, UNplanned pregnancy & Emergency contraception

Question 1

In patients requesting the start of new contraception, there is the quick start algorithim Quick start contraception - be it pogesterone only pilll, implant, injection, IUS or COCPor copper IUD - when must the first day of the last menstrual period have been to immediately start the contraception?

Answer 1

First day of LMP to have been within the last 5 days

Question 2

If the day of the unprotected sexual intercourse was in the past 5 days, what can be given as treatment?

Answer 2

Can give emergency contraception Be it levenogestrel (Levonelle - can only be given up to 72 hours), ulipristal acetate (UPA - EllaOne) or The Copper IUD

Question 3

If the patient has had unprotected sex and the first day of LMP was greater than 7 days ago, are they allowed to be started on quick start contraception?

Answer 3

If the pregnancy test is negative then yes - re do a pregnancy test in 2 weeks however

Question 4

If the patient takes emergency contraception if the last sexual intercourse was 5 days prior When can they start on contraception? (for both UPA and Levenogestrel) How long should backup contraception be used for in each?

Answer 4

Levenogestrel Can start the contraception (pill, implant, , IUS) today and use backup contrception fot 7 days, if POP then 2 days and if depot then 9 days UPA Start the contraception in 5days and use backup contraception for 12 days (7days for POP and 9days for depot)

Question 5

For all methods of quick start contraception, if the contraception is started when the patient requests it to be immediately, when is the pregnancy test re-carried out ? (either patient has no had unprotected sex or the urine pregnancy test is negative)

Answer 5

Pregnancy test should be carried out again 2 weeks after starting the contraception if there was unprotected sexual intercourse after LMP that had the first day more than 7 days prior

Question 6

According to WHO, how many unplanned pregnancies are had every year?

Answer 6

80 million unplanned pregnancies annually

Question 7

What are the options when having an unplanned pregnancy?

Answer 7

a) continue with the pregnancy and keep the baby b) end the pregnancy by having an abortion c) continue with the pregnancy and give up for adoption

Question 8

What is the most commonly performed gynaeocological procedure in the UK?

Answer 8

Termination of pregnancy is the most commonly performed gynaecological procedure in the UK

Question 9

What socioeconomic status has a high link with termination of pregnancy?

Answer 9

Social deprivation has a high link with the TOP

Question 10

Abortion is a safe procedure Major complications and mortality are rare In Scotland almost all abortions take place in NHS hospitals WHy is there no data regarding abortions that took place before 1967?

Answer 10

This was because abortions were illegal before the introduction of the 1967 Abortion Act

Question 11

What area of scotland has the highest abortion rates? (same are that has the greatest rates of chlamydia in males and females)

Answer 11

Tayside

Question 12

What are the grounds under which an abortion can take place?

Answer 12

An abortion can only take place if two registered medical practitioners are of the opinion, in good faith, that an abortion is justified by the terms of the Act And Only a registered medical practitioner can terminate the pregnancy

Question 13

What are the three different legal forms involved with an abortion? One of them has to be signed in any case of an abortion

Answer 13

HSA 1 HSA 2 HSA 4

Question 14

What is the difference between the three forms? (which form is for emergency abortion and how long do you have to

Answer 14

HSA1 - two doctors are required to sign this form HSA2 - to be completed by the doctor within 24 hours of the emergency abortion HSA4 - must be completed by the doctor and sent to the chief medical officer (CMO) within 7 days of the abortion taking place

Question 15

What is the most common grounds of termination?

Answer 15

C - pregnancy has not exceeded its 24 weeks and continuation of pregnancy would involve risks, greater than if terminated, of injury to physical or mental health of pregnant women

Question 16

There are different aspects to assess when granting an abortion What are some ethical aspects?

Answer 16

If the patient is below 16 If the patient has a learning disability Domestic abuse Patient confidentiality

Question 17

If the patient is under 16, what must be assessed?

Answer 17

Gillock competence of the patient must be assessed if the patient is under 16 years of age

Question 18

Doctors have right to ‘opt out’ of certain procedures because of personal beliefs/values provided (GMC) Abortion Act - ‘no person shall be under any duty…to participate in any treatment authorised by this Act to which he/she has a conscientious objection’ If the doctor conscientiously objects to the abortion process, what must they do?

Answer 18

They must explain their religious or moral beliefs to the patient as there reason for objecting and they must ensure that arrangements are made for the patient to see another doctor

Question 19

Important points Respect patient’s dignity and views; avoid discrimination Must not impose views on others but may explain views to patient if invited Ensure patient’s treatment is not denied or delayed Timely onward referral to a colleague Can a conscientious objecting doctor deny treatment in the event of an emergency to do with the abortion?

Answer 19

Treatment in the event of an emergency may not not be denied on grounds of conscientious objection – ie if there is a haemorrhage you must deal with this complication regardless of your objection

Question 20

In the intial termination of pregnancy appointment, what is important to learn from the history? What test should initially be carried out also? How long do you have for the termination of pregnancy consultation?

Answer 20

First thing done when a woman comes for a TOP, is do a pregnancy test and the consult to find out how she got pregnant and why she doesn’t want to keep it Have one hour to carry out the TOP consultation

Question 21

Why is an USS carried out in the TOP consultation?

Answer 21

This determines the intrauterine position of the pregnancy Also allows you to estimate the gestation period and that it is not an ectopic pregnancy

Question 22

If a patient presents requesting a termination of pregnancy, when should referral to treatment be done and when should pregnancy be terminated within?

Answer 22

If she decides this is what she wants to do, the referral process should be a max of 2 weeks, from the time of presentation to the first consultation – the pregnancy should be terminated within 3 weeks

Question 23

What type of consent is required in a termination of pregnancy?

Answer 23

Written consent is required for the procedure and for foetal remains

Question 24

These are assessed prior to the termiantion of pregnancy Bloods obtained (FBC/G&S +/-BBV) Optional screening for STI Counselling re: ongoing contraception What does G&S stand for in the bloods test?

Answer 24

G&S is for testing the blood group and screening for rhesus negative blood group patients

Question 25

What prophylactic antibiotic is offered post termination of pregnancy? especially if the patient is undergoing a surgical procedure

Answer 25

Prophylactic antibiotic offered would be metronidazole

Question 26

What is the TOP of pregnancy deadline for social reasons? How long can it be continued if there is a foetal anomaly that could cause harm to it or the mother?

Answer 26

23 weeks and 6 days is when an abortion is allowed to be carried out until If there is a problem with the pregnancy that warrants an abortion, this can be carried out at any point in gestation

Question 27

What are the two methods of termination of pregnancy?

Answer 27

Medical method and surgical method

Question 28

What classifies as an early, late and mid trimester abortion?

Answer 28

Early abortion - less than 9 weeks gestation Late abortion - 9-12 weeks gestation Mid-trimester abortion - 12-24 weeks gestation

Question 29

The medicational termination of pregnancy can be carried out up until 24 weeks of pregnancy When is it no longer carried out in Tayside and patients will have to relocate to england?

Answer 29

No longer carried out in Tayside after 18 weeks and 6 days

Question 30

What are the medications given for medical abortion? (what type of drug are these medications) At what gestation period does the medication given change?

Answer 30

Oral mifepristone - anti-progesterone

Vaginal or oral misoprostolol (Prostoglandin)

Before 9 weeks

• * Single dose of oral mifepristone given
• * 24-48 hours later - single dose of misoprostolol given

After 9 weeks

• * Single dose of mifepristone given
• * Multiple doses of misoprostolol are required

Question 31

The medical TOP Consists of two pills, one called mifepristone blocking the production of progesterone. This means the lining of the uterus breaks down and the pregnancy cannot continue. The second is misoprostol makes the womb contract. – the pills are taken differently dependent on whether before 9 weeks or not How often is the prostoglandin given if after 9 weeks? What is the max amount of doses in one day?

Answer 31

The doses of prostoglandin are given 3 hourly with a max of 5 doses in a 24 hour period

Question 32

What are the two methods of surgical termination? When are they able to be carried out until? How long does scotland allow for the surgical procedure?

Answer 32

Can try vacuum aspiration from 6-12 weeks or Dilatation and evacuation available from 13 - 24 weeks

Scotland only carries out the vacuum aspiration, after 12 weeks would have to go to England for surgical abortion

Question 33

The surgical TOP is usually a day case Once the pregnancy is removed, what is recommended to be inserted?

Answer 33

It is recommended that a long acting reversible contraception is put inplace - IUS or IUD

Question 34

What is given to prime the vagina before the surgery takes place?

Answer 34

Vaginal prostoglandin is given - misoprostolol

Question 35

Electrical or manual vaccuum aspiration is usually carried out up until 12 weeks WHat is the anaesthetic used in both?

Answer 35

Local anaesthetic used in manual vaccum aspiration - can be carried out up until 9 weeks General anaesthetic used in electrical vaccuum aspiration - carried out up until 12 weeks

Question 36

What are the complications of a termination of pregnancy? (surgical procedure)

Answer 36

Risk of uterine perforation - 4in 1000 Haemorrhage Infection Pain Incomplete/failed procedure

Question 37

Is surgical or medical TOP more successful? Which causes more pain and heavy bleeding usually?

Answer 37

Surgical is 99% successful Medical is 97% successful Medical TOP causes more pain and heavy bleeding than surgical

Question 38

How long after the TOP is a urine pregnancy test carried out to ensure the procedure was successful? (why is a low sensitivity test used) What HCG does a normal pregnancy test pick up?

Answer 38

A urine pregnancy test is carried out 2-3 weeks post TOP procedure Low sensitivity test is used as just checking to make sure the HCG levels are below 1000 Normal sensitivity test picks up HCG levels of 25units

Question 39

The blood group status of the women is also checked Check blood group for rhesus status – women who are rehesus negative require anti-D How long is had to adminster the anti-D immunoglobulin to prevent sensitisation?

Answer 39

72 hours to administer injection Sensitisiation only occurs wheen the mother has been exposed to a child rhesus positive blood and therefore forms antibodies that recognise the foreign cells - this therefore means on next exposure (ie a second child), if exposed to blood the antbodies then attack the next baby upon exposureThe aim of Anti-D is to stop the antibodies forming in the first place

Question 40

Regarding contraception post abortion All methods should be available and initiated on-site prior to discharge What is the preferred contraception taken post-abortion?

Answer 40

The preferred method is a LARC

Question 41

What are the range of emotions that may be experienced that can require counselling post abortion?

Answer 41

May have feelings of guilt, sadness, loss or depression

Question 42

Emergency contraception can be used after an episode of unprotected sexual intecourse - it does not replace regular contrception How many COC must be missed during UPSI before giving emergency contraception?

Answer 42

Must have missed pills for greater than 48 hours (2 pills) and then had UPSI to be given emergency contraception

Question 43

What is the fertile time during a pregnancy cycle? (Add up how long egg and sperm survive separately)

Answer 43

Fertile time is 5 days (length of time sperm survives in the genital tract) + 24 hours (time ovum survives for) which means = 6 days of fertile time

Question 44

When can emergency contraception be given again?

Answer 44

It can be given up to 5 days after unprotected sexual intercourse or up to 5 days post ovulation

Question 45

What are the three methods currently available for emergency contraception? When can they be used following UPSI? What is the most reliable method?

Answer 45

Most reliable method copper IUD - can be used 5 days post UPSI or 5 days after earliest expcected date of ovulation

• Levenogestrel (LNG) - used up to 72 hours post
• UPSI Ulipristal acetate (UPA) - used up to 120 hours post UPSI

Question 46

How do UPA and LNG work?

Answer 46

UPA-EG is an anti-progesterone contraception LNG - this is a high dose progesterone contraceptive They both delay ovulation - progesterone has a negative feedback on hypothalamus and anterior pituitary meaning ovulation wont occur as no LH suurge (hoepfully sperm will die) The antiprogestogen - egg cant implant

Question 47

Both delay ovulation What is more expensive between levongesterel and ulipristal acetate? How effective are they across the time they can be taken?

Answer 47

UPA is more expensive 3fold UPA is 85% if taken at any point over 5 days Levenogestrel is 85% effective if taken wihin 24 hours and efficacy decreases to 58%

Question 48

When do both LNG and UPA work up until?

Answer 48

LNG works up until the just before the LH surge

UPA works up until the peak of the LH surge

Neither works after ovulation

Question 49

It would seem obvious to use UPA as the emergency contraception instead of levenogestrel When should UPA be avoided?

Answer 49

If the patient wishes to start on quick start contraception If hormonal contraception has been used within the past 7 days If the patient has severe asthma uncontrolled by oral steroids then avoid UPA

Question 50

How long must patient wait after taking the UPA to quick start on contraception?

Answer 50

Patient must wait five days before quick starting

Question 51

Copper IUD Should be offered to all eligible women requesting EC

• 10 x more effective than oral EC!!
• How does it work?

Answer 51

It is toxic to the sperm and ovum and prevents implantation

Question 52

Why can the copper coil only be given up until 5 days post ovulation?

Answer 52

Because the egg can implant at 6 days at earliest and therefore is unethical to give the copper coil after this as it could in theory kill the fertilised egg

Question 53

A pregnancy doesn’t implant during the first 5 days post fertilisation 84% implant at 8-10 days post fertilisation Earliest likely is at 6 days Hence Cu IUD can be fitted up to 5 days post UPSI OR after 5 days after likely ovulation How long after taking LNG or UPA can contraception be restarted?

Answer 53

LNG Can start immediately but take additional contraception (barrier) for 7 days post emergency contraception UPA Start 5 days post emergency contraception, take additional contraception (barrier methods) for 12 days post emergency contraception

Question 54

In an emergency consultation consultation, what questions should be asked?

Answer 54

Date and time of UPSI - Previous episodes during this cycle - Previous emergency contraception - Normal menstrual cycle length and LMP Medical and drug history - any contraindications Contraception - current and future STI risk & screening

Question 55

State again what the contraindications to giving ulipristal acetate as emergency contraception are?

Answer 55

* If the patient is wishing to quick start contraception - must wait 5 days * If the patient has used hormonal contraception within the last 7 days * If the patient has severe uncontrolled asthma by oral steroids Or * if the patient is breast feeding or on any liver enzyme inducers