Guidelines 2016 – Emergency Contraception
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
emergency contraception (eC), otherwise called postcoital contraception. the alternative names, such as “morning-after pill,” are misleading because eC can be used before the morning, after the morning, or up to 120 hours
after intercourse, depending on the method chosen. eC is a pharmacologic or mechanical intervention after exposure to the possibility of conception with no or uncertain contraceptive protection. such intervention is based on inhibiting fertilization or implantation. the means for intervention are either mechanical (an intrauterine device [iUd]) or hormonal (high-dose, short-term oral contraceptives [oCs], or progestational agents).
II. ETIOLOGY
a. disruption of fertilization or of implantation beginning within 120 hours after unprotected intercourse is based on several theoreti- cal premises:
1. progestational agents will change or interfere with sperm migra- tion or the capacity of a sperm to penetrate the egg.
2. progestational agents are thought to inhibit motility of the fallo- pian tubes—also to affect follicle growth and development of the corpus luteum.
3. estrogen, specifically ethinyl estradiol (ee), is thought to reduce the plasma level of progesterone and may therefore interfere with the function of the corpus luteum or, possibly, the function of lutein- izing hormone, thereby disrupting ovulation.
4. progestational agents and estrogen (estradiol) are known to shorten the luteal phase of the cycle.
5. intrauterine contraceptive devices (iUCds), specifically copper-bear- ing devices, are thought to interfere with the enzyme systems of the endometrium and perhaps alter the permeability of the endometrial microvasculature, which in theory interferes with implantation.
III. EFFECTIVENESS
Used within 120 hours, hormonal eC reduces the risk of pregnancy by 75% for those women who would have become pregnant (8 of 100), so 2 of 100 will become pregnant. the sooner eC is used after unprotected intercourse, the more effective it is.
IV. HISTORY
a. What the patient presents with
1. last act of unprotected intercourse within the past 120 hours
2. desire to inhibit fertilization or implantation
B. additional information to be obtained
1. Cycle history and any previous use of contraceptives
2. estimated day(s) of exposure to sperm without any protection or with known method failure (e.g., condom broke or slipped off; iUd [iUCd] expelled; cap, shield, or diaphragm displaced; missed seven or more combination of oCs in the past 2 weeks or missed two or more progestin-only oCs)
3. Contraindications to hormone or iUd (iUCd) use
4. Circumstance of unprotected exposure—rape, possible sti exposure, teratogen exposure
5. other acts of unprotected intercourse during this cycle
V. PHYSICAL EXAMINATION
a. pelvic exam—speculum and bimanual, if appropriate
B. Collect specimens per rape/sexual assault guidelines in practice set- ting as necessary/desired by the woman; complete assessment for evidence
VI. LABORATORY DIAGNOSIS
a. pregnancy test
B. sti testing as warranted by history
VII. DIFFERENTIAL DIAGNOSIS
a. Consider alternatives should the woman desire to keep a pregnancy if one occurs
B. sexual assault—consider rape counseling
C. pregnancy already established prior to current exposure with unpro- tected intercourse
VIII. TREATMENT
a. Combination oCs (yuzpe method) and progestin-only oCs must be initiated within 72 hours of exposure. see individual package inserts for use.
B. plan B and generic counterparts (levonorgestrel): treatment must be initiated within 120 hours1 (causes less nausea and vomiting); one white pill, then one more white pill 12 hours later, or both pills at the same time. plan B (and generics) are now available over the counter in some parts of the United states (check individual state regulations).
C. ellaone: a 30-mg tablet of ulipristal acetate (a synthetic progester- one) protects when taken up to 5 days after unprotected intercourse (approved by the U.s. food and drug administration [fda] in July 2010).
d. Mifepristone given within 72 hours of unprotected intercourse is 100% effective but is available only in 200 mg in the United states, a significantly higher dose than needed for eC (use, as eC is off label).
e. Mechanical agents
1. paragard or Mirena insertion within 5 to 7 days of exposure with precautions for iUd (iUCd) use, sti exposure, risk factors for iUd (iUCd) use; some guidelines specify prophylactic antibiotics with insertion
2. skyla iUd (iUCd) is not recommended.
IX. EXPLANATION OF METHOD
a. education for each woman is specific for a postcoital intervention method, including side effects of intervention and danger signs; if iUd (iUCd) is inserted, instructions about iUd (iUCd) use, danger signs, and complications and potential for 5 or 10 years of protection against pregnancy.
B. education about resumption of menses: Based on the woman’s cycle history, if hormones are taken during follicular phase, menses will follow at about day 21; if during ovulation, around day 26; and if in the luteal phase, about day 29.
X. COMPLICATIONS AND SIDE EFFECTS
a. pelvic infection with iUd (iUCd) use (see guideline for PID in Chapter 17)
B. ectopic pregnancy: there is possible increased risk with hormone use (up to 100% of pregnancies); copper iUd (iUCd) use will not inhibit tubal implantation (see information on ectopic pregnancy in the guideline on acute pelvic pain in Chapter 17).
C. pregnancy: decision making regarding continuation or termination of pregnancy
d. nausea and vomiting possible with hormonal eC
1. drink a glass of milk or eat a snack with each oral dose to reduce risk of nausea and vomiting.
2. Compazine 25-mg rectal suppository every 12 hours or 10 mg orally four times a day
3. tigan, 200-mg suppository every 12 hours
4. Meclizine hydrochloride (antivert, dramamine ii) 25 mg 1 hour before eC pills
5. give extra tablets of oCs in the event of vomiting dose; instruct the woman to take repeat dose if vomiting occurs within 1 hour after taking the dose and pills are visible in vomitus
XI. CONSULTATION AND REFERRAL
a. for pregnancy exposure as the result of sexual assault/rape, refer to rape crisis center, rape counseling, or a setting with a sexual assault nurse examiner (sane)
B. for complications of postcoital intervention as necessary
XII. FOLLOW-UP
a. no menses within 3 weeks after intervention, return for evaluation for continued pregnancy (failure of eC or preexisting pregnancy) to rule out ectopic pregnancy
B. for a contraceptive method chosen by the woman for use following the eC
1. immediate use: condoms, diaphragm, spermicides, sponge, quick- start oCs
2. With next menses
a. oCs sunday start or first-day quick start; injectable, contracep- tive patch, vaginal ring
b. iUds—insert with or after menses
c. natural family planning (nfp)—initiate with menses
3. sterilization any time
The Emergency Contraceptive Hotline, 1-800-NOT-2-LATE, is a 24-hour, toll-free service offered in English and Spanish. Callers can obtain names, phone numbers, and locations of three local clinicians. Internet access: www.not-2-late
.com; www.go2planB.com
See Appendix A and Bibliographies.