Emergency Contraception
Erin Shankel
Definition
A.Emergency contraception (EC) is a prospective method of pregnancy prevention when unprotected intercourse occurs.
Incidence
A.EC has been used by 11% of American women at least once. The use of EC can reduce the number of unintended pregnancies and thus reduce the number of abortions and deliveries of truly unwanted children. Eleven percent of women who do not wish to become pregnant are not using any method of birth control and are at risk for unintended pregnancy.
Pathophysiology
A.Hormones in oral contraceptive pills temporarily disrupt ovarian hormone production and cause an absent or dysfunctional luteal phase hormone pattern. This results in an out-of-phase endometrium that is unsuitable for implantation. Hormone disruption may likewise interfere with fertilization and cause disordered tubal transport. Hormones or minerals (copper) in an intrauterine device (IUD) as well as an inflammatory response occur, which makes the endometrium unsuitable for implantation and interferes with fertilization and transport.
Predisposing Factors
A.Rape.
B.Failure of other means of birth control, including broken condom, dislodged diaphragm or cervical cap, expelled IUD, lost or forgotten pills.
C.Unprotected intercourse.
Common Complaints
A.I’m worried that I might get pregnant because the condom broke.
B.My diaphragm slipped.
C.I went on vacation and forgot my pills.
Other Signs and Symptoms
A.Unprotected intercourse.
Subjective Data
A.Elicit a menstrual history. When was the patient’s last menstrual period (LMP)? Are her periods regular?
B.What form of contraception was used, if any? What was the date and time of the unprotected encounter? (i.e., how many hours ago?)
C.Has the patient experienced any early signs of pregnancy? If so, discuss.
D.Ask about early symptoms of pregnancy such as frequency of urination, nausea, breast tenderness, and late or missed period.
E.Ask the patient about her feelings or plans if she should get pregnant.
Physical Examination
A.Check blood pressure (BP), pulse, and weight.
B.Inspect abdomen for enlargement compatible with pregnancy.
C.Palpate abdomen for uterine size; if fundus is palpable, measure for fundal height.
D.Auscultate heart, lungs, abdomen. If the uterus is enlarged and is measured to be greater than 11 weeks gestation, attempt to hear fetal heart tones with fetal Doppler.
E.Pelvic exam:
1.Inspect the external genitalia for lesions; note female pubic hair pattern.
2.Speculum exam: Observe for bluish color of cervix (Chadwick’s sign). Observe vaginal discharge; note color and odor.
3.Bimanual exam: Palpate the cervix for softening associated with early pregnancy. Palpate uterine size.
Diagnostic Tests
A.Pregnancy test: Urine or serum human chorionic gonadotropin (HCG).
Differential Diagnoses
A.Unprotected intercourse, potential for pregnancy.
B.Pregnancy.
C.Dysfunctional uterine bleeding (DUB).
D.Amenorrhea from anovulation.
E.Polycystic ovarian syndrome (PCOS).
F.Perimenopause.
Plan
A.General interventions:
1.Review the patient’s past medical history, contraceptive history, date of LMP, estimated date of ovulation, date of unprotected intercourse, and number of hours since the first and most recent unprotected intercourse.
2.Discuss the likely risk of pregnancy.
3.Explore the patient’s feeling about continuing pregnancy.
4.Decide whether a physical exam and pregnancy test are needed if there is a possibility of a pregnancy from the previous month.
B. 
See Section III: Patient Teaching Guide Emergency Contraception.
1.Discuss options, risks, failure rates, necessary followup, alteration of menstrual period, and warning signs of complications.
2.Discuss interim plan for contraception.
3.Advise the patient to take oral contraceptive pills as prescribed or have IUD inserted within 96 hours of unprotected intercourse.
4.Treatment is most effective if taken within 12 to 24 hours for progestin estrogen methods and within 120 hours for progestin antagonist/antagonist.
5.Treatment is not effective in an already established pregnancy.
6.Educate the patient about the possibility of menstrual cycle disturbance with the next menstrual period.
7.If menstrual bleeding does not begin within 3 weeks, evaluate for possible pregnancy.
8.EC is not associated with an increased incidence of abnormal outcome of pregnancy should pregnancy not be averted. EC does not always work.
9.This is not to be used as a primary contraceptive method.
10.Have prescription or pack of pills available for an emergency situation.
11.The IUD should be used only for women at low risk for pelvic inflammatory disease (PID) and when the woman intends to continue use of the IUD for contraception.
C.Pharmaceutical therapy:
1.EC oral formulations:
a.Levonorgestrel (LNG) emergency contraceptive is available under the brand names Take Action, My Way, Next Choice, Plan B, and Plan B One-Step. Plan B, commonly called the morning-after pill,
is available in a one-dose (1.5 mg tablet of LNG) or two-dose (0.75 mg tablets each) packaging. Progestin-only EC is now available in the United States without age restrictions:
i.Plan B One-Step (LNG 1.5 mg tablet) should be taken as soon as possible after unprotected sex (no later than 72 hours).
ii.Plan B two-dose (LNG 0.75 mg tablet): Patients should take the first dose as soon as possible after unprotected intercourse (no later than 72 hours) and the second dose 12 hours after the first dose.
b.Using a standard packet of oral contraceptives; two doses of a combination of
ethinylestradiol and norgestrel or LNG, 12 hours apart. Table 17.2 provides the equivalent dosing that may be utilized as an emergency contraceptive:
i.Method must be utilized within 72 hours of unprotected intercourse. Treatment is most effective if taken within 12 to 24 hours.
ii.Side effects of nausea and vomiting with EC are common. Take each dose with food. Take antiemetic, dimenhydrinate (Dramamine) 50 mg orally, 30 minutes before dose of medication.
iii.If vomiting occurs within 1 to 3 hours of taking a dose, take another dose.
iv.Educate the patient about common side effects, such as breast tenderness, abdominal pain, headache, and dizziness.
c.Ella (ulipristal acetate [UPA]) is a progesterone antagonist/antagonist that is available only by prescription:
i.One tablet is taken orally as soon as possible after unprotected intercourse within 120 hours (5 days).
ii.Common side effects are headaches, abdominal pain, and nausea. Less common side effects include dysmenorrhea, fatigue, and dizziness.
iii.Repeated use of Ella within the same menstrual cycle is not recommended.
iv.If vomiting occurs within 1 to 3 hours of taking a dose, take another dose.
v.Educate the patient about common side effects, such as breast tenderness, abdominal pain, headache, and dizziness.
2.IUD:
a.Copper IUD (ParaGard’s CUT 380, Ortho Pharmaceuticals) must be inserted within 5 to 7 days after ovulation in a cycle when unprotected intercourse has occurred. The advantage is that the IUD may be left in place for continuing contraception for 10 years.
b.Mechanism of action: Two ideas have been proposed:
i.IUD leads to endometrial changes that prohibit implantation.
ii.The copper ions interfere with sperm transport and fertilization.
Consultation/Referral
A.Consult with a physician if there is no withdrawal bleed within 4 weeks.
B.Consult with or refer the patient to a clinically trained healthcare provider if necessary to insert IUDs.
C.Here are several ways patients can find emergency contraception:
1.Not 2 Late is operated by the Office of Population Research at Princeton University and the Association of Reproductive Health Professionals: 888-NOT-2-LATE or not-2-late.com
2.Websites:
a.Emergency contraception: ec.princeton.edu/for-providers.html.
b.Planned Parenthood: www.plannedparenthood.org/learn/morning-after-pill-emergency-contraception.
Follow-Up
A.Have the patient return in 3 to 4 weeks if she does not have a menstrual period. If she has a menstrual period, recommend that she return in 1 month to assess contraceptive use and offer options.
Special Considerations
A.Pregnancy: There is no increased incidence of anomalies if pregnancy does occur.
