EMERGENCY CONTRACEPTION (EC) DR. SUNESH KUMAR DEPT. OF OBST-GYNAE AIIMS

Emergency Contraception (EC) (Post coital contraceptive / Morning after pill) What is EC? “Administration of a contraceptive after unprotected coitus & before implantation of pregnancy”

History of Emergency Contraceptive (EC) Ancient Methods 1. Vaginal douches 2. Inducing menses by taking oral drugs Drugs 1. Diethyl stillbesterol (DES) 2. Yuzpe’s regimen 3. Levonorgestrel (LNG) 4. Intra-uterine contraceptive device 5. Mifepristone (RU-486)

Emergency Contraception (EC) “Seventy five percent of pregnancies are unwanted” “Women decide to continue since they just conceived and had no choice” “If they know about a method which could protect them after unprotected coitus, they would have used it”

Why there is a need for EC 1. More often than not they get exposed when they were not expecting it to happen. 2. Woman thinks she cannot conceive. 3. Unfortunate events - sexual assault / rape. 4. Failure of contraceptive : condom breakage

Mechanism of Action of EC 1. Prevent implantation of blastocyst 2. Tubal hurry 3. Changes in endometrium 4. Changes in cervical mucous

Emergency Contraception - Window Period “Emergency contraceptives (EC) are effective if taken within 120 hours”

Yuzpe’s Regimen Tab Ovral -G : 2 stat, 2 after 12 hours (Ethinyl estradiol : 50 µgm + Levonorgestrel : 500 µgm) Tab Ovral-L/Mala-D/Mala-N 4 stat, 4 after 12 hours (To be taken within 72 hrs after coitus) Success rate : 85%

Why Yuzpe’s Regimen is not Popular 1. High incidence of nausea and vomiting 2. Breast tenderness 3. Relatively unsafe in women with CVA/CAD/Ca Breast/Jaundice

Newer - Levonorgestrel (LNG) Levonorgestrel 750 µgm 1 stat, 1 after 12 hrs OR Levonorgestrel 1500 µgm stat Advantages- 1. Lesser nausea and vomiting 2. Relatively safe 3. Can be given upto 12 hrs 4. Success rate : 95-98%

Preparation of Levonorgestrel (LNG) 1. Pill 72® : Cipla 2. Ecee tablet® : German Remedies 3. Norlevo® : Shreya’s Cost : Rs. 35-75/2 tabs

“Not acceptable to some due to its use for inducing abortion” OTHER METHODS OF EC 1. Intrauterine Contraceptive Device Advantage : Can continue to use Disadvantage : Risk of PID 2. Mifepristone (RU-486) ‘Still under trial’ “Not acceptable to some due to its use for inducing abortion”

EC : Client Counseling and Useful Information Useful information to be provided to a client : 1. Emergency contraceptive is effective if taken within 120 hours after unprotected intercourse 2. Sooner the ECPs are taken after unprotected intercourse more effective they are 3. Repeated unprotected intercourse in the same cycle can not be protected by single use of ECPs 4. ECPs can prevent only 85% of pregnancies after unprotected intercourse.

EC : Client Counseling and Useful Information 5. Next period may be delayed upto 7 days after using ECPs. In case she fails to get period within 7 days after expected period she should contact her doctor. 6. Use of ECPs do not protect against STDs. She should be advised tests for STD and treatment accordingly 7. She should be advised against further act of intercourse in current cycle after using EC.

Client Screening & Assessment for EC use History 1. Date of last menstrual period (LMP) 2. Average length of menstrual cycle 3. Timing of last act of intercourse and previous acts in the current cycle 4. Time in hours since last act of unprotected intercourse 5. Current or recent use of contraception 6. History of medical disorders, sexually transmitted disease or major illness

Client Screening and Assessment for EC use Physical Examination : Not necessary except when pregnancy is suspected. Laboratory tests : 1. Urine pregnancy test if pregnancy is suspected. 2. Tests for sexually transmitted diseases.

Side Effects of EC 1. Nausea 2. Vomiting 3. Delay in menses : upto 7 days 4. Failure : 2-5%

When should she return after using EC 1. If periods are delayed > 7 days 2. Wants to use regular contraceptive 3. Any unexplained symptom/sign

Regular Contraceptive Use After EC Use “More than 75% women prefer to switch to a regular method after using EC once”

Contraindications for EC use Pregnancy seems to be the only contraindication for the use of Emergency Contraceptive Pill (ECPs). Levonorgestrel only regimen is devoid of any risks and can be safely used in situations where use of Combination Pills is a concern due to presence of Estrogen dependent conditions. Use of Copper intrauterine devices, although as effective as ECPs may be avoided in following situations due to risk of PID.

Misconceptions with Use of EC 1. Will promote promscuity 2. Will decrease use of regular contraception 3. Is a kind of abortion 4. Is a method of family planning

Record Keeping Example of Record Keeping for EC use 1. Name (optional) 2. Age 3. Marital Status 4. Date of LMP 5. Length of duration of menstrual cycle 6. No. of unprotected acts in current cycle 7. Time since last act of unprotected coitus (in hour) 8. Past use of ECPs 9. Past use of Regular Contraceptive 10. Method prescribed

Thank you