emergency contraception

Presenter: Dr. Suhasini KanyadiPresenter: Dr. Suhasini Kanyadi

October 20, 2014

Introduction History Indication Methods of EC Mode of action Side effects Evaluation Recommendations References

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Emergency contraception (EC) is a method of contraception used as an emergency procedure before menstruation is missed, to prevent pregnancy following unprotected intercourse or expected failure of contraception.

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EC is any method of contraception which is used after intercourse and before the potential time of implantation.

This nomenclature, advocated by WHO lately.

Accepted by international Medical Advisory Panel and others recently.

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Alternative terms: Postcoital contraception- still commonly

used ‘morning after’ contraception

Less appropriate – suggest immediate application.

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EC is not true contraception but rightly called interception.

Interceptives – agents that do not interfere with fertilization but act on blastocyst before or soon after missing periods.

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EC is a back up plan.

It cannot be used as a ongoing method of contraception because:

i) relatively high failure ratesii) High incidence of irregular bleeding

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Characteristics of EC:-1. It is a one time procedure & not an routine

approach to contraception

2. Used postcoitally

3. Its objective is prevention of pregnancy

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About 42 million abortions carried out worldwide each year.

Unsafe abortions – 20 million

Worldwide nearly 1 in 10 pregnancy ends in unsafe abortion.

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India has the highest number of unsafe abortions in the world.

6,20,472 abortions reported in India in 2012

Two-third of them were unsafe

A women dies every two hours due to unsafe abortion.

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Widespread availability of EC can help reduce these abortions.

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“First immediately after ejaculation let the two come apart and let the woman arise roughly, squeeze and blow her nose seven times and call out in a loud voice. She should jump violently backwards seven to nine times."

Abu Bakr Muhammad al-Razi Abu Bakr Muhammad al-Razi (865 AD-925AD)(865 AD-925AD)

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“Traditional” methods for post coital contraception have been used for decades.

Found as far back as 1500 BC High doses of vitamin C, aspirin or chloroquine Vaginal douches of coca cola, baking soda, urine

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Vaginal douching, inspite of its ineffectiveness, continued to exist until modern times.

Charles Knowlton (American physician) gave prominence to it.

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Mid-1920’s effect of oestrogenic ovarian extracts on infertility in lower mammals was demonstrated.

Findings led to veterinary use of oestrogens to prevent pregnancy.

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1967-The first widely used methods were five-day treatments with high-dose estrogens, using diethylstilbestrol (DES) in the USA and ethinyl estradiol in the Netherlands.

Early 1970s -the Yuzpe regimen was developed (Combined preparation containing both ethinyl estradiol & levonorgestrel (1974).October 20, 2014

1975 – Progestin only postcoital pill was investigated.

1975 – Copper IUD was first studied for use as EC.

1980’s – Danazol was tested, but was found to be ineffective.

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1980’s – Yuzpe regimen became the standard treatment for EC in many countries.

1998 - After a large WHO trial Yuzpe regimen was gradually withdrawn and levonorgestel widely used

2002- China was the first country were mifepristone was registered for use as EC.

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1. For aged couples who meet very infrequently

2. Following single act of sexual exposure in young girls

3. When pregnancy is apprehended owing to rupture of condom, premature ejaculation in couples practising coitus interruptus etc

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When unprotected isolated intercourse happens at some odd moments among couples otherwise using conventional coontraceptives

In case of rape and incest

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Saves the couple from unwanted pregnancies

From unnecessary operative interferences for fear of pregnancy

From the agony of waiting for the next menstrual cycle.

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Prevents adolescent pregnancies

Helps to reduce unsafe abortion

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Two methods of EC are available:1) Hormonal 2) Mechanical

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Hormonal

i)Combined oestrogen and progestin pills- Yuzpe regimen

ii) Progestin only pills- Levonorgerstrel (LNG)

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Corpus luteum… disrupted formation … interfe-rence with its function

Cervical mucus… alteration in it sperm entrapped or impaired function

Before ovulation… disrupt normal follicular development & maturation interference in ovulation , with deficient/ impaired luteal function & delay in LH surge

Fertilization… direct inhibition

Sperm… interferes with its migration & function in the genital tract

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Preven No longer available in USA since May 2004

1. Combined ethinyl estradiol and levonorgestrel 1. Combined ethinyl estradiol and levonorgestrel ( Yuzpe method) ( Yuzpe method)

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Yuzpe method (Canadian Prof. Albert Yuzpe)

consists of the oral administration of 2 doses

of 0.1mg(100 µg) ethinyl estradiol (EE) and

0.5mg(500 µg) levonorgestrel 12 hours apart.

Failure rate- 0-2%

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Ovral tablets (each containing 50 µg ethinyl estradiol and 250 µg levonorgestrel) are most commonly used to provide these doses.

2pills 12hours

2 pills

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Mala –D, Mala-N ,Ovral –L – low dose pills(4 pills)

Others- Noral, Ovidon

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Plan B, Levonelle , Postinor , Contraplan IIIn India- EC pill, Pill 72, ECEE2

2. Progestin-only (Levonorgestrel)

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LNG-only pills 2 doses of 0.75mg LNG pill to be taken orally

12 hours apart within 72hours of intercourse.

or Single dose of 1.5mg LNG pill to be taken

within 72 hours of intercourse.

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Trials have shown that a high proportion of pregnancies were averted even upto 5days(120hours).

WHO recommends levonorgestrel for emergency contraceptive pill use.

Failure rate- 0-1%

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Ideally, this progestogen-only method should be taken as a single dose (1.5 mg) within five days (120 hours) of unprotected intercourse.

The regimen is more effective the sooner after intercourse it is taken.

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Side effects:-1. Nausea- in 50% using Yuzpe regimen & 20%

for Levonorgestrel2. Vomiting – in 20% Yuzpe regimen & 5% using

LNG-only pillsIf vomiting occurs within 2hours of taking the

pills - the dose should be repeated.In cases of severe vomiting – administer pills

vaginallyOctober 20, 2014

Irregular uterine bleeding

Others- headache, dizziness, fatigue and breast tenderness.

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ECP cannot dislodge an established

pregnancy

They do not cause abortion

ECPs do not affect fetal development.

No evidence that their repeated use causes

ectopic pregnancy.

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Medical eligibility criteria for EC Contraindication or delay – no such

condition ( rule out pregnancy)

WHO Category 2: caution/extra precautions1. History of severe CVS complications- IHD,

thromboembolism2. Migraine3. Severe liver disease4. Angina pectoris

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WHO Category 2: accept – no reason to prevent use

1. Breast feeding2. H/o ectopic pregnancy3. Repeated ECP use(requires further

counselling)

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Follow- up

Report if amenorrhoea persists ( >1week )If there is acute pain or bleeding lighter than

usual menses – exclude ectopic pregnancy

Advice regarding contraception

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Mechanical emergency contraception(IUD)

Copper T is used Initially Cu 7, Cu T 200 were used Later Multiload Cu 250 & lately Cu 375 Cu

380A– without single failure rates

Failure rate-0- 0.1%

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IUD’S – upto 5days following sexual intercourse

IUD’s are preferred in women who desires IUD as an ongoing method of contraception.

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Contraindication:-1) Pelvic infection2) DUB3) Suspected pregnancy4) Nullipara5) Uterine anomaly

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Side effects-1)Bleeding2)Pain3)Expulsion4)Pelvic infection

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Antiprogesterone ( MIFEPRISTONE) It act as Anti-implantation agent - post-coitally Menses inducers - luteal phase Abortifacients - early pregnancy

Single low dose 10mg 72-120hours

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Failure rates- 0.06%

In the USA, it is most commonly used in 600 mg doses as an abortifacient, but in China it is commonly used as emergency contraception in 10-mg dose( since 2002).

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Ulipristal acetate ( progesterone receptor modulator ellaONE)

Single dose 30mg within 120hours Approved by European Medicines Agency

-2009 US FDA- 2010 Not available in India Available on prescription as EC in over 50

countries

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Mechanism of action:

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Side effects- abdominal pain, menstrual irregularity

Studies have shown- embryotoxicity in animals

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Carraguard gel: composed of LNG.

Single vaginal administration of 750 micrograms LNG in CARRA gel in the late follicular phase was found to be effective in interfering with ovulation.

Therefore, this is a promising method for use as an emergency contraceptive method

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Calculation of efficacy Measuring only pregnancy rate following EC

is not enough Calcalation of reduction in expected

pregnancies is important- prevented pregnancies

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Formula :-

1 – observed pregnancy

expected pregnancy

Expressed in two ways:-1) Overall pregnancy rate2) Pregnancies prevented

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Hormonal emergency contraception should be available without a prescription in:

1. Pharmacies, 2. Family planning clinics, 3. Emergency rooms, and 4. School health programs.

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Women who have had unprotected intercourse and wish to prevent pregnancy can be offered use of hormonal emergency contraception up to 5 days after intercourse,

Insertion of a copper IUD up to 5 days after intercourse, to reduce the risk of pregnancy.

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Users of emergency contraception should be evaluated for pregnancy if menses have not begun within 21 days following treatment.

Women and men of reproductive age should be counselled about emergency contraception.

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Jeffcoate’s principle of Gynaecology-7th edition Chaudhuri SK. Practice of Fertility Control. 7th edition

2008. Shovan Chaudhuri New Dehli. Contraception in clinical practice (module 3) Textbook of Obstetrics by D.C. Dutta WHO Fact Sheet on Emergency Contraception 2012 Park’s textbook of Preventive &Social Medicine 22nd

edition Advances in methods of EC available athttp://www.aiims.edu/aiims/events/Gynaewebsite/ec_site/report/1

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