emergency contraception
TRANSCRIPT
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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