EMERGENCY CONTRACEPTION



EMERGENCY CONTRACEPTION DEFINITIONEmergency contraception (EC) refers to the contraceptive options that can decrease the risk of pregnancy after intercourse but before the establishment of a pregnancy. These methods can be used after intercourse when no contraception was employed (i.e., unprotected intercourse [UPI]), a method was used imperfectly (i.e., a condom slipped or broke, pills or injection was missed), or sex was forced without use of contraception. Options include the copper intrauterine device (IUD), with a pregnancy rate of 0.1% if placed within 5 days of unprotected intercourse. It prevents fertilization and may prevent some pregnancies after fertilization. Hormonal methods of EC include ulipristal acetate (UPA) (Ella?) and levonorgestrel (LNG) EC (Plan B One Step? and several generic versions such as Econtra EZ and Next Choice?). These medications prevent or delay ovulation. They do not cause abortion, harm an established pregnancy, or increase the risk for ectopic pregnancy. UPA is the most effective, with a pregnancy rate of 1.3% if taken within 5 days (120 hours). LNG, if taken within 72 hours, has a pregnancy rate of 2.2%. ECPs may be less effective among clients with a body mass index (BMI) ≥30 kg/m2 than among clients with a BMI <25 kg/m2. The Cu-IUD or theUPA regimen is recommended for obese clients however clients should never be denied access to ECPs due to higher weights or BMI. (Note: the probability of clinical pregnancy after unprotected intercourse ranges from 0% to 9.7%, based on the time of intercourse relative to the day of the menstrual cycle.) SUBJECTIVEMust include:Reproductive Life PlanIf acute need for EC:LNMP and menstrual history.History of any unprotected acts of intercourse since LNMP.Including time of last unprotected intercourseLactation statusCalculation of BMI, as indicated, LNG ECPs might be less effective among clients with BMI≥26 kg/m2 than among clients with BMI ≤25kg/m2 UPA ECPs might be less effective among clients with BME≥35If prescription is being given in advance of need:Couple with using a method which might not be correctly and consistently usedClient interested in having EC available in case of needZika Risk Assessment- As per current CDC guideline- and partner(s)Past travel – where and whenPlans for future travel –where and whenAssessment of contraindications:PregnancyIf considering copper IUD, any US MEC category 4 condition for IUD placement (See IUD Protocol)OBJECTIVEMust include:Assessment of contraindications:PregnancyUSMEC category 4 condition for method of EC being consideredLABORATORYMust include:For acute need:Using copper IUD or UPA (Ella): Negative sensitive urine pregnancy test.Using LNG-EC: Negative sensitive urine pregnancy test needed only for clients with:Signs or symptoms of pregnancy Delayed menses Earlier episodes of unprotected intercourse which could have resulted in established pregnancyFor advance prescriptions of EC:LNG-EC: No pregnancy test neededUPA (Ella): Client must be able to perform home pregnancy test or come to clinic for testingASSESSMENTClient at risk for unintended pregnancy who is a candidate for EC.PLANAcute need for EC. Try to establish why the client’s method did not work and attempt to prevent repetition.Copper T-380A IUD is the preferred method for all clients without US MEC category 3 or 4 conditions to its use. Use of the copper IUD as EC is off-label. A pregnancy test should be performed prior to placement for documentation. No back-up method is needed after IUD placement. If the client is interested in using the copper IUD for EC, follow steps outlined in the protocol Identification of Intrauterine Device (IUD) Candidate.Note: The copper T380A IUD has many important features for EC:can be placed up to 120 hours after coitus.is the most effective method of EC especially for client’s who are obese. (failure rate of about 0.1 – 0.7%)is immediately effective as an ongoing method.no back-up method is needed. Hormonal EC. For clients who do not choose the copper IUD for EC, recommendation for EC should be based on client preference, client BMI and time since intercourse. There are 3 options available for hormonal EC:Ulipristal acetate (UPA)(Ella) 30mg tablet taken orally once. A pregnancy test should be performed prior to use for documentation. Allow at least 5 days before initiating CHCs, POPs, Implants, DMPA, or LNG IUC after UPA (Ella) has been taken. Advise abstinence or back up method for 14 days.Note: UPA (Ella) has many important features for EC:Can be taken up to 120 hours after coitus on labelIs more effective than LNG EC; may be more effective than LNG EC for clients with BMI>26 kg/m2 Efficacy does not diminish with time since coitus within 120 hours Works by inhibiting ovulation up to the time of follicle rupture. It has no impact on implantation.LNG EC (1.5 mg) taken as one dose orally (preferred dosing), or as 2 tablets LNG EC (0.75 mg) taken one tablet orally 12 hours apart. LNG-EC can be taken on label up to 72 hours after intercourse and off-label up to 120 hours following intercourse. Pregnancy testing is not necessary unless symptoms or history suggest the need. Note: LNG EC is not as effective as UPAEspecially in overweight and obese clientsEspecially if taken more than 12 hours after intercourse Its efficacy diminishes rapidly with time since intercourse, so advance prescription for future use is helpful.LNG-EC works by ovulation suppression up to the beginning of the LH surge.LNG-EC is available both by prescription and over the counter for clients of all ages. Clients should understand that insurance will not cover the cost without a prescription. Any gender can also purchase LNG-EC over the counter without age restriction.Refer to Contraceptive Technology, 21st edition (page 331) if combined oral contraceptive pills are used for emergency contraception.If a client does become pregnant despite use of EC, the risk of ectopic pregnancy is slightly higher than background rates. Advance prescription of EC.In general, the LNG-EC products are best for this application. Provide client with product or give prescription that should be filled at once to have on hand. If possible, write for several refills.Advise client to keep EC in a readily accessible site.Remind client to use EC as soon as possible following unprotected or inadequately protected sex.Ask client to request new prescription whenever it runs out or if the product expires.Let clients know that LNG-EC products are available at pharmacies without a prescription but will have to pay full price for the product without a prescription.UPA (Ella) may be provided by prescription in advance of need, but make sure client understands they should do a home pregnancy test before starting UPA (Ella), to confirm they are not pregnant. Because there are not adequate and well controlled studies in pregnant people, it is not clear if UPA (Ella) could have an adverse impact on an established pregnancy. UPA (Ella) –breastfeeding is not recommended for 24 hours after taking UPA because it is excreted in breast milk, with highest concentrations in the first 24 hours, and maximum maternal serum levels are reached 1-3 hours after administration. Mean UPA concentration in breast milk decreases markedly from 0 to 24-48 hours and then slowly decrease over 5 days. Breast milk should be expressed and discarded for 24 hours after taking UPA. Repeated use of ECIf using UPA (Ella), it is advised not to repeat use within the same menstrual cycle as safety and efficacy of repeat use within the same cycle has not been evaluated.If using LNG EC, there is no restriction on repeated use, however, client needs to be advised that EC is not a highly effective form of ongoing contraception. UPA (Ella) and LNG EC should not be taken within 5 days of one another.CLIENT EDUCATIONIf client uses copper IUD, provide client education from IUD protocol If client uses any hormonal EC, reinforce that hormonal EC works best if taken as soon as possible after unprotected or inadequately protected intercourseIf client uses ulipristal acetate: UPA (Ella)Advise that this is the most effective hormonal EC.Clients starting hormonal birth control method (CHC, POP, Implant, DMPA, LNG IUC) should wait at least 5 days after UPA (Ella) to start methoduse back up method for 14 daysFor clients who do not use LARC or hormonal methods advise using a back-up method for 14 days.Advise client of the possible risk of very early pregnancy and recommend repeating urine pregnancy test in 3 weeks.If client uses LNG-EC, advise:LNG EC works best if taken within 12 hours of intercourse.LNG EC may be used for up to 120 hours after exposure, but pregnancy rates are higher when it is used that late.Advise client to resume use of primary method of contraception immediately and to use backup method for 7 days following EC.Caution that the LNG-EC may not work as well in overweight clients and may not be effective for obese clients.Advise client to return for pregnancy testing if menses does not start within 2 weeks or if symptoms of pregnancy develop.Explain that all hormonal methods of EC are contraceptives and work by suppressing ovulation and are not an abortifacient.Advise client that hormonal EC will not work if already pregnant. Inform clients that if they conceived less than 10 days ago, a pregnancy test may not be able to detect pregnancy at this time.Advise client that LNG EC will not harm a fetus if the client uses it while pregnant.Describe temporary common side effects with hormonal EC:Irregular bleeding or spotting.Change in onset of next menses.Short term headache, bloating, breast tenderness and other hormonal side effects.Nausea and/or vomiting. Tell client that nausea may occur, especially with estrogen- containing pills; incidence significantly lower with levonorgestrel EC than with conventional pills. Nausea may be reduced if pills are taken with food. If vomiting occurs within 2 hours of taking hormonal EC, consider an additional dose. Reinforce concept that hormonal EC is for emergency use only and should not be considered a primary method of contraception.Advise that hormonal EC will not protect against any future acts of unprotected intercourse. Clients should resume an ongoing method as instructed.Remind client that pregnancy testing is advised if no menses in 3 weeks after using hormonal EC.For client getting EC ahead of time (advanced prescription):Advise that some pharmacies may not rapidly fill prescription.Recommend having a prescription filled soon and keep EC readily available.Instruct client to check for expiration date and to review instructions on how to use.Remind client that EC is not effective if already pregnant.Reinforce need to promptly resume ongoing method after using LNG-EC and to use backup methods. EC will not protect from additional acts of unprotected intercourse.Remind clients planning to get Ella in advance of the need for a pregnancy test before starting Ella. Instruct clients that EC will not protect against STIs and Zika Virus transmission.Zika virus education and prevention strategies Avoid traveling to impacted areasAvoiding mosquito bites if traveling to impacted areasUsing condoms to prevent transmission of virusAvoiding pregnancy if infected or partner infectedRisk to unborn fetus REFER TO MD/ERNoneREFERENCESACOG Practice Bulletin No. 152: Emergency contraception. Obstet Gynecol. 2015; 126: e1-11.Centers for Disease Control and Prevention. U.S. medical eligibility criteria for contraceptive use, 2016. Available at for Disease Control and Prevention. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. Available at RA, et al (editors). Contraceptive Technology, 21st Ed. New York: Ayer Company Publishers, Inc. 2018; 329-365Centers for Disease Control and Prevention (CDC). Zika Virus Homepage-: 2021 ................
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