Emergency Contraception – SOGC 2012

5 In all patients, especially those using barrier methods or when efficacy of hormonal methods is decreased, advise about post-coital contraception.

6 In a patient who has had unprotected sex or a failure of the chosen contraceptive method, inform about time limits in post-coital contraception (emergency contraceptive pill, intrauterine device).

Emergency contraception
  • Effective after intercourse and before implantation

Hx:
1) Time of unprotected intercourse: coerced? risks for STI, need for ongoing birth control
2) LMP
3) Offer Appropriate counselling, testing, and treatment – see below for couseling points
4) Inform the potential side effects and potential failure of EC (see below)
5) Inform hormonal EC will not prevent pregnancy after Tx


FOLLOW-UP / Couselling
  • Advice to have a pregnancy test if no normal menstrual bleeding by 21 days following EC treatment or by 28 days if an oral contraceptive was started after taking hormonal EC.
  • If indicated, a follow-up appointment can be made to address ongoing birth control or to test for sexually transmitted infections.
  • Advice ongoing barrier protection
  • Take anti-emetics prn
  • Discuss HPV testing / Pap test

Rx:

1) Hormonal: up to 5 days

  • Plan B (NorLevo, Next choice) – levonorgestrel 1.5mg (2 tabs) x 1 or 750 μg q12h x 2
  • Yuzpe method – 2 tablets of Ovral (50 μg of ethinyl estradiol and 250 μg of levonorgestrel) q12h x2
    Antiemetic prn
Relative Contraindication: Pregnancy (won’t work)
S/E:   1. Nausea         2. Vomiting       3. Dizziness        4.Fatigue

2) Copper IUD (off-label)- Flexi-T / NOva-T: up to 7 days

  • If successful in preventing pregnancy, may remain in place to provide ongoing contraception.
  • Mirena is not recommended for EC.
  • A pre-existing pregnancy must be excluded. This may require a urine pregnancy test or serum hCG test,
    especially in women who have had sexual intercourse at the beginning of their cycle.
  • There should be no history of recent PID and no apparent vaginal or cervical infection on examination.
  • At the time of insertion, consider obtaining endocervical specimens to test for gonorrhea and Chlamydia.
  • Antibiotics such as a single dose of azithromycin (1g) or doxycycline 200 mg should be considered in women at high risk to reduce the risk of pelvic infection.
  • If the copper IUD fails to prevent pregnancy the device should be removed immediately once the diagnosis of pregnancy is made. It is also important to rule out ectopic pregnancy.
C/I:  1. Pregnancy       2. PID         3. STI
S/E and complications:
  1. pelvic pain
  2. abnormal bleeding
  3. pelvic infection
  4. uterine perforation
  5. expulsion

Source: http://sogc.org/wp-content/uploads/2013/01/gui280CPG1209ErevB.pdf


Summary:
1. Hormonal emergency contraception may be effective if used up to 5 days after unprotected intercourse. (II-2)

2. The earlier hormonal emergency contraception is used, the more effective it is. (II-2)

3. A copper IUD can be effective emergency contraception if used within 7 days after intercourse. (II-2)

4. Levonorgestrel emergency contraception regimens are more effective and cause fewer side effects than the Yuzpe regimen. (I)

5. Levonorgestrel emergency contraception single dose (1.5 mg) and the 2-dose levonorgestrel regimen (0.75 mg 12 hours apart) have similar efficacy with no difference in side effects. (I)

6. Of the hormonal emergency contraception regimens available in Canada, levonorgestrel-only is the drug of choice. (I)

7. A pregnancy that results from failure of emergency contraception need not be terminated (I)

Recommendations

1. Emergency contraception should be used as soon as possible after unprotected sexual intercourse. (II-2A)

2. Emergency contraception should be offered to women if unprotected intercourse has occurred within the time it is known to be effective (5 days for hormonal methods and up to 7 days for a copper IUD). (II-2B)

3. Women should be evaluated for pregnancy if menses have not begun within 21 days following emergency contraception treatment. (III-A)

4. During physician visits for periodic health examinations or reproductive health concerns, any woman in the reproductive age group who has not been sterilized may be counselled about emergency contraception in advance with detailed information about how and when to use it. (III-C)

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Posted in 16 Contraception, 99 Priority Topics, Gyne

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