EMERGENCY CONTRACEPTION

BY OBINNA OKAFOR
OUTLINE
• Introduction
• Indications for use of ECPs
• Types of ECPs
• Complications of ECP use
• Conclusion
Introduction
• Emergency contraception is defined as a birth control measure taken to
reduce the risk of pregnancy following unprotected, ejaculatory,
penovaginal intercourse or when other regular contraceptive measures
have failed or have not been used correctly.
• Emergency contraceptive pills (ECPs), sometimes simply referred to as
emergency contraceptives (ECs), or the morning-after pill, are
medications intended to disrupt or delay ovulation or fertilization,
following unprotected, ejaculatory, penovaginal intercourse.
• Emergency contraception does not disrupt/halt an ongoing pregnancy.
Indications for use of ECPs
• Absence of any prior form of contraception
• Sexual assault/rape without any form of protection for the female
• Concern for possible contraceptive failure from improper use such as
condom breakage/slippage, dislodgement of the cervical
cap/diaphragm, Depo-Provera injection over 1 week late, 2 or more
missed contraceptive pills, partial or complete IUD expulsion etc.
• Mistimed fertility awareness
• Ejaculation on the external genitalia of the female
• Recent use of suspected teratogens such as cytotoxic drugs or live
vaccines.
Types of ECPs
• Copper-bearing intrauterine devices
• Combined Oral Contraceptive Pills (COCPs)
• Selective progesterone receptor modulator (ulipristal acetate)
• Levonorgestrel-containing ECPs (progestin-only formulations)
• Mifepristone (RU 486)
Copper-bearing Intrauterine Devices
(IUDs)
• This is the most effective form of emergency contraception
available, with an efficacy of 99% when inserted within 5 days of
unprotected intercourse (WHO 2021).
• WHO recommends that a copper-bearing IUD, when used as an
emergency contraceptive method, be inserted within 5 days of
unprotected intercourse. Once inserted, women can continue to use
the IUD as an ongoing method of contraception, or may choose to
convert to another contraceptive method.
• The mechanism of action is by inhibiting fertilization of the ovum
and/or preventing implantation of the conceptus in the
endometrium.
• Copper IUDs are a relatively safe form of emergency contraceptive
and can be used for up to 10 years without replacement.
• Insertion and removal/replacement of the contraceptive should
always be done by a qualified health care professional.
• Possible side effects include dysmenorrhea and menorrhagia in
the first few months of use. Both side effects usually reduce within
one year of use of the contraceptive.
• Contraindications to Copper IUD use include the presence of an
ongoing PID, puerperal sepsis, unexplained vaginal bleeding,
cervical cancer or severe thrombocytopenia. It is also
contraindicated in victims of sexual assault due to the risk of
contracting an STI, and also in pregnant women.
Combined Oral Contraceptive Pills (Yuzpe
regimen)
• This consists of contraceptive pills containing both oestrogen and
progesterone formulations.
• The Yuzpe regimen involves the use of 2 high-dose COC pills, taken 12
hours apart, with the first dose being taken within 72 hours of
unprotected intercourse.
• Each dose of the COCPs used in the Yuzpe regimen contains 100mcg of
ethinyl oestradiol and either 0.5-1mg of levonorgestrel or 1mg of
norgestrel.
• Its mechanism of action is by the delaying of ovulation.
• COCPs are not as effective as progestin-only pills in preventing
pregnancy.
Selective progesterone receptor modulator
(ulipristal acetate)
• This is the most effective emergency contraceptive pill currently available.
• It involves the administration of a single dose of 30mg of ulipristal acetate
preferably as soon as possible, or within 5 days of unprotected intercourse.
• Its mechanisms of action include the antagonism of progesterone receptors to
produce an anti-progesterone contraceptive effect on the ovaries (ovulation
suppression/delay) and on the endometrium (decreasing endometrial
thickness).
• This method has no change in efficacy when taken up to 5 days after
unprotected intercourse.
• It requires prescription by a qualified health care professional.
• It is contraindicated in patients with severe kidney or liver pathologies.
• There is limited knowledge on its effects on current/ongoing pregnancies.
Levonorgestrel-containing ECPs (progestin-
only formulations)
• These are the second most effective forms of emergency
contraceptive pills currently available.
• The mechanism of action of is by the prevention of ovulation and
fertilization. Levonorgestrel is not effective if the implantation has
occurred.
• There are two variations of this type of ECP. There is the single-pill type
and the double-pill type.
• Examples of the single-pill type include Plan B-One Step, Next Choice, My
Choice, My way, etc. Each preparation contains 1.5mg of levonorgestrel
which is taken as a single, highly-efficacious dose.
• For the double-pill type, the most common example in our current
setting is POSTINOR-2 .
• Postinor-2 is a levonorgestrel-containing contraceptive medication
intended for use only an emergency contraceptive and not as a
regular method of contraception.
• It is used to prevent pregnancy when taken within 72 hours of
unprotected, ejaculatory intercourse, and is estimated to prevent
85% of expected pregnancies.
• 95% of expected pregnancies will be prevented if taken within the
first 24 hours, declining to 58% if taken between 48 hours and 72
hours after unprotected intercourse.
• It is not known whether Postinor-2 is effective if taken more than
72 hours after unprotected intercourse.
• The first pill/dose should be taken preferably immediately after
intercourse, but no less than 72 hours after intercourse, with the
second pill/dose taken exactly 12 hours after administration of the
first dose.
• Each pill/dose contains 0.75mg of levonorgestrel, making for a
combined dose of 1.5mg of levonorgestrel.
• Contraindications to postinor-2 use include: an ongoing
pregnancy, previous unprotected intercourse more than 72 hours
earlier in the same menstrual cycle, vaginal bleeding, breast
cancer, allergy to any of the ingredients in the pills.
Mifepristone (RU 486)
• Mifepristone, formerly known as RU 486, is an antiprogestogen
which is most commonly known as “the abortion pill” because of
its use (in conjunction with misoprostol) in the termination of
early pregnancies at 10 weeks.
• It can also be used as a form of emergency contraception due to its
antiprogestogen properties.
• Its mechanisms of action include: the inhibition of the action of
progesterone by binding to its receptors (receptor antagonism),
inhibition of subsequent ovulation if given in the follicular phase
and inhibition of endometrial development in the luteal phase.
• Mifepristone is given as a single dose of 10-25mg, which should be
taken within 120 hours following unprotected intercourse. Studies
have indicated that a larger dose of mifepristone correlates with a
longer delay of menses, so it should be used with caution.
• It has an estimated efficacy of 98% in the prevention of pregnancy.
• Absolute contraindications to mifepristone use include chromic
adrenal failure, ongoing steroid therapy, severe asthma, bleeding
disorders, hypersensitivity to prostaglandins or mifepristone and
porphyria.
Complications of ECP use
• Headache
• Nausea and vomiting (especially for COCPs)
• Delayed menses
• Breast tenderness
• Abdominal pain
• Dizziness
• Fatigue
• Allergic reactions
Conclusion
• Emergency contraception is a birth control measure taken to
reduce the risk of pregnancy following unprotected, ejaculatory,
penovaginal intercourse or when other regular contraceptive
measures have failed or have not been used correctly.
• Emergency contraceptives should not be relied upon as a method
of long-term contraception or as a prophylaxis for sexually
transmitted infections.
• Arising complications from emergency contraceptive use should
be reported to a qualified ob/gyn or any other health care
professional as soon as possible.