News

Emergency Contraception
By Dr. Ashok Kumar MD,MAMS, FICMCH Professor ,Department of Obstetrics & Gynaecology Maulana Azad Medical College & Lok Nayak Hospital,New Delhi

Emergency Contraception (EC)

refers to a particular type of contraception that is used as an emergency procedure to prevent pregnancy following unprotected, possibly fertile intercourse. In short, any reason that a woman is concerned that she might become pregnant is an appropriate reason to use it.

EC pills (Morning after pills or Post coital pills) are hormonal method of contraception. The various types of agents can be used for EC (Table 1). Levonorgestrel-only regimen and combined estrogen-progestin regimen are most commonly advocated for EC.

Average chance of pregnancy after unprotected coitus in second or third week of cycle is around 8% and after emergency contraceptives is 2%.

Implantation of a fertilized egg in the lining of a women’s uterus usually occurs at least 5 days after the intercourse.

Mechanism of action

The exact mode of action of ECPs is uncertain and may be related to the time they are used in a woman’s menstrual cycle. In the beginning of the cycle, they may cause disruption of follicular maturation and thus prevent ovulation just as oral contraceptive (OC) pills taken daily would, or they may delay ovulation. After ovulation, they may interfere with fertilization and/or, in theory, prevent implantation of a fertilized egg in the wall of the uterus due to asynchronous endometrial maturation. ECPs will not protect against other acts of unprotected intercourse later in the menstrual cycle. In fact, ECPs can delay ovulation, so a woman might still get pregnant later in the same cycle. To keep avoiding pregnancy, a woman should start an ongoing method of contraceptive as soon as possible.

They do not interfere with established pregnancy and hence ineffective, once implantation has begun. Therefore, they are not abortifacient. ECPs do not cause ectopic pregnancy

Furthermore, there is no evidence that combined or progestin-only contraceptive harm a developing fetus in case of failure. ECPs offer no protection against sexually transmitted infections (STIs).

Table 1.

Comparision of Methods for Emergency contraception

N = nausea, V = vomiting, I C = Intercourse

Timing of Use

The sooner treatment is started, the better. There is reduction in the efficacy of method with increase in coitus – treatment interval. Therefore, it is given

as early as possible for maximum efficacy. The pills have been shown to be effective through five days (120 hours) after intercourse. No data are available establishing efficacy if ECPs are taken more than 120 hours after intercourse.

The first dose should be taken no later than 72 hours after an unprotected intercourse. The second dose should follow 12 hours after the first dose. Nowadays, it is recommended that two tablets (single dose) of levonorgestrel should be given within 72 hours of intercourse.

Women who request ECPs more than 72 hours after unprotected intercourse may be given pills, but they should be told that pregnancy might already have begun, and therefore ECPs may not be effective. For women who request emergency contraception between 72 and 120 hours and are appropriate IUD candidates, a copper IUD may be a better option.

ECPs – Prescription

ECPs are safe for virtually all women, including those who may have health conditions that rule out daily use of OCs. Prescription of more than the recommended dosage of ECPs will NOT make ECPs more effective. The extra pills will only cause more nausea.

ECPs have not been found to increase the risk of the complication associated with ongoing OC use. ‘WHO medical eligibility criteria’ for contraceptive use list no medical conditions that rule out use of ECPs. The confirmation of pregnancy status is not required before writing a prescription of ECPs. There is no harm to a pregnant woman or to her pregnancy. The routine screening tests, any examination, pregnancy test and blood tests are not necessary. ECPs are not indicated in women with confirmed pregnancy because they will not have any effect.

The pill will not make menstruation start immediately. The next period may come a few days earlier or later than expected. The pregnancy should be suspected, if:

• The menstrual period is more than one week later than expected,
• There is no menstruation within three weeks after treatment, or
• The menstrual period is unusually scanty.

Table 2

The pregnancy rates, estimated efficacy and side effects in the Yuzpe and Levonorgestrel groups

a = p<0.01,,,b= p<0.005, * = p<0.05

Side Effects

Women taking ECPs sometimes experience side effects (Table 2) which usually subside within a day or two. It is not possible to predict which ECP users will have nausea or vomiting or which women will benefit from antiemetic pretreatment. The best way to minimize nausea and vomiting is to use the levonorgestrel-only regimen instead of the combined regimen whenever possible. Nausea and vomiting are uncommon enough with the levonorgestrel-only regimen that prophylactic administration of an antiemetic drug is not routinely warranted (Table 2). If required, antiemetics like meclizine or metoclopramide should be taken 30-60minutes before the first dose of ECPs. Taking ECPs with food has not been shown to alter the risk of nausea. If vomiting occurs within two hours after taking ECPs, the dose should be repeated. In cases of severe vomiting, vaginal administration of ECPs may be effective.

Irregularly bleeding due to ECPs is not dangerous and will resolve without treatment. However, it is important not to discount the possibility that irregular bleeding after ECP use may be due to another more serious cases, such as ectopic pregnancy. There is no increase in the risk of thromboembolic disorders.

Information to be provided to Clients

Information about ECPs and related issues may be provided in person, over the telephone, in writing, or by a combination of these approaches. At a minimum, the following messages should be conveyed :

• The clients should start treatment as soon as possible after intercourse.
• Following ECP use, if the client’s menstrual period has not come within a week after it was expected; she should seek evaluation and care for possible pregnancy.
• If the client has irregular bleeding and lower abdominal pain, she should contact a health care provider for possible evaluation for ectopic pregnancy.
• The client should use another form of contraception after using ECPs. ECPs are not suited for ongoing contraception.
• ECPs do not protect against HIV or other sexually transmitted infetion (STIs).

Conclusion

Emergency contraceptive pills (ECPs) offer a chance to avoid pregnancy to women who did not or could not use contraception or who suspect that their regular method failed. Both progestin only and combined estrogen-progestin formulations are effective. According to recent research, progestin-only ECPs are more effective and cause less nausea and vomiting.

ECPs are safe and easy to use. Virtually all women can use them, even women who have medical conditions that rule out ongoing use of OCs. Pills from an ordinary OC pill packet can be used for emergency contraception, so long as the pill contain the progestin -levonorgestrel, or norgestrel. Thus in effect, ECPs are available wherever these combined oral contraceptive pills or progestin- only pills are available. ECPs are not as effective as correct and consistent use of most other modern contraceptive methods. They are more likely to cause nausea and vomiting than OCs taken daily. Therefore ECPs should not be used regularly as a substitute for ongoing contraception