Emergency Contraception and Sterilisation

Emergency Contraception


Indications

  • Any unprotected sexual intercourse (UPSI)

  • Sexual assault

  • Missed pills

    • for COCP if miss > 2 active pills

    • for progesterone-only pill – >27 hours after last POP or >36 hours after last POP

  • IM Depo Provera

    • >14 weeks since last injection

  • IUCD

    • removal without any new method

    • missing thread/unable to localise IUCD

    • expelled IUCD

  • Condom accident – broken/came off

Issues

  • Risk of pregnancy

  • Risk of sexually transmitted infection (condom accident)

Important points in history taking

  • When was the last menstruation cycle?

  • What is the current method used for contraception?

  • Any other contraception methods used previously? Were there any complications/issues?

  • How many hours ago since the first episode of unprotected sexual intercourse?

  • Any other episodes of unprotected intercourse in this cycle?

Other medical history

  • Is she on any medication? – antibiotics/anti-epileptics etc that may reduce the efficacy of EC

  • Any medical problems or contraindications to OC?

 

Assess risk of sexually transmitted infections

  • Any past history of STI?

  • Any contraindication for IUCD?

Emergency Contraception – Options

Options – Levonogestrel 1.5mg

Postinor

  • 750mg levonogestrel

  • 2 tabs stat

Escapelle

  • 1.5g levonogestrel
  • 1 dose
  • Can be used within 72 hours (3 days) of UPSI

  • Ineffective if taken more than 96 hours after UPSI

  • Mechanism of action is to inhibit ovulation

  • May not work if ovulation has already occurred

  • Causes nausea, vomiting and headache

  • If the patient vomits within 3 hours – repeat the dose

  • 97 – 98.5% effective

  • Can be taken more than once in a cycle

  • Caution in patients with contraindications – liver disease, migraine, etc

  • Next menses may be delayed or early

  • For women who are on drugs that may reduce efficacy (e.g. liver enzyme inducers) or when concurrent HIV post-exposure prophylaxis is required advised to take 3mg of levonogestrel. However, the effectiveness is not known

Options – Ulipristal acetate

 

  • Also known as ellaOne

  • Dose – 30mg stat

  • Can be used within 5 days of unprotected intercourse (120 hours)

  • It is a progesterone receptor modulator

  • Mechanism of action is by inhibition or delay of ovulation

  • If the patient vomits within 3 hours, repeat the dose

  • Not suitable for women with severe asthma on oral steroids

  • Breastfeeding women should be advised not to breastfeed and to express and discard breast milk for a week after taking UPA

  • Can be taken more than once in a cycle

  • Effectiveness is reduced in women taking enzyme-inducing drugs

  • Double dosing is not recommended

  • Need to wait for 5 days before starting hormonal contraception

Options – Copper IUCD

  • Most effective EC

  • Can be inserted up to 5 days after UPSI or up to 5 days after ovulation (whichever is later)

  • Can be used for women who want an ongoing contraception

  • Inhibits fertilisation and implantation

  • Should be offered to women on enzyme inducing drugs

  • Contraindications are the same as for routine IUCD insertion

  • Risk of STI, previous ectopic pregnancy, young age and nulliparity are not contraindications

  • Complete antibiotics before insertion if known symptomatic chlamydia trachomatis infection or current neisseria gonorrhoeae infection

  • Women who are breastfeeding have a slightly higher risk of uterine perforation

  • Effectiveness not affected by weight or BMI

Effectiveness of EC – pregnancy rates

  • Overall risk of pregnancy with EC – 1%

  • Copper IUD – <0.1%

  • Ulipristal acetate 1-2%

  • Levonogestrel – 0.6 – 2.6%


Risk of sexually transmitted infections

  • Women who are at risk should be test.

  • Antibiotic prophylaxis can be given to women who are having Cu-IUCD inserted


Aftercare

  • Aftercare Check UPT if menses delayed/light or painful

  • If on hormonal contraception (quick start after EC) – check UPT anyways

  • There is no risk of anomaly to the fetus if she gets pregnant after hormonal EC


Pre-sterilisation information and advice

Information given to men and women considering sterilisation should:

  • ideally be conducted with both partners together, where acceptable and appropriate

  • include information on sterilisation procedures

  • highlight the irreversibility/permanence of sterilisation and that sterilisation reversal is not routinely available

  • include information on failure rate associated with sterilisation procedures

  • include information on risk and complications associated with sterilisation procedures

  • discuss myths and misconceptions associated with sterilisation

  • inform individuals that vasectomy is safer, quicker to perform and is associated with less morbidity than female sterilisation by laparotomy or laparoscopy

  • include information on other methods of contraception, including long-acting reversible contraception (LARC)

  • assess individuals for known predictors of regret and highlight the possibility of regret associated with sterilisation

  • ensure that individuals are aware that sterilisation does not confer protection against sexually transmitted infections

  • highlight the need to use contraception until sterilisation has been carried out and the potential need to continue use beyond the procedure

  • enable individuals to make an informed decision and should include obtaining consent

  • be recorded/documented in clinical records

  • be carried out at a suitable interval prior to the procedure


Regret

Factors associated with a higher rate of regret

  • young age (<30 years at time of procedure)

  • nulliparous or low parity (the number is not always defined in the literature but usually refers to two or fewer children)

  • being in an unhappy relationship/in conflict with partner or spouse

  • not being in a relationship

  • remarriage/change of partner/change in relationship status

  • death of a child

  • desire to have children/more children – including with a new partner

  • psychological problems/issues (implications beyond fertility issues)

  • psychosexual issues

  • coercion by health professional or partner/spouse

  • timing of procedure in relation to pregnancy – interval sterilisation results in a reduced risk of regret

  • information requirements in terms of the procedure, its efficacy, and alternative contraceptive choices.

Vasectomy

  • Interrupting the vas deferens with an intention to provide permanent contraception.

  • Done under local anaesthesia

  • Outpatient setting

  • Minimally invasive vasectomy or no scalpel vasectomy

  • Small incision made on the skin, vas deferens isolated and cauterized and divided with diathermy

  • Need additional contraception until semen analysis shows no more sperm – usually after 12 weeks

  • Failure rate is 1:2000

  • Small incidence of chronic pain

Tubal ligation/Occlusion

  • Can be done via laparotomy or laparoscopy

  • Usually done under GA

  • For laparoscopy – using fallope ring or filshie clip

  • Laparotomy – mini-laparotomy or during caesarean section

  • Pomeroy or Parkland method

  • Risks are the ones associated with surgery – bowel/bladder/blood vessel injury 1:2000

  • Risk of death 1:12000

  • Failure rate 1:200

Important points before procedure

  • Rule out pregnancy

  • Counsel patient risk of luteal phase pregnancy

  • If any chance of patient being pregnant – consider postponing procedure

 


Risk of ectopic pregnancy

  • Women who get pregnant after a tubal ligation/occlusion are at a higher risk of having an ectopic pregnancy

  • Must be aware of menstrual cycles and check UPT if menses is missed

  • Educate patients about signs and symptoms of ectopic pregnancy

 

References

1. Faculty of Sexual & Reproductive Healthcare (FSRH). Emergency Contraception. 2017

https://www.fsrh.org/standards-and-guidance/documents/ceu-clinical-guidance-emergency-contraception-march-2017/fsrh-guideline-emergency-contraception-2017.pdf

2. Faculty of Sexual & Reproductive Healthcare (FSRH). Male and Female Sterilisation. 2014.

https://www.fsrh.org/standards-and-guidance/documents/cec-ceu-guidance-sterilisation-cpd-sep-2014/

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