Emergency Contraception Pathway

Emergency contraception is the use of a drug or device after unprotected or inadequately protected sex to prevent pregnancy. This article sets out how to assess the patient, choose among the available options, give the method, start ongoing contraception and arrange follow up. It covers unprotected sex, contraceptive failure (condom breakage, missed pills, late injections, expelled IUD), sexual assault and use of interacting drugs.

Options and effectiveness.

• Copper IUD inserted within 5 days of unprotected sex: the most effective method, with fewer than 1 pregnancy in 100 women; it then continues as long-term contraception.

• Ulipristal acetate 30 mg orally as a single dose within 120 hours: at least as effective as levonorgestrel and better close to ovulation.

• Levonorgestrel 1.5 mg orally as a single dose (two 750 microgram tablets together, preferred) within 120 hours: prevents up to 95 percent of expected pregnancies when taken early; effectiveness falls with delay. An alternative is 750 micrograms repeated after 12 hours.

• Combined pills (Yuzpe regimen): four tablets of 30 microgram ethinylestradiol pills, repeated after 12 hours, or two tablets of 50 microgram pills, repeated after 12 hours, within 120 hours; prevents about 75 percent of expected pregnancies and causes more nausea. Used only when other options are unavailable.

Scope. All patients who may become pregnant after unprotected sex, regardless of age or marital status. Emergency contraception does not end an existing pregnancy and does not harm one.

Access. No prescription, pregnancy test, pelvic examination, laboratory test or parental consent is needed before an oral emergency method. A trained provider is needed for copper IUD insertion.

Providers. Pharmacists, nurses, clinical officers, doctors and trained community health providers can give oral emergency contraception. Doctors, nurses and clinical officers trained in IUD insertion provide the copper IUD.

Stock. Facilities hold levonorgestrel 1.5 mg, ulipristal acetate 30 mg where available, and copper IUDs with insertion kits. Stock is checked regularly and placed where it can be given at any hour.

Responsibilities. Provide the method promptly, respect privacy and confidentiality, give accurate information without judgement, and offer ongoing contraception, STI and HIV care and support after sexual violence.

Contraindications. Known pregnancy is the only reason not to give an oral method; ectopic pregnancy history, breastfeeding, liver disease, migraine, obesity and repeated use are not contraindications. Copper IUD contraindications are those of interval insertion (pregnancy, current pelvic infection or purulent cervicitis, unexplained bleeding, uterine distortion).

Clinical process.

• Greet the patient, provide privacy and ask how long ago unprotected sex occurred, whether there was other unprotected sex in the last 5 days, the date of the last menses and cycle regularity, any use of emergency contraception already this cycle, current method, current medicines, breastfeeding, and weight or BMI.

• Offer the copper IUD first when the patient is willing and can reach a trained provider.

• If choosing an oral method, select the product using the table that follows.

• Give the tablet at the facility and observe the first dose when possible. If vomiting occurs within 2 hours of levonorgestrel or within 3 hours of ulipristal acetate, repeat the dose.

• Advise on what to expect and when to test.

• Start or restart ongoing contraception using the timing rules that follow the table.

• Screen for STI and HIV risk, and offer testing, post-exposure prophylaxis within 72 hours and hepatitis B and tetanus prevention after sexual assault.

Choice by situation.

Ongoing contraception.

• After levonorgestrel: start or restart a hormonal method immediately and use condoms for 7 days (2 days for progestin-only pills).

• After ulipristal acetate: wait 5 days before starting a hormonal method, use condoms meanwhile, and then use condoms for 7 days (2 days for progestin-only pills) after the start.

• After copper IUD: no further method is needed.

• Provide condoms, and offer a long-acting method at the same visit when wanted.

Repeated use. Repeat doses in the same cycle are safe, although emergency contraception should not be used regularly because it is less effective than other methods. Offer an ongoing method to any patient who needs it repeatedly. Patients may be given a pack in advance for future use.

Documentation. Record time since unprotected sex, the method and dose given, any vomiting, ongoing contraception plan, STI and HIV actions, and follow up. Record doses given in the daily family planning register.

Follow up. Advise a pregnancy test if the next menses is more than 7 days late, if menses is unusually light or short, or if there is lower abdominal pain. Menses may come earlier or later by up to a week.

Safety points.

• A pregnancy that occurs after emergency contraception needs assessment, including for ectopic pregnancy when there is pain or bleeding.

• Emergency contraception does not reduce the effectiveness of a later contraceptive when waiting periods are respected.

• Side effects (nausea, headache, breast tenderness, fatigue, spotting) are usually mild and settle within 1 to 2 days; ondansetron or an antiemetic can be considered for severe nausea when needed.

Quality indicators. Time from presentation to dose; proportion of patients offered the copper IUD; proportion started on an ongoing method; repeat users offered ongoing methods; stock-out days for emergency contraception; patients lost after sexual assault care.

Escalation.

• Sexual assault: provide care in the same visit and refer to gender-based violence, legal and psychosocial services.

• Pregnancy after emergency contraception, or ectopic pregnancy suspected: urgent assessment and ultrasound.

• Adverse events and product problems: report to the pharmacovigilance system.