Emergency Contraception

• Clarify timing of unprotected intercourse (UPSI) and menstrual history (LMP, cycle length).
• Screen for sexual assault and safeguarding concerns; follow local protocols where relevant.
• Exclude known pregnancy if possible (urine pregnancy test and history); EC does not work if already pregnant.
• Discuss future contraception and offer referral for ongoing care (family planning/gynae/PHC clinic).

Note: Specific products, availability, and legal frameworks vary by country and institution – follow local guidelines.

1. Confirm indication: UPSI, condom break/slip, missed pills, sexual assault, late/failed method.
2. Determine time since UPSI (hours/days) and where in the cycle patient likely is.
3. Check for:
   • Known pregnancy.
   • Allergies, severe liver disease, uncontrolled asthma (for UPA), or contraindications to IUD insertion.
   • Current medication that induces liver enzymes (may reduce oral EC efficacy).
4. If copper IUD feasible within time window → offer/arrange IUD (explain highest efficacy and ongoing contraception).
5. If IUD not feasible or declined:
   • Within 72 hours → LNG or UPA (depending on local availability and interactions).
   • Between 72–120 hours → UPA preferred if available.
6. Provide oral EC dose in ED where possible (directly observed) and document.
7. Arrange follow-up for ongoing contraception and pregnancy testing if menses delayed > 3 weeks.

Levonorgestrel (LNG)

• Typical regimen: single dose 1.5 mg (or 0.75 mg × 2 twelve hours apart; single dose preferred for simplicity).
• Licensed for use up to 72 hours after UPSI; efficacy greatest within 24 hours.
• Mechanism: primarily delays or inhibits ovulation.
• Effectiveness may be reduced at higher body weights/BMI – check local guidance for alternatives (e.g. copper IUD or UPA).

Ulipristal Acetate (UPA)

• Single 30 mg tablet, prescription-only in some settings.
• Licensed up to 120 hours after UPSI; more effective than LNG especially after 72 hours.
• Mechanism: selective progesterone receptor modulator; delays ovulation even when LH surge has already started.
• Do not start a hormonal contraceptive immediately after UPA – follow local guidance (often need a short delay).
• Use caution with severe asthma on glucocorticoids and severe liver disease.

Combined Oral Contraceptive (Yuzpe Regimen)

• Uses higher doses of standard combined pills (e.g. containing ethinyl estradiol + levonorgestrel).
• Less effective and more nausea/vomiting compared with LNG alone.
• Generally reserved for situations where dedicated EC products are unavailable.

• Most effective form of EC with failure rates <1%.
• Can usually be inserted within 5 days of UPSI; some guidelines allow later insertion in relation to ovulation – follow local protocol.
• Mechanism: copper ions are spermicidal, impair fertilisation and may prevent implantation.
• Provides long-term contraception (up to several years) once in place.
• Requires:
  • Exclusion of existing pregnancy as far as possible.
  • Screening for pelvic infection risk; STI tests as per local policy.
• Risks include: pain, bleeding, expulsion, perforation (rare), and pelvic infection (mainly in first few weeks if existing STI).

• Common side effects of oral EC:
  • Nausea, headache, fatigue, dizziness.
  • Temporary changes in timing or amount of next menstrual period.
• Vomiting within a short period after dose (e.g. 2–3 hours) may require re-dosing; check local guideline.
• Combined (Yuzpe) regimens cause more nausea and vomiting than LNG or UPA alone.
• EC does not affect an established pregnancy and is not associated with congenital abnormalities if pregnancy continues.

• High BMI / Body weight: Efficacy of oral EC, particularly LNG, may be reduced at higher BMI – consider copper IUD or UPA as per local policy.
• Drug interactions: Enzyme-inducing drugs (e.g. some anti-epileptics, rifampicin) may reduce oral EC effectiveness – IUD preferred if feasible.
• Breastfeeding: Check local guidance regarding timing of breastfeeding after UPA; LNG is often preferred if breastfeeding.
• Sexual assault: Always consider EC as part of comprehensive post-assault care (including STI prophylaxis, HIV PEP assessment, forensic examination, psychosocial support).

• Explain clearly:
  • What was given (LNG/UPA/IUD) and how it works (delays ovulation or prevents fertilisation).
  • That EC does not disrupt an existing pregnancy and is not an abortifacient.
  • Possible side effects and expected changes in the next period.
• Advise a pregnancy test if:
  • No period occurs within 3 weeks of EC use, or
  • Period is unusually light or there are pregnancy symptoms.
• Provide written safety-net advice and information on local family planning services.
• Discuss and, if possible, initiate a reliable ongoing contraceptive method (pill, injection, implant, IUD, etc.) or arrange referral.