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“Clinicians should proactively talk to their patients of reproductive age about ECPs and offer advance prescriptions for ECPs during routine gynecologic office visits….”

“Clinicians should proactively talk to their patients of reproductive age about ECPs and offer advance prescriptions for ECPs during routine gynecologic office visits….”

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  • 06/23/10
  • 06/23/10
  • 06/23/10
  • 06/23/10
  • 06/23/10 Because emergency contraception is used only once or infequently, its effectiveness cannot be measured the way other contraceptive methods that are used more frequently are measured. A more accurate measurement of the efficacy of emergency contraception can be obtained by comparing the number of pregnancies in a study with the number of pregnancies that would have been expected without treatment. An analysis of data from 10 studies (Yuzpe regimen) showed that the weighted average of the effectiveness rates was 74%. Hatcher et al 1998.
  • 06/23/10
  • 06/23/10 Although the exact mechanism of EC is not clear, several studies have shown that EC pills delay or inhibit ovulation and may prevent implantation.
  • 06/23/10
  • 06/23/10

Transcript

  • 1. Emergency Contraception “the morning-after pill” Dr.Sujnanendra Mishra MD(O&G)
  • 2. Emergency contraception (EC)
    • Emergency contraception (EC) is any method of contraception which is used after intercourse and before the potential time of implantation
  • 3. Emergency Contraception
    • Also known as:
    • Morning-After Pills
    • Postcoital Contraception
    • Secondary Contraception
    These terms do not convey the correct timing of use nor that these methods should be used only for emergencies. Emergency contraception (EC) is any method of contraception which is used after intercourse and before the potential time of implantation
  • 4. HISTORY of EC -
    • "First immediately after ejaculation let the two come apart and let the woman arise roughly, squeeze and blow her nose seven times and call out in a loud voice. She should jump violently backwards seven to nine times."
            • Abu Bakr Muhammad ibin Zakariya' al-Razi
      • (865 AD-925 AD)
  • 5.
    • Hormonal methods originated in mid-1920s with discovery that estrogenic ovarian extracts have anti-fertility effect
    • High-dose estrogen (DES or EE) post-coitally as a treatment for rape survivors in the 1960s
  • 6.
    • How about a post-coital
    • Coca-Cola douche!
    • (The New England Journal of Medicine published a study on that one as late as the 1980s.)
  • 7. CURRENT EC -
    • Yuzpe’s original article – 1974
    • Dosage was two doses of two Ovral tablets, 12 hours apart
      • within 72 hours of unprotected intercourse
    • Effectiveness believed to be about 95%
    • Problems = nausea, time frame
  • 8. Women Who May Need Emergency Contraception (Primary Users)
    • Women who:
      • Have unplanned, unprotected intercourse
      • Used a condom that may have leaked or broken
      • Missed multiple COC pills
      • Waited > 16 weeks beyond last injection (DMPA)
      • Failed in using withdrawal method of contraception (ejaculation in vagina or external genitalia)
      • Failed to abstain when needed while using NFP
      • Incorrectly used a diaphragm or the diaphragm or cervical cap dislodged, broke or tore, or was removed early
      • Are rape victims
  • 9. Other Situations When Emergency Contraception May Be Used (Secondary Users)
    • Although EC is intended for primary users, there may be other situations or circumstances when other users may need EC.
    • The other users may be women who:
      • Are sexually active adolescents in need of contraception
      • Are currently not using a contraceptive
      • Have intercourse infrequently
      • Are postpartum (before menses returns)
      • Are over age 35 (presumed decreased fertility)
      • Are post abortion (before menses returns)
  • 10. WHAT’S THE DIFFERENCE ? Between “the morning-after pill” and “the abortion pill” “ the morning-after pill” EMERGENCY CONTRACEPTION “ the abortion pill” MIFEPRISTONE WHAT DOES IT DO? Prevents a pregnancy from occurring after unprotected sex. Ends a pregnancy without surgery. WHAT IS IT? A high dose of birth control pills. One of two pills used to end a pregnancy without surgery. WHEN CAN I TAKE IT? Effective within 5 days of unprotected sex, but the sooner the better. Effective to terminate pregnancies up to 8 weeks duration. IS IT SAFE? Yes. effective contraceptive for pregnancy prevention after unprotected sex. Yes. effective for pregnancy termination.
  • 11. Emergency Contraception
    • These methods have enormous potential for use as safe and effective postcoital contraceptives.
    • If integrated with ongoing family planning information and services, may encourage new clients to come to clinic.
    • Emergency contraception should be promoted to reduce unwanted pregnancies .
  • 12. Emergency Contraception: Benefits
    • All are very effective (failure rate less than 2% in women who use it correctly)
    • IUDs also provide long-term contraception
    Source: Consortium for Emergency Contraception 1998.
  • 13. Emergency Contraception: Methods
    • Combined Oral Contraceptives (COCs):
      • Low-dose (30–35 µg EE and 150 µg LNG), or
      • High-dose (50 µg EE and 250 µg LNG)
    • Progestin-Only Pills (POPs):
      • 750 µg LNG (preferred)
      • 30 µg LNG
      • 37.5 µg LNG
      • 75 µg norgestrel
    • IUDs:
      • TCu 380A, Multiload
      • 375, Nova T
    • Antiprogestins
  • 14. Emergency Contraception: COCs
    • Mechanisms of action
      • May alter endometrium (mixed proliferative/secretory pattern)
      • May block ovulation
      • May alter tubal motility
    • Effectiveness
      • 2% failure rate when used correctly 1
    • Safety
      • No long-term problems in nearly all women
      • Nausea (and vomiting) most common short-term side effect (due to estrogen)
    1 Source : Consortium for Emergency Contraception 1999.
  • 15. DOSE for Combine OCP
      • Low-dose (30–35 µg EE and 150 µg LNG), Total = 8 tablets
      • High-dose (50 µg EE and 250 µg LNG)
      • Total = 4 tablets 1
    STEP I Take 4 tablets of a low-dose COC (30–35 µg EE) orally within 72 hours of unprotected intercourse. Take 2 tablets of a high-dose COC (50 µg EE) orally within 72 hours of unprotected intercourse. STEP II Take 4 more tablets in 12 hours. Take 2 more tablets in 12 hours STEPIII If no menses (vaginal bleeding) within 3 weeks, the client should consult the clinic or service provider to check for possible pregnancy.
  • 16. DOSE for POP (Prog. Only Pills) Plan- B
      • 750 µg LNG (preferred)
      • Total = 2 tablets
      • 30 or 37.5 µg of LNG or 75 µg of norgestrel Total = 40 tablets
    STEP I Take 1 tablet (750 µg of LNG) orally within 72 hours of unprotected intercourse. Take 20 tablets (30 or 37.5 µg of LNG or 75 µg of norgestrel) orally within 72 hours of unprotected intercourse. STEP II Take 1 more tablet in 12 hours. Take 20 more tablets in 12 hours. STEP III If no menses (vaginal bleeding) within 3 weeks, the client should consult the clinic or service provider to check for possible pregnancy.
  • 17. Plan B One-Step
  • 18. New emergency contraceptive
    • Ulipristal is a selective progesterone receptor modulator. By preventing progesterone from occupying its receptor, ulipristal is thought to inhibit or delay ovulation and possibly also suppress maturation of the endometrium necessary for implantation of the embryo.
    1. Ellaone Summary of Product Characteristics, 2009. 2. CHMP Assessment Report for Ellaone. EMEA/261787/2009
  • 19. The two emergency contraceptives work differently:
    • Plan B One-Step contains levonorgestrel, a progestin hormone used in lower doses in many birth control pills.
    • Ellaone contains ulipristal, a non-hormonal drug that blocks the effects of key hormones necessary for conception.
    • Plan B should be taken as soon as possible after sex. It may work for up to 72 hours, but is ineffective once the hormonal surge that leads to ovulation occurs.
    • Although emergency contraception should not be delayed, Ellaone's efficacy does not fade for 120 hours (five days) after sex, regardless of whether the hormonal surge has occurred.
  • 20. The two emergency contraceptives Difference Plan B One-Step Ellaone Active ingredients Levonorgestrel ,a progestin hormone used in lower doses in many birth control pills. ulipristal, a non-hormonal drug that blocks the effects of key hormones necessary for conception. TIMING As soon as possible after sex. It may work for up to 72 hours, but is ineffective once the hormonal surge that leads to ovulation occurs. As soon as possible after sex., Ella's efficacy does not fade for 120 hours (five days) after sex, regardless of whether the hormonal surge has occurred. Drawbacks It ineffective once the hormonal surge that leads to ovulation occurs. Ella may be less effective in obese women.
  • 21. IUDs: Instructions for Use as Emergency Contraception
    • Step 1: Insert IUD within 5 days of unprotected intercourse.
    • Step 2: If no menses (vaginal bleeding) within 3 weeks, the client should consult the clinic or service provider to check for possible pregnancy.
    • Step 3: If pregnancy not prevented, counsel client regarding options.
  • 22. ANTIPROGESTINS
    • Different action from its use in medical abortion, same dose
    • A single 600mg dose of Mifepristone (RU-486) within 72 hrs after unprotected intercourse is highly effective
    • Fewer side-effects than Yuzpe
    • 10mg dose may be equally effective
  • 23. Emergency Contraception: Limitations
    • COCs are effective only if used within 72 hours of unprotected intercourse.
    • COCs cause nausea and vomiting.
    • POPs must be used within 72 hours of unprotected intercourse but cause much less nausea than COCs.
    • IUDs are effective only if inserted within 5 days of unprotected intercourse.
    • IUD insertion requires minor procedure performed by a trained provider.
    • IUDs are not best choice for women at risk for STDs (e.g., HBV, HIV/AIDS).
  • 24. FINAL WORDS….