42 | Nursing in Practice | Winter 2023
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1
What would be the most effective method of emergency contraception ( EC ) for Isabelle ?
A Levonorgestrel pill ( LNG )
B Ulipristal acetate pill ( UPA )
C Copper intrauterine device ( Cu-IUD , or ‘ coil ’ or ‘ IUD ’)
D These three methods have approximately the same effectiveness as each other
2
You outline all available options and Isabelle is particularly unimpressed with the idea of a coil – she thinks it ‘ sounds horrible ’ and wants to take a tablet . She ’ s worried she has left it too late . Which of the following is true about the use of oral EC in terms of time frame ?
A LNG is licensed for up to 48 hours after unprotected sexual intercourse ( UPSI )
B UPA is licensed for up to 120 hours after UPSI
C LNG will only work if taken before ovulation , but UPA is effective at any point in the cycle
D LNG EC consists of two tablets taken 24 hours apart
QUICK QUIZ Emergency contraception
SCENARIO Isabelle is 18 , has a regular 28-day cycle and her last period was seven days ago . She had unprotected sex two nights ago and asks about ‘ the morning after pill ’. She ’ d also like a repeat for her inhaler – her asthma is well controlled and it ’ s been years since she ’ s needed oral steroids . She weighs 80kg with a BP of 110 / 76 and a BMI of 28
1 2 3 4 5
3
From the information given , what is the best oral EC for Isabelle ?
A UPA at the usual dose B LNG at the usual dose
C There isn ’ t enough information given to make that decision
4
You are about to issue a prescription for UPA , when you remember hearing something about asthma being a contraindication . Is this an issue for Isabelle ?
A Yes B No
5
Isabelle would like to go on some regular contraception , ideally the implant . You notice that your colleague , who fits implants , has a free appointment today . Can Isabelle get the implant put in today for future contraception ?
A Yes , that ’ s fine B No , because you can ’ t rule out pregnancy C No , because the implant might stop the UPA from working D No , because the implant shouldn ’ t be used for teenagers
By Dr Toni Hazell , a GP in north London
Answers . 1 C . The copper intrauterine device ( Cu-IUD ) – known as ‘ the coil ’ or ‘ IUD ’ – is the most effective method of EC and should be considered for every woman . The overall pregnancy rate is less than 0.1 %, compared with 1 % -2 % for UPA and 0.6 % -2.6 % with LNG . 2 B . LNG and UPA are both single doses ; LNG is licensed up to 72 hours after UPSI whereas UPA has a licence up to 120 hours . Oral EC given after ovulation is likely to be ineffective but for a woman with regular cycles , a Cu-IUD can be fitted up to five days after ovulation ( no matter when the UPSI was , or how many times it occurred ), at a point when oral EC will be unlikely to help . The term ‘ morning after pill ’ is unhelpful , as it may discourage women from coming if they have left it later than ‘ the morning after ’. 3 A . The Faculty of Sexual and Reproductive Healthcare guideline on EC has a useful flowchart to guide the decision about which to give . 1 In most cases UPA would be given first line , as it is more effective even when the UPSI was less than 72 hours ago . For a first episode of UPSI two days earlier , at this point in her cycle , the guideline recommends either UPA or LNG . However , for women who weigh more than 70kg , or have a BMI above 26 kg / m 2 , the effectiveness of LNG is reduced and so Isabelle should have either UPA , or a double dose of LNG . 4 B . UPA should not be used by women who take regular oral steroids for their asthma . This is a tiny subset of the whole population with asthma , and so in most cases asthma is not a contraindication . 5 C . Every EC consultation should include a discussion about future contraception and the implant is a good choice , as it has the lowest failure rate of all contraceptive methods . However , if any hormonal method is given in the first five days after taking UPA , it risks reducing the effectiveness of the UPA and increasing the risk of pregnancy . Isabelle should therefore wait five days before having her implant fitted under the quick-start rules , which would also require her to do a pregnancy test three weeks after her UPSI to rule out UPA failure .
References 1 Faculty of Sexual and Reproductive Healthcare . Clinical Guidelines : Emergency Contraception . March 2023 . tinyurl . com / FSRH-EC
GETTY : ALBERTO POMARES