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The Importance of Emergency Contraception:-

The Importance of Emergency Contraception:-. By - Dr. Ashwini Bhalerao Gandhi , - Consultant Gynecologist P.D. Hinduja National Hospital & Medical Research Centre ,Mahim, Mumbai. - Chairperson of Adolescent Health Committee of The Federation of Obst. &

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The Importance of Emergency Contraception:-

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  1. The Importance of Emergency Contraception:- By - Dr. Ashwini Bhalerao Gandhi , - Consultant Gynecologist P.D. Hinduja National Hospital & Medical Research Centre ,Mahim, Mumbai. - Chairperson of Adolescent Health Committee of The Federation of Obst. & Gynec Societies of India (2004-2008). - Ex Associate Professor, T.N. Medical College & BYL Nair Hospital

  2. Historical aspects of Post coital contraception 1. A foetus-preventing tampon of Ajowan seeds and rock salt ground in oil. (Sacred Vedas of the Hindus) 2. Grease, m’atet herb, sweet ale - cook them. To be swallowed for four mornings. (The Berlin Medical Papyrus; Circa 1, 300 B.C.) 3. Colocynth pulp, bryony, iron scoria, sulphur, scammony & cabbage seed; Grind these up thoroughly and mix with tar - Insert one after intercourse. (Al-Razi, 924 A.D.)

  3. In India - • 78% of conceptions occurring annually are unplanned; • 25% are unwanted; • 6.7 million abortions induced every year • A ratio of 10-11 illegal abortions for each legal abortion. (National Family Health Survey, 1995) • Contraceptive prevalence rate only 41%.

  4. Reasons - 1. Lack of awareness regarding F.P. methods 2. Lack of willingness to use the methods 3. Lacunae in service delivery system 4. Overall weakness in the social, economical and health status of women.

  5. Indications for Emergency Contraception Defn - Used after unprotected intercourse to prevent pregnancy. When ? 1. Not using any contraceptive 2. Sexual assault, rape, coercion 3. Recent use of suspected teratogens - cytotoxic drugs, live vaccines. 4. Sex against will, failure to plan ahead 5. Contraceptive accidents

  6. Contraceptive accidents • Failed coitus interruptus • Ejaculation on external genitalia • Miscalculation of rhythm method • Condom rupture, dislodgment or misuse • Diaphragm / Cap inserted incorrectly, dislodged, found to be torn or removed too early. • Complete or partial expulsion of IUD. • Mid-cycle IUD removal due to side effects • Missed combined pills • Missed progestin - only pill.

  7. Types of EC 1. Estrogens - 50mg of DES was first tried on a rape victim (1960). • DES - 25 to 50mg/day for 4-5 days • EE - 2 - 5mg/day for 3-5 days • CE - 30 - 50mg/day for 2-5 days Side effects - Nausea, vomiting, headache, dizziness, breast tenderness, irregular bleeding.

  8. Types of EC - contd 2. Yuzpe method - Canadian Physician tried single dose of 100ugm of estrogen and 1 mg of dl-norgestrel (1970). • 2 tabs of EE 50 ugm + LNG 250 ugm stat, to be repeated after 12 hours. • 4 tabs of EE 30 ugm + NG 300 ugmstat,to be repeated after 12 hrs. (PC 4, Tetragynon, Fertilan)

  9. Types of EC - contd 3. Only Progestins - Levonorgestrel (0.75 mg) or Norgestrel (1.5 gm) stat and repeat after 12 hrs. LNG - Ecee 2 (German Remedies) Pill 72 (Cipla Ltd) Norlevo (Win-Medicare) This method is most commonly used all over the world today. Mechanisms of Action - 1. Inhibit / Delay ovulation 2. Effect on tubal transport 3. Hamper development of fertilized ovum 4. Prevent implantation in endometrium by making it out of phase by hormonal imbalance 5. Does not interrupt an established pregnancy

  10. Types of EC - contd 4. Anti ProgestogenMifepristone - 600mg single dose of RU - 486 - MA - Competes with progesterone for receptor binding, alters ovarian follicular maturation, effect on ovulation / fertilisation / tubal transport / implantation. 5. Danazol - 2 or 3 doses of 400 mg each at 12 hr interval. MA - Anti-implantation agent. 6. Centchroman - Anti-implantation agent 7. Copper IUD - Inserted within 5 days MA - prevent fertilization, implantation, blastotoxic / embryotoxic. In case of method failure - MTP recommended.

  11. Management of a Request for EC 1. History - LMP, Duration of cycle, timings of all unprotected acts in relation to the current cycle; medical history; FP. 2. Examination - BP, PS-PV not mandatory (Risk of pregnancy 20 to 30% in midcycle, under 1.0% at other times.) 3. Contraindications for E+P - Current focal migraine, current hepato-cellular jaundice, past H/o thrombotic disease. C.I. For IUD - Nulliparity, PID 4. Antiemetic 1 hr before the dose 5. Barrier method / abstinence till next period.

  12. Counselling • Supportive non-judgemental way • Assess necessity • Explain proper use • Discuss side-effects, effectiveness • Need for ongoing contraception • First contact point for Reproductive Health Follow - up • Within 3-4 weeks of Rx • Delay in menses of more than 1 week • Lower abdominal pain • Heavy bleeding • Next period scanty

  13. When to start Regular Contraception ? Barrier methods - Immediately IUD- Immediately OCS - First day of next period Injectables - within 7 days of next period Sterilisation - After next period Effectiveness EC not used - 8% lead to pregnancy Progetin only - 1% lead to pregnancy E+P used - 2% lead to pregnancy Most effective when taken early

  14. Frequently Asked Questions • ECPS are not abortion pills, not an abortifacient agent. • Dose should be repeated if vomiting occurs within 1 hour. • Can be used at any time during menstrual cycle. • Not a regular method of FP • Do not prevent STDS.

  15. Frequently Asked Questions - Contd • Double ECP doses when on anticonvulsants & antibiotics • Will not cause menses to start immediately - may start 2 to 3 days early or late. • Will not provide protection for the rest of the cycle. • Will not harm a pregnancy

  16. Legal, Ethical & Regulatory Aspects of EC • Grossly underutilized method especially in developing countries. • No legal risk in prescribing • Infact legal risks incurred if the client not told about EC. • Will it promote irresponsible, promiscuous life-style specially in adolescents ? • Can be provided even in countries where abortion is illegal.

  17. Legal, Ethical & Regulatory Aspects of EC - contd • Should be available over-the-counter (No counselling, no follow-up)? • Desirable to hold a dialogue between medical community, drug regulatory bodies, youth & women activist groups.

  18. The World’s Best Contraceptive Secret !!

  19. Thanks to all contributors. Dr Adarsh Bhargava. Dr Ashwini Bhalerao. Dr Alka Kriplani. Dr. Kalpana Apte. Dr Mala Arora. Dr.Meenakshi Bharath. Dr. Mandakini Parihar. Dr.Nozer Sheriar. Dr.Parikshit Tank. Dr. Roza Olyai. Dr.Sasikala Kola. Dr.Sujata Mishra.

  20. THANK YOU

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