This document discusses emergency contraception (EC), including its history, methods, mechanisms of action, indications, and recommendations. EC aims to prevent pregnancy after unprotected intercourse by disrupting ovulation or fertilization. The two main methods are hormonal EC using combined or progestin-only pills, and mechanical EC using a copper IUD. Hormonal EC is most effective when used as soon as possible within 5 days of intercourse. The document recommends making EC widely available without a prescription to help prevent unwanted pregnancies and unsafe abortions.

1. PPrreesseenntteerr:: DDrr.. SSuuhhaassiinnii KKaannyyaaddii
October 20, 2014

2. Introduction
History
Indication
Methods of EC
Mode of action
Side effects
Evaluation
Recommendations
References
October 20, 2014

3. Emergency contraception (EC) is a
method of contraception used as an
emergency procedure before menstruation is
missed, to prevent pregnancy following
unprotected intercourse or expected failure
of contraception.
October 20, 2014

4. EC is any method of contraception which is
used after intercourse and before the
potential time of implantation.
This nomenclature, advocated by WHO
lately.
Accepted by international Medical Advisory
Panel and others recently.
October 20, 2014

5. Alternative terms:
Postcoital contraception- still commonly
used
‘morning after’ contraception
 Less appropriate – suggest immediate
application.
October 20, 2014

6. EC is not true contraception but rightly called
interception.
 Interceptives – agents that do not interfere
with fertilization but act on blastocyst before
or soon after missing periods.
October 20, 2014

7. October 20, 2014

8. EC is a back up plan.
It cannot be used as a ongoing method of
contraception because:
i) relatively high failure rates
ii) High incidence of irregular
bleeding
October 20, 2014

9. Characteristics of EC:-
1. It is a one time procedure & not an routine
approach to contraception
2.Used postcoitally
3. Its objective is prevention of pregnancy
October 20, 2014

10. About 42 million abortions carried out
worldwide each year.
Unsafe abortions – 20 million
Worldwide nearly 1 in 10 pregnancy ends in
unsafe abortion.
October 20, 2014

11. India has the highest number of unsafe
abortions in the world.
6,20,472 abortions reported in India in 2012
Two-third of them were unsafe
A women dies every two hours due to unsafe
abortion.
October 20, 2014

12. Widespread availability of EC can help
reduce these abortions.
October 20, 2014

13. “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."
 AAbbuu BBaakkrr MMuuhhaammmmaadd aall--RRaazzii
((886655 AADD--992255AADD))
October 20, 2014

14. “Traditional” methods for post coital
contraception have been used for decades.
Found as far back as 1500 BC
 High doses of vitamin C, aspirin or chloroquine
 Vaginal douches of coca cola, baking soda, urine
October 20, 2014

15. Vaginal douching, inspite of its
ineffectiveness, continued to exist until
modern times.
Charles Knowlton (American physician) gave
prominence to it.
October 20, 2014

16. Mid-1920’s effect of oestrogenic ovarian
extracts on infertility in lower mammals was
demonstrated.
Findings led to veterinary use of oestrogens
to prevent pregnancy.
October 20, 2014

17. 1967-The first widely used methods were
five-day treatments with high-dose
estrogens, using diethylstilbestrol (DES) in
the USA and ethinyl estradiol in the
Netherlands.
Early 1970s -the Yuzpe regimen was
developed (Combined preparation containing
both ethinyl estradiol & levonorgestrel
(1974). October 20, 2014

18. 1975 – Progestin only postcoital pill was
investigated.
1975 – Copper IUD was first studied for use as
EC.
1980’s – Danazol was tested, but was found
to be ineffective.
October 20, 2014

19. 1980’s – Yuzpe regimen became the standard
treatment for EC in many countries.
1998 - After a large WHO trial Yuzpe regimen
was gradually withdrawn and levonorgestel
widely used
2002- China was the first country were
mifepristone was registered for use as EC.
October 20, 2014

20. 1. For aged couples who meet very infrequently
2. Following single act of sexual exposure in
young girls
3. When pregnancy is apprehended owing to
rupture of condom, premature ejaculation in
couples practising coitus interruptus etc
October 20, 2014

21. When unprotected isolated intercourse
happens at some odd moments among
couples otherwise using conventional
coontraceptives
In case of rape and incest
October 20, 2014

22. Saves the couple from unwanted pregnancies
From unnecessary operative interferences for
fear of pregnancy
From the agony of waiting for the next
menstrual cycle.
October 20, 2014

23. Prevents adolescent pregnancies
Helps to reduce unsafe abortion
October 20, 2014

24. Two methods of EC are available:
1) Hormonal
2)Mechanical
October 20, 2014

25. Hormonal
i)Combined oestrogen and progestin pills-
Yuzpe regimen
ii) Progestin only pills- Levonorgerstrel (LNG)
October 20, 2014

26. Corpus luteum…
disrupted formation …
interfe-rence with its function
Cervical mucus… alteration in it
sperm entrapped or
impaired function
Fertilization…
direct inhibition
Before ovulation… disrupt normal
follicular development & maturation
interference in
ovulation , with deficient/ impaired
luteal function & delay in LH surge
Sperm… interferes with its
migration & function in the
genital tract
October 20, 2014

27. 1. Combined ethinyl eessttrraaddiiooll aanndd lleevvoonnoorrggeessttrreell
(( YYuuzzppee mmeetthhoodd))
Preven No longer available in USA since
May 2004
October 20, 2014

28. Yuzpe method (Canadian Prof. Albert Yuzpe)
consists of the oral administration of 2 doses
of 0.1mg(100 μg) ethinyl estradiol (EE) and
0.5mg(500 μg) levonorgestrel 12 hours apart.
Failure rate- 0-2%
October 20, 2014

29. Ovral tablets (each containing 50 μg ethinyl
estradiol and 250 μg levonorgestrel) are most
commonly used to provide these doses.
2pills
12hours
2 pills
October 20, 2014

30. Mala –D, Mala-N ,Ovral –L – low dose pills(4
pills)
Others- Noral, Ovidon
October 20, 2014

31. 2. Progestin-only (Levonorgestrel)
Plan B, Levonelle , Postinor , Contraplan II
In India- EC pill, Pill 72, ECEE2
October 20, 2014

32. LNG-only pills
2 doses of 0.75mg LNG pill to be taken orally
12 hours apart within 72hours of intercourse.
or
Single dose of 1.5mg LNG pill to be taken
within 72 hours of intercourse.
October 20, 2014

33. Trials have shown that a high proportion of
pregnancies were averted even upto
5days(120hours).
WHO recommends levonorgestrel for
emergency contraceptive pill use.
Failure rate- 0-1%
October 20, 2014

34. Ideally, this progestogen-only method should
be taken as a single dose (1.5 mg) within five
days (120 hours) of unprotected intercourse.
The regimen is more effective the sooner
after intercourse it is taken.
October 20, 2014

35. October 20, 2014

36. Side effects:-
1. Nausea- in 50% using Yuzpe regimen & 20%
for Levonorgestrel
2. Vomiting – in 20% Yuzpe regimen & 5% using
LNG-only pills
If vomiting occurs within 2hours of taking the
pills - the dose should be repeated.
In cases of severe vomiting – administer pills
vaginally
October 20, 2014

37. Irregular uterine bleeding
Others- headache, dizziness, fatigue and
breast tenderness.
October 20, 2014

38.  ECP cannot dislodge an established
pregnancy
They do not cause abortion
ECPs do not affect fetal development.
No evidence that their repeated use causes
ectopic pregnancy.
October 20, 2014

39. Medical eligibility criteria for EC
 Contraindication or delay – no such
condition ( rule out pregnancy)
 WHO Category 2: caution/extra precautions
1. History of severe CVS complications- IHD,
thromboembolism
2. Migraine
3. Severe liver disease
4. Angina pectoris
October 20, 2014

40. WHO Category 2: accept – no reason to
prevent use
1. Breast feeding
2. H/o ectopic pregnancy
3. Repeated ECP use(requires further
counselling)
October 20, 2014

41. Follow- up
Report if amenorrhoea persists ( >1week )
If there is acute pain or bleeding lighter than
usual menses – exclude ectopic pregnancy
Advice regarding contraception
October 20, 2014

42.  Mechanical emergency contraception(IUD)
Copper T is used
Initially Cu 7, Cu T 200 were used
Later Multiload Cu 250 & lately Cu 375 Cu
380A– without single failure rates
Failure rate-0- 0.1%
October 20, 2014

43.  IUD’S – upto 5days following sexual
intercourse
 IUD’s are preferred in women who desires
IUD as an ongoing method of contraception.
October 20, 2014

44. Contraindication:-
1) Pelvic infection
2)DUB
3) Suspected pregnancy
4)Nullipara
5)Uterine anomaly
October 20, 2014

45. Side effects-
1)Bleeding
2)Pain
3)Expulsion
4)Pelvic infection
October 20, 2014

46. October 20, 2014

47. Antiprogesterone ( MIFEPRISTONE)
 It act as
Anti-implantation agent - post-coitally
Menses inducers - luteal phase
Abortifacients - early pregnancy
 Single low dose 10mg 72-120hours
October 20, 2014

48. Failure rates- 0.06%
In the USA, it is most commonly used in
600 mg doses as an abortifacient, but in
China it is commonly used as emergency
contraception in 10-mg dose( since 2002).
October 20, 2014

49. Ulipristal acetate ( progesterone receptor
modulator ellaONE)
 Single dose 30mg within 120hours
 Approved by European Medicines Agency
-2009
US FDA- 2010
Not available in India
Available on prescription as EC in over 50
countries
October 20, 2014

50. Mechanism of action:
October 20, 2014

51. October 20, 2014

52. Side effects- abdominal pain, menstrual
irregularity
Studies have shown- embryotoxicity in
animals
October 20, 2014

53. Carraguard gel: composed of LNG.
 Single vaginal administration of 750
micrograms LNG in CARRA gel in the late
follicular phase was found to be effective in
interfering with ovulation.
 Therefore, this is a promising method for use
as an emergency contraceptive method
October 20, 2014

54. Calculation of efficacy
Measuring only pregnancy rate following EC
is not enough
Calcalation of reduction in expected
pregnancies is important- prevented
pregnancies
October 20, 2014

55. Formula :-
1 – observed pregnancy
expected pregnancy
Expressed in two ways:-
1) Overall pregnancy rate
2)Pregnancies prevented
October 20, 2014

56. Hormonal emergency contraception should be
available without a prescription in:
1. Pharmacies,
2. Family planning clinics,
3. Emergency rooms, and
4. School health programs.
October 20, 2014

57. Women who have had unprotected
intercourse and wish to prevent pregnancy
can be offered use of hormonal emergency
contraception up to 5 days after intercourse,
Insertion of a copper IUD up to 5 days after
intercourse, to reduce the risk of pregnancy.
October 20, 2014

58. Users of emergency contraception should be
evaluated for pregnancy if menses have not
begun within 21 days following treatment.
Women and men of reproductive age should
be counselled about emergency
contraception.
October 20, 2014

59.  Jeffcoate’s principle of Gynaecology-7th edition
 Chaudhuri SK. Practice of Fertility Control. 7th edition
2008. Shovan Chaudhuri New Dehli.
 Contraception in clinical practice (module 3)
 Textbook of Obstetrics by D.C. Dutta
 WHO Fact Sheet on Emergency Contraception 2012
 Park’s textbook of Preventive &Social Medicine 22nd
edition
 Advances in methods of EC available at
http://www.aiims.edu/aiims/events/Gynaewebsite/ec_site/October 20, 2014

60. October 20, 2014