EMERGENCY CONTRACEPTION

Emergency contraception is a backup plan. It should not be used continuously as a method of contraception because of its relatively high failure rates and incidence of irregular bleeding. It is a one-time therapy or procedure and not a routine approach to contraception. It is used after sex and its objective is to prevent pregnancy. Contraception can be defined as all measures, temporary or permanent designed to prevent pregnancy due to sexual act. Emergency contraception is defined as any medication or device used after sex to prevent pregnancy. According to the World Health Organization, all women and girls at risk of an unintended pregnancy should have access to emergency contraception and these methods should be routinely included within all national family planning program.

Between 2015 to 2019 the annual unintended pregnancies globally were 121million which corresponds to 64 unintended pregnancies per 1000 women aged 15 to 49 years. 61% of unintended pregnancy ends in abortion, 73.3million abortions take place each year corresponding to 34 to 44 per 1000 women age 15-49years in the world [1]. 25million unsafe abortion occurred worldwide each year between 2010-2014 according to the World Health Organization (WHO). Abortion rates are higher in areas with unmet need for contraception. The WHO estimated that 47,000 women die from unsafe abortion each year.

HISTORY OF EMERGENCY CONTRACEPTION

Traditional methods for post coital contraception have been used for decades, as far back as 1500 BC, “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 Ibn Al-Razi 865Ad- 925AD). Charles Knowlton (1832) an American physician gave prominence to vaginal douching. In 1967 the first widely used methods were five-days treatment 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). In 1975, Progestin only postcoital pill was investigated. In 1975 Copper intrauterine contraceptive device was first studied for use as emergency contraceptive. In 1998 after a large WHO trial Yuzpe regimen was gradually withdrawn and levonorgestel widely used. In 2002 China was the first country were mifepristone was registered for use as an emergency contraceptive.

WHEN IS EMERGENCY CONTRACEPTION REQUIRED

• When no contraceptive has been used.
• Sexual assault when the woman was not protected by an effective contraceptive method.
• When there is concern of possible contraceptive failure, from improper or incorrect use such as:
  • condom breakage, slippage, or incorrect use.
  • 3 or more consecutively missed combined oral contraceptive pills (28days pills).
  • more than 3 hours late from the usual time of intake of the progestogen-only pill (minipill), or more than 27 hours after the previous pill (21days pills).
  • more than 12 hours late from the usual time of intake of the desogestrel-containing pill (0.75 mg) or more than 36 hours after the previous pill.
  • more than 2 weeks late for the norethisterone enanthate progestogen-only injection (2 monthly injection).
  • more than 4 weeks late for the depot-medroxyprogesterone acetate progestogen-only injection (3 monthly injection).
  • more than 7 days late for the combined injectable contraceptive.
  • dislodgment, breakage, tearing, or early removal of a diaphragm or cervical cap.
  • failed withdrawal (e.g. ejaculation in the vagina or on external genitalia).
  • failure of a spermicide tablet or film to melt before intercourse.
  • miscalculation of the abstinence period, or failure to abstain or use a barrier method on the fertile days of the cycle when using fertility awareness based methods.
  • expulsion of an intrauterine contraceptive device (IUD) or hormonal contraceptive implant.

According to WHO, an advance supply of emergency contraceptive pills may be given to a woman to ensure that she will have them available when needed and can take as soon as possible after unprotected intercourse. The Methods of emergency contraception is either hormonal or mechanical.

HORMONAL EMERGENCY CONTRACEPTION

There are no absolute restrictions for the medical eligibility of who can use hormonal emergency contraceptive pills;

• COMBINED ORAL CONTRACEPTIVE (COC); 2 doses of 0.1mg (100 μg) ethinyl estradiol (EE) and 0.5mg (500 μg) levonorgestrel to be taken orally 12 hours apart after coitus. Its failure rate is 0 to 2%.
• LEVONORGESTREL(LNG); 2 doses of 0.75mg LNG pill to be taken orally 12 hours apart within 72hours of intercourse or a single dose of 1.5mg LNG pill to be taken within 72 hours of coitus. Its failure rate is 0 to 1%.
• ULIPRISTAL ACETATE; Single dose 30mg should be taken within 120hours of coitus. Its failure rate is 0 to 1%.

MECHANICAL EMERGENCY CONTRACEPTION

Intrauterine device (IUD) such as Copper T is used; initially Cu T 7 and Cu T 200 were used but later Multi-load Cu 250 and lately Cu 375 and Cu 380A are in use. Its failure rate is 0 to 0.1%. It can be used even after 5days following sexual intercourse. Eligibility criteria for general use of a copper IUD also apply for use of a copper IUD for emergency purposes. It should not be used in women with conditions classified as Medical Eligibility Criteria (MEC) category 3 or 4 such as;

• current pelvic inflammatory disease (PID)

• puerperal sepsis

• unexplained vaginal bleeding

• cervical cancer

• severe thrombocytopenia

• Dysfunctional uterine bleeding

• Suspected pregnancy

• Uterine anomaly

MODE OF ACTION OF EMERGENCY CONTRACEPTIVES

Emergency contraceptive medications act via various mechanism such as;

1-disrupting the formation or interference with the function of the corpus luteum.

2-alteration in the sperm entrapment or impaired function of cervical mucus.

3- interferes with fertilization by disrupting normal follicular development and maturation, delay surge of the luteinizing hormone and impaired luteal function.

4- interferes with the migration and function of the sperm in the female genital tract.

SHIFTING TO REGULAR CONTRACEPTION

• Copper IUD: No additional contraceptive protection needed
• LNG/COC: you can resume or start regular contraception immediately including copper bearing IUD
• Ulipristal: you can resume or start regular contraception on the 6^th day, for LNG-IUD or Copper IUD can be inserted immediately

POSSIBLE SIDE EFFECTS OR COMPLICATIONS OF EMERGENCY CONTRACEPTION

HORMONAL; Nausea, vomiting, irregular uterine bleeding, headache, dizziness, fatigue, breast tenderness.

MECHANICAL; Bleeding, Pain, Pelvic infection, perforation.

Emergency contraception should be integrated into health care services for populations most at risk of exposure to unprotected sex, including post-sexual assault care and services for women and girls living in emergency and humanitarian settings.

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