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7.0 Practical Problems

7.1 Special situations

+ Pregnancy

ECP is ineffective in women with confirmed pregnancy. There will be no harm to a pregnant woman or her foetus if ECP is inadvertently used during early pregnancy.

+ Lactation

In women using Lactation Amenorrhoea Method (LAM) and doing exclusive breast-feeding, risk of pregnancy is low. If there is fear of conception LNG as ECP does not affect milk production and can be safely used.

+ Drug Interactions

It is not known whether interactions are associated with one-time, short-term ECP use. Efficacy of regular COC is less when used concurrently with antibiotics, anti-convulsants, rifampicin and griseofulvin.

+ Medical diseases

ECP can be safely used by women suffering from diabetes mellitus, hypertension, varicose veins, severe headaches, fever or other medical illnesses.

7.2 Frequently asked questions

What are the advantages of levonorgestrel only regimen over the previously available Yuzpe regimen ?

+ Levonorgestrel only regimen is better tolerated in the form of fewer side effects like nausea (23% vs 50.5%), vomiting (5.6% vs 18.8%)6

• Levonorgestrel regimen can be used upto 120 hrs after the unprotected intercourse as compared to 72 hours with yuzpe regimen

• levonorgestrel regimen is more effective than yuzpe regimen. The crude pregnancy rate has been quoted as 1.1% (11/976) in levonorgestrel group compared with 3.2% (31/979) in yuzpe regimen group.6

• Levonorgestrel only regimen has an advantage of a single dose administration as compared to two doses of Yuzpe regimen.11

Can ECP be prescribed if the client gives history of more than one unprotected sexual act?

+ ECP can be given if these acts of intercourse have occurred not more than 120 hours ago. ECP should not be withheld if the client has had more than one unprotected act of intercourse with at least one not more than 120 hours. However, the client should be explained that the act of intercourse occurring more than 120 hours before taking ECP might have resulted in pregnancy already.

Can ECP be used repeatedly ?

+ ECPs are not intended for repeated use. However, given the low likelihood of harm from limited repeated use, these can be prescribed to a woman who has used them before or within the same menstrual cycle. At the same time, client should be explained about the less efficacy of ECP as compared to most modern methods over long term use. Pregnancy rates with ECP are based on single use and cannot be directly compared to failure rates of ongoing contraception for prolonged period of use (1 year) and are likely to be higher than the regular hormonal contraception, male condoms, and other barrier methods17 . Side-ffects are going to limit repeated use.

What can be done if a women requests for ECP more than 120 hours after unprotected intercourse ?

+ The client should be counseled that the maximum efficacy or ECPs have been reported up to 120 hours for Levonorgestrel and Mifepristone regimens. However, Copper intrauterine device can be prescribed up to 7 days if there is no contraindication for its use.4

Most women come requesting for a pill when they are 1 or 2 days overdue. Can they be given ECP?

+ If one is already pregnant, or time lapse is more than 120 hours since sexual exposure ECP will not work. It is only if there has been recent unprotected intercourse and no previous exposure, ECP can be given.

Is emergency contraceptive pill contraindicated during breast-feeding?

+ ECP is safe during breast-feeding. Single treatment with ECP is unlikely to have any significant effect on milk quantity or quality or to produce steroid level in the plasma of infant, significant enough to affect the infant adversely. Progestin-only regimen when used for long term contraception results in steroid level in the infant plasma of 1 to 6% of maternal plasma level. But it is shown that these pills have neither affected the health, growth or development of infant nor the quality and quantity of milk.18

Should ECP be used during safe period ?

+ Fertilization results from intercourse only during a five to seven-day interval around the time of ovulation8. Theoretically, ECPs are not needed if unprotected intercourse occurs at other times of the cycle because chances of pregnancy even without ECPs are nearly zero.

However, in practice, ECPs generally should be provided any time unprotected sex occurs and if the client is concerned that she is at risk for pregnancy, as it is often difficult to determine for certain whether a specific act of intercourse occurred on a fertile or infertile day. In situations when the unprotected act is extremely unlikely to result in pregnancy, the client’s anxiety level will determine the use of ECP.

Note :Women using oral contraceptives who have missed pills on two or more successive days must be prescribed ECPs even if thought to be in safe period because these women do not have a true menstrual cycle.

Can Emergency Contraceptive pill cause birth defects?

+ No studies have specifically ruled out the possibility of teratogenic effects. Available scientific data suggest that there should not be increased risk of birth defects if a woman inadvertently takes ECP while pregnant or pregnancy results from ECP failure. The possible reason for not causing teratogenic effect include is that ECPs are taken long before organogenesis starts.

Babies born to mothers who have inadvertently taken oral contraceptive pill containing levonorgestrel during early pregnancy have not been found to have any adverse effects.18

ECP has failed, but the woman is not willing for abortion, how should she be counseled?

+ She needs to be explained the pros and cons in detail. There is no evidence that ECP causes birth defects. There are no potential risks to the embryo following exposure to Levonorgestrel. Thus, she can safely continue pregnancy with routine regular antenatal care.

Do ECPs have any drug interactions?

+ No specific data are available about the interaction of ECPs with other drugs that the client may be taking. However, it seems reasonable that the drug interactions would be similar to those with regular oral contraceptive pills and progestogen-only pills. Women taking drugs that may reduce the efficacy of oral contraceptives and progestogen-only pills (e.g. rifampicin, certain anticonvulsants) should be advised that the efficacy of ECPs may be reduced. Consideration should be given to increasing the amount of hormone administration in ECPs, either by giving a double dose of hormone in one or both pills or by giving an extra pill.

Should antiemetics be prescribed routinely along with ECP to take care of nausea and vomiting ?

+ Routine prescription of antiemetics is not recommended when using levonorgestrel only regimen as EC because of extremely low incidence of nausea and vomiting. However, antiemetics may be prescribed alongwith Yuzpe regimen or if the client gives a history of intolerance to OCPs.

What should a woman be advised if she vomits soon after administration of ECP?

+ If the woman vomits within 2 hours of ECP administration or the pill is visible in the vomitus, a repeat dose should be prescribed along with antiemetics. Vomiting after 2 hours of ECP administration does not necessitate repeat dosing as the drug has already been absorbed in the system. Antiemetics can be given but these are unlikely to be effective if taken after the onset of symptoms.

Can ECPs be used before intercourse?

+ No data are available about how long the contraceptive effect of ECPs persists after the pills have been taken. Presumably ECPs taken immediately before intercourse are as effective as ECPs taken immediately afterwards. However, if a woman has an opportunity to plan to use a contraceptive method before intercourse, a method other than ECPs, such as condoms or another barrier method is recommended.

Is emergency contraceptive an abortifacient ?

+ In medical terms pregnancy begins once the fertilized ovum gets implanted in the uterus. ECPs act either prior to implantation or prevent implantation. Therefore, these are not abortifacients.

Will ready-access and easy-availability of emergency contraception adversely affect the use of regular contraceptives ?

+ Client should be counseled properly at the time of prescription of the ECPs regarding the lower efficacy and higher cost of the ECPs as compared to the currently available contraceptive methods for regular use. These are two major dis-incentives against routine use of ECPs. In addition to these, ECPs can cause some unpleasant side-effects like nausea and vomiting and sometimes headache and breast tenderness or fluid retention. These side-effects although not serious from medical point of view, may discourage the use of ECPs as a regular method.

Will availability of emergency contraception reduce the number of abortions?

+ Emergency contraception can reduce the need for abortion by preventing unintended pregnancies. In Netherlands, which has the lowest abortion rate of any industrialized country, contraceptive use is high among young people and emergency contraception has been widely available as ‘back-up’ for decades. In Finland, early evidence suggests that abortion rates among teenagers have dropped following the spread of information about emergency contraception.

Unsafe abortions are a leading cause of death among women of reproductive age group. Abortions are also a major drain on medical resources. In these settings, the availability of emergency contraception could prevent much needless suffering and death. It could also reduce the growing pressure on hospital beds, nursing staff, blood supplies, and medications needed to treat the life threatening medical complications of abortions performed by untrained practitioners under unhygienic conditions.

Will access to emergency contraception encourage promiscuity and sexual irresponsibility among young people ?

+ There is no evidence to suggest that knowledge of emergency contraception increases sexual activity among young people, instead the need for emergency contraception often brings sexually active young people : into family planning clinics where they can receive other services and counseling including help in learning how to say 'no' when they choose to be abstinent. For adolescents who are already sexually active, emergency contraception provides a bridge to effective birth control and disease prevention.

What is the legal status of emergency contraception?

+ Conventionally the term "contraception "is used for methods to prevent pregnancy and "abortion" for methods used for termination of pregnancy.

The term "interception" or "contragestion" refers to chemical intervention aimed to act between fertilization and implantation or counter gestation by obstructing a zygote’s viability or its successful embedding in the uterine lining and continuing gestation.19

Abortion laws around the world recognise a clear distinction between abortion and contraptions. Legally term abortion implicitly excludes procedures carried-out prior to implantation of fertilized egg in the uterine wall.

Governments and activist groups who are opposed to EC because of legal prohibition of abortion, should know that biochemical evidence of pregnancy is possible only 6-9 days after fertilization. Thus, a physician prescribing EC within 120 hours of intercourse cannot intent pregnancy termination. Since all methods of emergency contraception act either prior to implantation or prevent implantation, EC cannot be considered synonymous with termination of pregnancy or abortion.

A recent case in California ruled that a hospital could be held liable for failing to provide a rape victim with information and access to emergency contraception.

What is the legal status of EC in our country ?

+ In many countries like New Zealand, Germany, Netherlands, abortion laws clearly define "abortion" as procedure carried out to remove products of conception after implantation of fertilized egg in the uterine wall. Whereas in our country as well as many others like China, Israel, France, phrases like "termination of pregnancy" implicitly mean the same i.e. procedures used after implantation.

Besides Medical Termination of Pregnancy Act of India (1971) creats no legal bar what so ever to the use of emergency contraception.

Can ECP be offered to a woman who comes several times, within a short period of time?

+ Yes, though ECP is not meant for repeated use, there is no harm in limited repeat use. Women should not be denied benefit of ECP just because they have used it before, even within the same menstrual cycle. However, counseling for avoiding future contraceptive accidents or using regular contraception should be provided. A women using it four times a month will be consuming same dose of hormone which is present in a montly pill pack, while will have more side-effects, thus will be better of using regular pills.

Can ECP be preseribed to a woman in advance of need?

+ Providing information, instructions and prescription for ECP in advance of need is a convenient option. EC is more effective, the earlier it is taken, following unprotected intercourse. Thus advance prescription will provide an opportunity to take the drug as soon as possible. This is specially useful for women using barrier or fertility awareness based methods. Advance prescription does not comprosmise the correct use of regular contraception.

Can a woman take ECP herself?

+ Though ECP is very safe for self-prescription or over the counter availablity. Currently GOI recommends its use only on a prescription. At present, awareness in India is very limited and chances of misuse are more if proper counseling is not done. It is advisable to take it under doctor’s guidance, and this opportunity can also be utilized to gain information about regular contraception and STI prevention.

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