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. | 
