David Chelmow
History of present illness
A 19-year-old gravida 1, para 1 woman presents to your urgent care clinic with complaint of a torn condom the prior evening.
She has regular cycles. Her last menstrual period began two weeks ago. She is in a stable relationship with a single partner. They are using condoms as their birth control method, although irregu- larly. She has diabetes and chronic hypertension.
Due to lack of insurance and her other medical problems, she has had difficulty obtaining effective contraception. With her prior episodes of birth control failure, she took over-the- counter emergency contraception pills. She has done this sev- eral times in the last year, but is both worried about pregnancy and frustrated with the cost. She reports she is working while her partner completes college, and she hopes to have another child when he is employed and they have insurance.
Physical examination
General appearance:Well-developed, well-nourished woman appearing frustrated but in no apparent distress Vital signs:
Temperature: 37.0°C Pulse: 95 beats/min
Blood pressure: 142/90 mmHg Respiratory rate: 16 breaths/min Oxygen saturation: 100% on room air Abdomen:Soft, nontender
External genitalia:Unremarkable Vagina:Unremarkable, scant discharge Cervix:Parous, no mucopurulent discharge Uterus:Anteverted, nontender, normal size, mobile Adnexa:Nontender, without masses
Laboratory studies: Urine pregnancy test: Negative
How would you manage this patient?
The patient had inadequately protected intercourse at mid- cycle. She has had recurring episodes of unprotected sex and contraceptive failure. She has not completed childbearing. She needs both emergency contraception to prevent unwanted pregnancy at present, and long-acting reversible contraception (LARC) to prevent pregnancy until she is ready to conceive.
A copper intrauterine device (IUD) would safely and effect- ively meet both these needs.
Emergency contraception
This patient clearly needs emergency contraception. She has had a contraceptive failure at midcycle, which can have as high as a 25% risk of pregnancy. There are multiple options for emergency contraception (Table 4.1) [1]. Despite her medical comorbidities, she could use any of the available forms of emergency contraception. Recommendations for emergency contraception are outlined by the Centers for Disease Control and Prevention (CDC) in their“US selected practice recom- mendations for contraceptive use, 2013” [2] and their “US medical eligibility criteria for contraception use, 2010” [3].
The CDC’s medical eligibility criteria are clear that, regardless of medical comorbidities, benefits likely exceed risks for each emergency contraceptive option, even use of combined (estro- gen and progestin) hormonal contraception. This recommen- dation reflects the increased risks associated with continuing pregnancy in patients with comorbidities. Even with combined hormonal emergency contraception, the two doses required
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
Table 4.1 Options for emergency contraception
Option Formulation
Progestin Plan B One-Step®(1.5 mg levonorgestrel single dose)*
Ulipristal acetate Ella®(ulipristal acetate 30 mg single dose up to 5 days after unprotected sex or birth control failure)
Combined oral
contraceptives One dose within 120 hours after unprotected intercourse and a second dose 12 hours after thefirst dose† Copper intrauterine
device (IUD) ParaGard®
* Available over the counter to women over age 15 with proof of age. The package labeling states to use within 72 hours of unprotected sex, but it is still likely effective up to 120 hours.
†Per the Centers for Disease Control and Prevention’s“US medical eligibility criteria for contraceptive use, 2010”[3], the FDA declared the following 22 brands of oral contraceptives to be safe and effective for emergency contraception: Ogestrel®or Ovral®(1 dose is 2 white pills); Levlen®or Nordette®(1 dose is 4 light-orange pills); Cryselle®, Levora®, Low- Ogestrel®, Lo/Ovral®, or Quasence®(1 dose is 4 white pills); Tri-Levlen®or Triphasil®(1 dose is 4 yellow pills); Jolessa®, Portia®, Seasonale®, or Trivora®(1 dose is 4 pink pills); Seasonique®(1 dose is 4 light blue-green pills); Empresse®(1 dose is 4 orange pills); Alesse®, Lessina®, or Levlite® (1 dose is 5 pink pills); Aviane®(1 dose is 5 orange pills); and Lutera® (1 dose is 5 white pills).
for emergency contraception would be expected to have negli- gible risk, particularly when compared to those associated with long-term use for contraception in patients with medical comorbidities. This patient has appropriately used single-dose levonorgestrel emergency contraception in the past, which was Food and Drug Administration (FDA) approved and available without prescription for women 18 years of age and older when she used it. Related regulations are rapidly changing at the time of writing, and it is hoped that levonorgestrel emer- gency contraception will soon be available without prescrip- tion to women of any age. The FDA-approved single-dose levonorgestrel (Plan B One-Step®) is safe and effective, but unfortunately expensive, with retail prices typically in the
$30–50 range. While it can be safely used as often as necessary, it is a poor substitute for an effective first-line birth control method.
This patient would also greatly benefit from effective LARC. She has no contraindications to any of the available methods [4]. The copper IUD (ParaGard® T380A) is particu- larly attractive in this situation as it is an effective option for LARC and is effective for emergency contraception. The Cochrane review [5] found limited data meeting inclusion criteria for their review. However, on the strength of seven nonrandomized studies included in their discussion, they quoted a 0.09% failure rate and explicitly stated that the copper IUD was the most effective method of emergency contracep- tion, with the added benefit of long-term contraception. In comparison, the levonorgestrel regimen is 60–94% effective [1]. According to the Cochrane review, 80% of women who had their IUD placed for emergency contraception continued use of the IUD long-term [5]. A second systematic review also estimated a failure rate of 9% [6].
There are several barriers to use of the copper IUD for emergency contraception, with cost being the largest. Device and placement costs can be in excess of $500. Some patients have insurance that will cover the insertion and device. Under the Affordable Care Act, it should be available without copay.
Some of these insurance companies will allow insertion with- out preapproval, while others have telephone preapproval processes that can be done while the patient waits. In other circumstances where the preapproval process is lengthy, it may not be possible to place the IUD for emergency contra- ception unless the patient is willing to pay. As emergency contraception in general appears to be most effective when administered as soon as possible after inadequately protected intercourse, if there is going to be a significant delay in obtaining the device or insurance preapproval, administration of pharmacologic emergency contraception would be advis- able. For some patients without insurance coverage, anxiety related to potential pregnancy combined with accumulating costs from repetitive purchase of pharmacologic emergency contraception may make self-payment an acceptable option.
Cost of the device and insertion is not dissimilar from the cost of pregnancy termination, and it is significantly lower risk. Alternatively, standard pharmacologic emergency
contraception could be provided, with a plan to initiate long- term reversible contraception as soon as possible. This option would be particularly appropriate for a woman who would strongly prefer a contraceptive implant or levonorgestrel- containing IUD, neither of which has been studied as emer- gency contraception.
The CDC’s selected practice recommendations [2] are to place the copper IUD within five days of unprotected inter- course or suspected contraceptive failure, although they allow extending this as far as five days after ovulation in patients where the timing of ovulation can be determined. The CDC medical eligibility criteria [3] place only two limitations on copper IUD use for emergency contraception. First, it should not be used if the patient is already pregnant because of concerns about serious pelvic infection and septic spontaneous abortion. Second, caution needs to be exercised if placing for emergency contraception in the setting of rape. The criteria state that use is category 1 (no restriction) when the risk for sexually transmitted infection is low, but category 3 (risks usually outweigh benefits) when the risk is high. They provide no guidance as to how to make this determination in this setting, which would typically be associated with a high risk of sexually transmitted infection.
For this patient, the risk of pregnancy is not insignificant given the inconsistent use of condoms, and verifying a nega- tive pregnancy test is important. The American College of Obstetricians and Gynecologists (ACOG) practice bulletin number 112 [1] states that administration of emergency contraception should not be delayed by pregnancy testing, but this statement was likely intended to refer to emergency contraception pills, which are unlikely to cause harm if administered to someone already pregnant. As placing an IUD in someone already pregnant poses a significant risk, verification of a negative pregnancy test is prudent for this patient.
In placing the device, consideration needs to be given to choice of the copper IUD as the long-term contraceptive method. There are several advantages of the copper IUD, including a low failure rate compared to nonlong-acting methods. Its major advantage compared to other long-acting reversible methods is its effectiveness for up to 10 years with- out change. This patient’s plans are unlikely to require 10 years of contraception, but the device becomes cost effective relative to alternatives in a much shorter period of time. Removing the emergency contraceptive need from the decision, other LARC methods have some important advantages. In particular, the levonorgestrel IUD is chosen by many women because it decreases menstrual length andflow, and it is FDA approved as a treatment for heavy menstrual bleeding. For this patient, with otherwise normal menses, it would be expected that she would do well with the copper IUD.
The CDC’s medical eligibility criteria [3] recommend that the copper IUD not be placed in the setting of high risk for sexually transmitted infection present at the time of method initiation. This patient does not appear to be at high Case 4: A 19-year-old woman with diabetes and hypertension requiring emergency contraception
risk. Thought about the relationship between IUD use and pelvic inflammatory disease (PID) has evolved. The ACOG practice bulletin number 121 [4] states:“There are no studies demonstrating an increased risk of pelvic inflammatory disease (PID) in nulliparous IUD users, and no evidence that IUD use is associated with subsequent infertility.” The medical eligibility criteria list IUDs as category 2 for nul- liparous and adolescent women, and ACOG encourages their use in these populations [4,7]. Despite her young age, the copper IUD is very appropriate for this patient. It is import- ant not to place a copper IUD in an emergency contracep- tion setting with intent of long-term use unless the patient meets the criteria for placement in an elective setting.
This patient underwent a physical examination as part of her evaluation. An examination is not necessary before administration of pharmacologic emergency contraception, which should be made available to patients with as few barriers as possible [1,2]. However, it is required to assess for mucopurulent cervicitis and uterine abnormalities prior to IUD placement [2], so an examination is appropriate here.
Given her age, screening should be performed for chlamydia as per the US Preventative Services Task Force screening recommendations. Gonorrhea screening is also typically
performed. The technique for placement of the IUD in emergency contraception setting is the same as when placed in a nonemergency setting.
Key teaching points
Emergency contraception should be offered to anyone after unprotected intercourse not desiring pregnancy.
Progestin-only and combined hormonal contraceptives, as well as the copper intrauterine device (IUD), are all safe and effective for emergency contraception.
The Centers for Disease Control and Prevention’s“US medical eligibility criteria for contraceptive use, 2010”[3]
cite no medical conditions for which risks outweigh benefits for hormonal regimens for emergency contraception.
The copper IUD is the most effective method of emergency contraception, with greater than 99% effectiveness, higher than the 60–95% effectiveness for the oral levonorgestrel regimen.
Of the different methods for emergency contraception, only the copper IUD provides for long-term
contraception.
References
1. American College of Obstetricians and Gynecologists. Emergency contraception. Practice Bulletin No. 112.Obstet Gynecol2010;115:
1100–9.
2. Centers for Disease Control and Prevention. US selected practice recommendations for contraceptive use, 2013.MMWR2013;62:
1–60.
3. Centers for Disease Control and Prevention. US medical eligibility
criteria for contraceptive use, 2010.
MMWR2010;59:1–86.
4. American College of Obstetricians and Gynecologists. Long-acting reversible contraception: implants and intrauterine devices. Practice Bulletin No. 121.Obstet Gynecol2011;118:184–96.
5. Cheng L, Che Y, Gülmezoglu AM.
Interventions for emergency
contraception.Cochrane Database Syst Rev2012, Issue 8. Art. No.: CD001324.
DOI: 10.1002/14651858.CD001324.
pub4.
6. Cleland K, Zhu H, Goldstruck N, Cheng L, Trussel T. The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience.Hum Reprod 2012;27:1994–2000.
7. American College of Obstetricians and Gynecologists. Adolescents and long-acting reversible contraception: implants and intrauterine devices. Committee opinion no. 539.Obstet Gynecol 2012;120:983–8.