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1
Question:

A 39-year-old woman, gravida 4 para 4, comes to the office for emergency contraception.  The patient stopped breastfeeding a month ago and has not restarted her oral contraceptives because her husband is scheduled for a vasectomy in a few weeks.  She had unprotected intercourse last night and is concerned she might get pregnant.  The patient has no chronic medical conditions and takes no medications.  She does not use tobacco, alcohol, or illicit drugs.  Her last menstrual period was 9 days ago.  Vital signs and physical examination are normal.  Urine pregnancy test is negative.  Which of the following is the best emergency contraceptive option for this patient?

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Explanation:

Emergency contraception

Method

Timing after
intercourse

Efficacy

Contraindications

Copper-containing
intrauterine device

0-120 hr

>99%

  • Wilson disease
  • Active pelvic infection
  • Severe uterine cavity distortion

Progestin-releasing
intrauterine device

0-120 hr

>99%

  • Breast cancer
  • Active pelvic infection
  • Severe uterine cavity distortion

Ulipristal

0-120 hr

98%-99%

  • None

Oral levonorgestrel

0-72 hr

92%-98%

  • None

Oral contraceptives*

0-72 hr

75%-89%

  • None

*Combined estrogen/progestin oral contraceptive pills containing levonorgestrel or norgestrel.

Patients who have had recent unprotected intercourse may be candidates for postcoital or emergency contraception (EC) for pregnancy prevention.  Pregnancy status determines eligibility for EC use:

  • Patients with a positive pregnancy test are not candidates for EC because implantation has already occurred. 
  • In contrast, patients with a negative pregnancy test are still at risk for unintended pregnancy and are candidates for EC (Choice B).

A highly effective (ie, 98%-99%) EC option is the ulipristal pill, a progestin receptor blocker that prevents pregnancy by delaying ovulation and impairing implantation.  Ulipristal can be taken up to 120 hours after unprotected intercourse; however, it should be administered as soon as possible because its effectiveness decreases with time.  Other effective EC options include the copper-containing intrauterine device and oral levonorgestrel (ie, Plan B).

(Choice A)  Combination oral contraceptives, commonly used for precoital contraception, may also be used for EC by taking multiple pills simultaneously to achieve the progestin level required to delay ovulation.  However, the high estrogen content typically causes intolerable side effects (eg, severe nausea), and this method is less effective (ie, 47%-89%) than ulipristal.

(Choices C and E)  A progestin-releasing subdermal implant is a long-acting, reversible contraceptive used for precoital contraception.  Because it provides sustained release of low-dose progestin, it cannot achieve the acute increase in progestin levels required to delay ovulation for EC.  Similarly, the transdermal estrogen-progestin patch is a slow-releasing combined hormonal contraceptive used only for precoital contraception.

Educational objective:
Ulipristal is a highly effective emergency contraception option that prevents pregnancy by delaying ovulation and impairing implantation.  It can be taken up to 120 hours after unprotected intercourse.