Overview
Definition:
Emergency contraception (EC) refers to methods used to prevent pregnancy after unprotected sexual intercourse or contraceptive failure
For adolescents, it is a crucial component of sexual and reproductive health services, aimed at reducing unintended pregnancies and associated risks.
Epidemiology:
Adolescent (15-19 years) unintended pregnancies remain a global concern
While rates vary, access to and utilization of EC is critical
Factors influencing use include knowledge, access, provider attitudes, and legal barriers
Indian data indicates significant unmet needs for contraception among sexually active youth.
Clinical Significance:
Providing comprehensive EC counseling to teens is vital for preventing unintended pregnancies, which can lead to significant psychosocial, economic, and health consequences
It empowers adolescents with knowledge and options, promoting responsible sexual decision-making and reducing abortion rates
This is a core area of responsibility for pediatricians and adolescent medicine specialists.
Age Considerations
Legal Aspects:
In India, the age of consent is 18 years
While legal frameworks exist, ethical considerations and the child's maturity and capacity to understand are paramount in providing EC
Pediatricians must be aware of local laws and guidelines regarding adolescent healthcare access without parental consent, especially in cases of rape or coercion.
Developmental Stage:
Adolescents are in various stages of physical and psychosocial development
Counseling should be age-appropriate, sensitive to their developmental maturity, and delivered in a non-judgmental manner
Empathy and understanding are crucial for effective communication.
Risk Assessment:
Assessing the adolescent's understanding of sexual health, contraceptive methods, STIs, and the circumstances of unprotected intercourse is essential
This includes identifying any potential coercion, abuse, or medical contraindications to EC methods.
Clinical Presentation
History Taking:
Key history points include: Date and time of unprotected intercourse
Number of episodes
Menstrual history (LMP, regularity)
Current contraceptive use (if any) and failure
Past sexual history
History of STIs
History of previous EC use
Any known allergies or medical conditions
Reason for seeking EC
Any signs of sexual coercion or assault.
Associated Factors:
Consider factors contributing to unprotected sex: contraceptive failure (condom breakage, missed pills), inconsistent condom use, lack of access to regular contraception, and situations of sexual coercion or assault
Understanding the context is crucial for comprehensive care.
Urgency:
The urgency of the situation dictates immediate assessment and provision of EC
The efficacy of EC methods decreases with time, making prompt consultation essential.
Diagnostic Approach
Patient Centered Interview:
Conduct a confidential and supportive interview
Use open-ended questions
Active listening is key
Ensure privacy and a safe environment
Assess readiness to discuss sexual health openly.
Medical History:
Review past medical history for contraindications to hormonal EC (e.g., active thrombophlebitis, history of breast cancer, uncontrolled hypertension, significant liver disease)
However, most contraindications are relative for EC use.
Pregnancy Test:
A pregnancy test may be indicated if the LMP is unknown, if the patient is more than 7 days past their expected period, or if EC has been taken previously during the same cycle
A baseline pregnancy test is recommended if there is significant delay since unprotected intercourse, or if there are signs suggestive of pregnancy.
STI Screening:
Discuss the risk of STIs and offer screening, especially if there are risk factors
EC does not protect against STIs.
Management
Emergency Contraceptive Options:
Offer the most effective and accessible options: 1
Levonorgestrel (LNG) 1.5 mg (single dose)
2
Ulipristal acetate (UPA) 30 mg (single dose)
3
Copper-T Intrauterine Device (IUD) inserted within 5 days of unprotected intercourse (most effective method).
Pharmacological Management:
Levonorgestrel: Most commonly available and recommended as first-line
Administer a single 1.5 mg tablet orally
Efficacy decreases with time but can be used up to 72 hours post-intercourse
Ulipristal acetate: More effective than LNG, particularly between 72-120 hours post-intercourse
Contraindicated in severe asthma requiring oral corticosteroids.
Intrauterine Device Insertion:
Copper-T IUD: Highly effective as EC when inserted within 120 hours of unprotected intercourse
Also provides ongoing contraception
Requires a skilled provider and careful insertion
Discussed as an option for adolescents requiring long-term contraception.
Follow Up Counseling:
Provide counseling on future contraception
Discuss barrier methods, hormonal methods, and LARC options
Schedule a follow-up appointment to discuss ongoing contraceptive needs and screen for STIs
Counsel on signs and symptoms of pregnancy and when to seek further medical attention.
Complications
Side Effects:
Common side effects of hormonal EC include nausea, vomiting, headache, fatigue, dizziness, and menstrual irregularities (lighter or heavier periods, or spotting)
These are usually transient.
Failure To Prevent Pregnancy:
No EC method is 100% effective
If pregnancy occurs after EC use, it is important to reassure the patient and ensure appropriate prenatal care
EC does not typically harm a developing fetus.
Emotional Distress:
Adolescents may experience anxiety, guilt, or distress related to unprotected sex or seeking EC
Provide emotional support and refer to counseling services if needed.
Key Points
Exam Focus:
Understand the different EC methods, their efficacy timelines, and contraindications
Be familiar with Indian guidelines for adolescent reproductive health
Emphasis on patient-centered, confidential counseling.
Clinical Pearls:
Always assess for coercion or abuse
EC is not an abortifacient
it prevents pregnancy
Discuss STI risk and screening
Offer long-term contraceptive planning
Advocate for adolescent-friendly healthcare settings.
Common Mistakes:
Assuming adolescents are not sexually active
Providing judgmental counseling
Failing to offer all available EC options
Not addressing ongoing contraceptive needs
Not considering the Copper-T IUD as a highly effective EC option and long-term contraceptive.