Emergency Contraception and Pregnancy Termination

What is important to note about the MOA of EC?

CANNOT prevent pregnancy once implantation has occurred

Define the Yupze method

Take multiple regular oral CHCs as two doses 12 hours apart (less common!)

What are the three forms of EC?

Levonorgestrel (Plan B One Step and other generics)

Ulipristal (Ella)

Copper IUD

Is levonorgestrel Rx or OTC?

OTC

What is the efficacy window of levonorgestrel?

Within 72 hours of unprotected sexual intercourse

What is the dosing of levonorgestrel?

1.5 mg x 1 dose

What are the dispensing requirements for levonorgestrel?

OTC for any age and any gender

What are the directions for restarting HC after use of levonorgestrel?

Restart immediately

Use back-up x7 days

Is ulipristal Rx or OTC?

Rx

What is the efficacy window of ulipristal?

Within 120 hours of unprotected sexual intercourse

What is the dosing of ulipristal?

30 mg x 1 dose

What are the dispensing requirements for ulipristal?

N/A since by Rx only

What are the directions for restarting HC after use of ulipristal?

Wait 5 days to restart HC

Use back-up until next period

Are copper IUDs Rx or OTC?

Rx

What is the efficacy window of copper IUDs?

Within 120 hours of unprotected sexual intercourse

What is the dosing of copper IUDs?

Must refer to a provider for insertion

What are the dispensing requirements for copper IUDs?

N/A inserted at a provider's office

What are the directions for restarting HC after use of copper IUDs?

N/A

What are common AEs of EC?

Headache, nausea, irregular bleeding

When should another EC pill be taken?

If vomiting occurs within 2 hours

What are monitoring parameters for EC?

Check pregnancy test if menses does not start within 21 days of EC or if menses is > 1 week late

What is important to note about the effectiveness of EC?

Oral EC may be less effective in obese women

DO NOT withhold treatment

What are directions for use of all EC?

Take ASAP

What medications are typically used for early pregnancy termination (< 70 days)?

Mifepristone + misoprostol OR misoprostol alone

Mifepristone

Mifeprex

What is the MOA of mifepristone?

Binds and blocks progesterone receptors

Blocking progesterone = softening cervix, increased uterine contractility, increased prostaglandin sensitivity

What are expected and possible ADRs of mifepristone?

Expected = abdominal pain and vaginal bleeding

Possible = N/V/D, dizziness, fever/chills

Describe the metabolism of mifepristone

CYP3A4 substrate

Use with caution with strong CYP3A4 inhibitors or inducers

What is the BBW of mifepristone?

Infection and bleeding

What are contraindications of mifepristone?

Bleeding disorder or taking anticoagulant

What is the MOA of misoprostol?

Prostaglandin E1 analog = softens cervix and induces contractions

What is the approved use for misoprostol?

Gastric ulcers

What are off label uses for misoprostol?

Abortion, labor induction, prevent/treat postpartum hemorrhage, cervical ripening, treatment of early pregnancy loss

What are ADRs of misoprostol?

Stomach upset, diarrhea, headache, dizziness, chills, fever

Why should oral misoprostol be avoided?

Less absorbed, less effective

Describe the misoprostol + mifepristone regimen for pregnancy termination

Mifepristone 200 mg orally on day 1, then misoprostol 800 mcg bucally 24-48 hours later

98% effective in pregnancies up to 49 days

Works faster and is more effective in later gestational ages

Describe the misoprostol alone regimen for pregnancy termination

Various regimen

93-99% effective

What are counseling points for pregnancy termination regimens?

Bleeding = if soaking through pads at a rate of > 2 maxi pads per hour for more than 2 hours, seek medical help

May use APAP or ibuprofen for pain to inhibit NEW prostaglandins but no effect on efficacy