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Family Planning

Emergency Contraception (EC)

Methods used to prevent pregnancy after unprotected sexual intercourse, contraceptive failure (e.g., condom break), or sexual assault. Available methods include Emergency Contraceptive Pills (ECPs) and the Copper Intrauterine Device (Cu-IUD).

Also known as: EC, Morning After Pill, Plan B

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Referral and warning signs

When to refer

Referral needed for: Emergency Cu-IUD insertion. Severe side effects from ECPs. Suspected pregnancy despite EC use. Cases involving sexual assault (for comprehensive medical/legal/psychosocial care).

Red flags

  • Symptoms of established pregnancy
  • Severe abdominal pain after EC use (rule out ectopic if pregnancy occurs)

Signs and symptoms

  • Side Effects of ECPs (usually mild, short-term): Nausea, vomiting, Headache, Abdominal pain, Breast tenderness, Dizziness, Fatigue, Changes in next menstrual bleeding (may be early, late, heavier, or lighter).

Risk factors

  • Unprotected intercourse.
  • Condom breakage or slippage.
  • Missed regular contraceptive pills (esp. COCs).
  • Late injectable contraceptive dose.
  • Dislodged IUD or implant.
  • Sexual assault (rape, defilement).

Diagnosis

Clinical assessment

Assessment based on history of recent (<5 days / 120 hours) unprotected intercourse or contraceptive failure. Rule out established pregnancy (ECPs do not interrupt existing pregnancy).

Investigations

  • Pregnancy test usually not needed before providing ECPs unless period is already late or clinical suspicion high.
  • Pregnancy test needed before inserting emergency Cu-IUD.

Diagnostic criteria

Request for EC following unprotected sex within the effective time window (up to 5 days).

Management

Non-pharmacological management

  • Counseling: Explain available methods (ECP, Cu-IUD), effectiveness (higher if used sooner), mechanism (primarily delays/inhibits ovulation), side effects, lack of STI protection. Emphasize EC is not for regular use. Discuss need for ongoing contraception.
  • Offer STI testing/treatment and psychosocial support if sexual assault occurred.

Pharmacological treatment

  • Emergency Contraceptive Pills (ECPs):
  • - Levonorgestrel (LNG) ECP: Preferred ECP method. Dose: Single dose of 1.5 mg LNG taken ASAP within 120 hours (5 days) of unprotected sex. (May come as two 0.75mg pills taken together or 12 hours apart, but single dose simpler and equally effective). Note for ARV users (Efavirenz/Nevirapine): UCG recommends double dose (3mg LNG) due to potential interaction.
  • - Combined ECPs (Yuzpe method - less common now due to more side effects): Specific doses of certain COCs taken 12 hours apart (refer to guidelines for specific pills/doses). Less effective and more nausea than LNG ECP.
  • - Ulipristal Acetate (UPA) ECP: Selective progesterone receptor modulator. More effective than LNG, especially 3-5 days post-intercourse. Prescription often needed. Potential interaction with hormonal contraception.
  • Copper Intrauterine Device (Cu-IUD):
  • - Most effective EC method. Can be inserted up to 5 days after unprotected intercourse.
  • - Also provides ongoing highly effective contraception.
  • - Requires trained provider for insertion. Contraindicated if existing PID or high STI risk without screening/treatment.

Monitoring

Advise follow-up if next period is delayed >1 week (perform pregnancy test). Monitor for side effects.

Complications

  • Method failure (pregnancy occurs despite EC use - risk higher the later it's taken).
  • Side effects (nausea, vomiting etc).
  • Complications related to emergency IUD insertion (rare - perforation, infection).

Prevention

  • Consistent and correct use of regular contraception.
  • Use of condoms.
  • Having ECPs available in advance ('advance provision') for women at risk.

Patient education

  • EC is for emergencies, not regular use.
  • Take ECPs as soon as possible for best effectiveness.
  • How ECPs work (prevent/delay ovulation).
  • Common side effects and how to manage (e.g., repeat dose if vomit within 2-3 hours).
  • EC does not cause abortion.
  • EC does not protect against STIs/HIV.
  • Need to start/resume regular contraception immediately or after next period.
  • When to expect next period and when to do pregnancy test if delayed.
  • Information about emergency Cu-IUD as most effective option.

Uganda-specific notes

LNG ECPs (e.g., Postinor-2, ECee 2) widely available over-the-counter. Crucial to counsel on correct dose (often 2 pills taken together), timing, and NOT using as regular method. Remember double dose needed for women on Efavirenz/Nevirapine based ART.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 15, Section 15.2.7

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