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BusySpR MRCOG PART II
MRCOG Part 2, MRCOG II

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MRCOG 2 Past Questions Tutorial: GROUP 3: Sat 16/11 from 10:00 - Statistics. Sun 17/11 from 10:00 - Oncology 1. Group 2: Sat 16/11 from 19:00 - Contraception & STI. See DISCUSSIONS below for details.

 

 

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Forum >> ESSAY 259 - Contraception
ESSAY 259 - Contraception Posted by PAUL A.
Sun Feb 3, 2008 12:07 am
A 16 year old nulliparous woman presents to you following an episode of sexual intercourse during which no contraception was used. She requests emergency (post-coital) contraception. (a) What information will you obtain from the history? [8 marks] (b) Evaluate the options for emergency contraception in this patient [4 marks]. (c ) Justify your follow-up arrangements and management during the follow-up visit [8 marks].
Posted by hoping ..
Sun Feb 3, 2008 01:16 am
a) I would like to gather more information regarding time of unprotected sexual intercourse. If there were any previous episodes of unprotected sex since her last menstrual period should be checked.History regarding her last menstrual period and cycle length is important to asses her risk of pregnancy. Her risk of getting sexually transmitted infection should be assesed. Enquiry regarding partner should be made sensitively, if partner was stranger , new or long term partner. Her medical history should be checked especially hypertension, migraine, recent pelvic inflammatory disease. Her drug history and if she had contraceptive pill in past should also be taken into account.

Her options include levonelle 1500mg stat if episode happened not more than 72 hours ago. It can be considered upto 96 hours but efficacy is poor. Antiemetic along with reduces risk of vomiting.It is simple method, doesnot involve examination, but efficacy declines with duration.
Intrauterine device other than mirena can be used if with in 5 days of ovulation or un protected intercourse. This is highly effective and if patient wishes can be continued as followon contraceptive.However it requires internal examination, can give discomfort during insertion and rare risk of perforation. If she is at risk of infection then antibiotic cover should be provided, otherwise risk of PID. If unfortunately patient is not eligible for any of these then she should be counselled regarding risk of pregnancy according to fertility period of her menstural cycle and advised to do pregnancy test if misses next period. However vaginal and endocervical swabs and antibiotics may be indicated if at risk of infection.

I would advise her that her period might be early or delayed if she had levonelle.I would advise to see her GP or family planning clinic around time when her next period is due to check pregnacy test , discuss swab results and future contraception. If pregnancy test is negative then to reassure with advice to repeat if still no period after a week. If pregnancy test is positive then her views regarding pregnancy should be gathered, if she would continue or opt for termination.Appointment with counsellor should be considered. If she is unsure followup appointment in few days should be arrranged. If patient decides to have termination then she should be reffered at earliest and her blood group should be checked to asses need for anti-D. IF she decides to continue with pregnancy then USS to asses viability and site of pregnancy should be arranged and referal to antenatal clinic shouls be arranged.If swabs show sexually transmitted infection then empirical treatment and referal to GU clinic should be arranged to attain contact tracing and followup. Future contraception should be discussed and importance of safe sex be discussed.
Posted by Srivas  P.
Sun Feb 3, 2008 04:19 am
a) Detailed menstrual history-Age at menarche, regularity of periods and LMP will be asked. Ask for complaints like vaginal discharge, post coital bleeding or lower abdominal pain suggesting PID.

Sexual history like how many hours now since the sexual exposure, is the partner her only sexual contact, does she regularly have sex, and does this partner have any other sexual contacts. Does she feel coercised to have sex and was she offered money or gifts for the act and is she afraid of her partner. It is important to rule out sexual abuse. Though she is above age for consent for sex and is Frazer competent for requesting contraception, she is still a minor and her partner could be charged for rape if he is a major. Age of her partner should be asked.

I will take contraceptive history if any and her need in future. I will ask her if she has knowledge of the contraceptive methods and STIs. I will enquire about her medical history and drug history?liver enzyme inducing drugs like phenytoin, carbamazepin, rifampicin which would require higher dose of LNG EC.
b) In Kwan and Ho method Levonorgestrel one step or Levonelle2 containing LNG 1.5mg is given ideally within 72 hrs of sex for 84% effectivity in preventing pregnancy but it decreases to 63% effectivity when given from 72-120days. The EC can be repeated if she has further sexual exposure but Ideally she should be encouraged to follow regular contraception. There are no contraindications to this method. Advantages are it is single dose method, non-invasive, no risk of intrauterine infection and can be prescribed by GP, midwife without delay.

Cu IUD can be inserted within 5 days of sexual exposure or within 5 days of ovulation whichever is earlier. The effectivity is 99% in preventing pregnancy. Risk of pregnancy varies in menstrual cycle and is 20-30% close to ovulation and this method is most effective if exposure has occurred during this period. It can be continued if she wants to continue the method and will protect her rest of the cycle. Does not need daily use of contraception, which is most useful if she has unplanned sexual exposures. Yuzpe\'s method is now not used due to less efficacy. Use of Mifepristone as Post coital contraception is under evaluation
c) She should followup after 1st menses or 3-6 weeks of IUD insertion. There is increased chance of infection within 20 days of insertion. I would explain to her the symptoms of pelvic infection and ask her to report if she has such symptoms, or is unable to feel threads suggesting expulsion or she misses a period suggesting pregnancy. If she gets pregnant there are chances it could be ectopic pregnancy though the risk of ectopic pregnancy is not increased due to IUD.Contraception lasts 5 years with Cu380A and after reviewing her risks of getting STI, I would enquire whether she would like to continue it.Cu IUD does not protect her against it so she would need concurrent use of condoms if at risk.

Following LNG one step, I would ask her to use condoms for rest of the cycle as she is not protected. She should follow up as soon as gets her period or if she misses it. At the followup visit I will discuss various options of contraception with her. No contraception is contraindicated based on her age alone and it depends on her life style, risk of pregnancy and STI.I would give her information booklets, website address like www.fpa.org.uk for more information and an appointment after she makes her decision.
Posted by S M.
Sun Feb 3, 2008 06:08 am
A 16 year old nulliparous woman presents to you following an episode of sexual intercourse during which no contraception was used. She requests emergency (post-coital) contraception. (a) What information will you obtain from the history? [8 marks] (b) Evaluate the options for emergency contraception in this patient [4 marks]. (c ) Justify your follow-up arrangements and management during the follow-up visit [8 marks].

a)From the history, I need to know when the episode of unprotected intercourse occurred. I will find out the date of the last menstrual period, length and regularity of the menstrual cycle. This will enable me to determine the approximate time of ovulation and also whether there was a possibility that she may already have conceived in a previous cycle. I would enquire about previous episodes of unprotected intercourse, the number of sexual partners and the presence of sexually transmitted infections such as chlamydia. A personal or family history of venous thrombolism or thrombophilias would increase her risk of developing thromboembolism and would affect the choice of emergency contraceptive. Smoking will also have an impact. A history of medication such as antibiotics or antiepileptic drugs is important because a higher dose of the hormonal emrgency contraceptive would be needed. I would also ask whether she had heart disease, since some conditions such as Eisenmenger\'s syndrome have a high incidence of maternal mortality and this would need to be considered in her follow up if she did conceive.

b) The intrauterine contraceptive device is an option for emergency contraception. It functions by preventing implantation. It may also have a toxic effect on sperm. It is beneficial because it can be effective up to 5 days after unprotected intercourse. In the presence of chlamydia this can cause the infection to spread if untreated. The levonorgestrel pill is also effective oral form of emergency contraception. It is beneficial because it is effective if taken within 72 hours of the unprotected intercourse. It is also good becuase it is not invasive such as the IUCD.

c) Follow up arrangements must be made because of the risk that she becomes pregnant. This may be an intrauterine pregnancy or ectopic. The conception may be due to failure of the emergency contraception or she may have conceived in the previous cycle. The first visit should be approximately 2 weeks after the estimated date of ovulation.

In the follow up a pregnancy test must be done. If it is positive, an ultrasound scan would need to be done for location, dating and viability. If there is no intrauterine pregnancy identified then serial beta HCG\'s must be done to help determine the likelihood that the pregnancy is intrauterine or an ectopic pregnancy. If the pregnancy is intrauterine, then she should be referred for antenatal booking or termination of pregnancy depending on the patient\'s wishes. If the pregnancy is an ectopic, then mediacl treatment or laparscopic salpingectomy should be discussed based on the findings of the scan and level of serum beta HCG. The results of the vaginal and cervical swabs for infection must be reviewed, since infections such as chlamydia can lead to significant tubal damage and subfertility, if the infection is not treated. A referral to the geniturinary clinc should be made for further assessment of sexually transmitted diseases and contact tracing. Advice on future contraception and sexual health should be given.
Posted by Anna A.
Sun Feb 3, 2008 11:54 am
a.This patient is required emergency contraception (EC). Her last normal menstrual period is important information. The last event of unprotected sexual intercourse (SI) should be obtained as well. Intrauterine contraceptive device (IUCD) is contraindicated for patient with history of recent sexual transmitted diseases or pelvic inflammatory diseases especially in the last 3 months. Family history of breast cancer or venous thrombo-embolism (VTE) should avoid the prescription of combined oestrogen and progestogen group. Current usage of enzyme inducing agent medication will require the patient to take higher dosing of EC. History of multiple sexual partners should be asked as screening of STD should be carried out. Allergic history to copper or Wilson?s diseases will make IUCD become contraindicated. Her wishes for further contraception and her preference method of contraception should be noted.
b.Option of EC include Yupze regime ( contain of ethinyloestradiol 100microgram and levonorgestrel 500microgram), first dose is given within 24-72 hours of last unprotected SI and repeat another dose within 12 hours later. It has 77% of efficacy (if given within 24 hours of last unprotected coitus) but associated with vomiting and nausea or breast tenderness. Two doses of Levonorgestrel of 750microgram, has better side effect with efficacy of 95% (first dose is within 24 of unprotedted coitus and second dose is after 12 hours later). Copper IUCD has less than 1 % of failure rate if it is inserted within 5 days of last unprotected SI or within 5 days of calculated ovulation period. Mifepristone can be used up to five days of last unprotected SI with less side effect profile. Information leaflet should be given to the patient to enable inform decision.
c.She should be informed that the hormonal EC would cause a delay of period or abnormality bleeding. She should return earlier for pregnancy test if she has one week delayed of her expected menses or abnormal bleeding. STD screening should be arranged if she has high risk behavior. She should be fully informed that IUCD will be removed during her next period. Should she vomited after 2 to 3 hours of taking the hormonal EC, she should repeat another dose immediately. Prescription of anti-emetic is prudent to reduce vomiting or nausea. Termination of pregnancy can be discussed with the patient should she got pregnant. Future long term contraception should be discussed to her to avoid unwanted pregnancy. Advice to reduce risk of STD or safe sex should be given to her if necessary. Written information and further follow-up should be provided.
Posted by Azza S.
Sun Feb 3, 2008 03:33 pm
The main concerns are an unwanted pregnancy or contracting a sexually transmitted infection [STI]. I should ask about when that happened and whether there is previous episodes of unprotected intercourse in this cycle and when. The date of her last menstrual period [LMP] and the regularity and length of her cycles. I would like to ask about history of contraception and any associated complications, as well as the need for a contraception method. I would like to ask about sexual history as number of sexual partners and a previous history of STI. The medical history is also important as history of venous thrombo- embolism or focal migraine, as well as drug history like enzymes inducers.
If there was less than 72 hours from the episode then she can use either the combined estrogen and progesterone [Yuzpe], progesterone only, estrogen only, mifepristone or the intra- uterine contraceptive device [IUCD]. Yuzpe can prevent 75% of pregnancies that would have occur that cycles, but associated with increased risks of side-effects especially nausea and vomiting. Progesterone and mifepristone are both more effective than Yuzpe with less side effects. With all these methods next period can be early, in time or delayed. They delay or prevent ovulation and there need to use barrier method during the rest of the period. The IUCD is almost effective in all cases, and can be used when more than 72 hours had passed, or till 5 days of calculated date of ovulation. It can be used for longer contraception, but relatively contraindicated in nuliparous
A follow-up appointment at 3-4 weeks should be advised. If missed period then pregnancy test should be requested. If positive she should be assured that there is no increase in risk of malformations, but if she want termination of the pregnancy then it will be arranged. IUCD if not desired for longer period then it can be removed. Discuss future contraception. To review the results of STI screening.
Posted by Maud V.
Sun Feb 3, 2008 08:35 pm
a) A 16 year old girl must be given a non-judgemental, sensitive approach. She should be asked when and what time she had the episode of unprotected intercourse and whether there have been any previous episodes, as emergency contraception isn\'t affective when it\'s been more than 5 days. She should also be asked when her last menstrual period was and what her cycle length is and a pregancy test done if there is a possibility of this being positive.
Because she is underage, sensitive enquiries should be made whether she gave consent to have intecourse, whether this is with a boyfriend and how old he is. She should also be asked whether either a parent or an adult she trusts is aware that she is sexually active. If she has had more episodes of unprotected intercourse, she is at risk of sexually transmitted disease, especially chlamydia.
Finally, she should be asked whether she has used contraception in the past and if she has, what the reason is she discontinued this. A medical and drug history will show whether there are any contra-indications to certain types of contraception.

b) Levonelle is a high progesterone dose which can be given in a single dose or divided over two doses. A single dose gives higher compliance and only for that reason is more effective. It is effective in the first 72 hours following unprotected intercourse and is more effective the sooner it is taken.
An intra-uterine contraceptive device is an effective method when inserted in the first 5 days following intercourse. it prevents implantation of the embryo in the endometrial cavity and does not prevent ectopic preganacies. It carries a risk of pelvic inflammatory disease if Chlamydia is allready present and for this reason cervical swabs should be taken and a single dose of 1 gram of azithromycin offered. It is painfull to insert in a nullip and she can take analgesia following insertion to ease the pain. An advantage is that it also provides reliable, long-term contraception and can be left in-situ for up to 5 years, or taken out any time sooner if no longer required. It needs to stay in for at least 2 weeks to provide the emergency contraception though. It may make her periods heavier and more painfull.
Information leaflets about themethod given should be provided and contact numbers in case she has any problems.

c) A follow-up appointment gives another opportunity to enquire after her social background and whether she is having intercourse with consent. This is also when contraception can be offered with written information on the various options available. If she hasn\'t had a period since, a pregnancy test can be done with counselling if this is positive. If she hasn\'t had swabs taken at the previous visit, these can be taken now, as the prevalence of Chlamydia amongst sexually active teenagers in the UK is high and has long-term risks of PID, subfertility, chronic pain and ectopic pregancies. If swabs had been taken before, the results can be discussed and GUM referral and treatment offered. Condoms can be given to her and she should be encouraged to use these in addition to her contracetion, to protect her form sexually transmitted disease. She should be encouraged to re-attend if another episode of unprotected intercourse happens in the future. Everything that has been done and said will remain confidential. Further follow-up will allow opportunity to ask about compliance with the methods used and any possible side-effects.
Posted by Sarwat F.
Sun Feb 3, 2008 10:55 pm
I will ask how many hours have passed since she had sex. I will also ask her last menstrual period to check if she has not already missed her period. I will enquire about her menstrual history if she has regular menstrual cycle to check the likelihood of ovulation. I will ask any history of sexually transmitted diseases, any abnormal vaginal discharge, any treatment she is taking for any medical disease for example epilepsy. This will alter the dose of emergency contraception. I will ask if she has used any contraception before and any problems with different methods of contraception. This will help in counseling her regarding regular method of contraception in future. I wiil ask her about use of condoms to prevent STDs. I will ask if her parents are aware that she is sexually active or not so that the medical staff will keep confidentiality.
Best option will be 1.5 mg of levonorgestrel as a single dose if she presents within 72 hours of sexual intercourse. Other option is intrauterine contraceptive device but it is extremely difficult to insert in a 16 yrs old nulliparous woman.
I will tell her that her expected period can be delayed by a few days because of hormonal emergency contraceptive but she should contact her gp if her period is delayed by more than 7 to 10 days. I will arrange a followup appointment in 2 weeks time to check if she is able to use a regular method of contraception or to advise regarding any problems that may arise during this period. On the other hand if emergency contraception fails, a followup appointment will help in discussing matters relatin to pregnancy. I will discuss the options of continuing or termination of pregnancy, methods of termination and what it involves. This will be backed up by written information. In case she decides to continue with pregnancy she will be informed regarding social help if she needs and appropriate antenatal care will be arranged.
Posted by Reiaz M.
Sun Feb 3, 2008 11:19 pm
Eliciting the history should be done in a sensitive and non judgemental manner. She is assured that her responses are confidential.
It is important to determine how long ago the sexual act occureed. The nature of the sexual act and whether or not it was consensual should also be obtained. The date of her last normal menstrual period and whether or not she has regular menses should be determined.
A prior history of contraceptive use is elicited and if she has any concerns about contraceptive use should be addresses. A history of past or current sexuallt transmitted infections is important. Age of coitarche and number of sexual partners are personal questions which are best avoided.
Use of enzyme inducing drugs eg antiepileptics is elicited. Any use of alcohol or illicit drugs that can potentilly lead to unsafe sexual practices is also important.

b) The patient is presented with the options and allowed to decide in conjunction with the obstetrician which is best for her.
One option is use of leonorgestrel 0.75mg taken orally 12 hours apart. The first dose must be taken within 72 hours of sex. It is associted with nausea and vomiting and an antiemetic can also be prescribed. This is 95% effective in preventing pregnancy. Alternatively a single dose of levonorgestrel can be taken within 72 hours os sex.
The copper containing IUCD is the most effective form of emergency contraception. It can be used within 5 days of sex or 5 days within the earliest estimated date of ovulation. Active PID is a contraindication to this method.
Mifepristone is another alternative. Its efficacy rate is simplilar to that using levonorgestrel. Information leaflets should be given.

c) She is advised that if she vomits within 2 hours of taking the oral method she will need to take another dose. Use of enzyme inducing drugs will necessitate an increase in the dosage used. She is advised that her menses can be delayed following use of hormonal emergency contraception. A follow uo visit is scheduled for 4-6 weeks.
At the follow up visit an enquiry is made about if she has menstruated. If not a sensitive UPT is done. She is counseled about contraceptive methods. She is encouraged to uise a barrier form of contraception to prevent STIs in conjuction with any hormaonal method chosen. Chlamydia infection is very prevalent in sexually active teenagers and screening for chlamydia should be encouraged. Testing for other STIs eg HIV should also be discussed with her.
Information leaflets are provided to her to supplement the discussion.
Posted by Sahathevan S.
Mon Feb 4, 2008 02:09 am
(a) What information will you obtain from the history? [8 marks]
A detailed menstrual history and timing of unprotected sexual intercourse in relation to the current menstrual cycle and history of recent pelvic infection should be elicited. Medical history is important to rule out contraindication for Emergency contraception particularly higher dose of COCP. History of migraine and thromboembolism should be asked. Previous contraceptive history including emergency contraception is useful to assess the patient compliance.

(b) Evaluate the options for emergency contraception in this patient [4 marks].
Progesterone only pill (Levonelle) is the current treatment of choice .0.75mg levenorgestrel taken 12 hr apart. This has fewer side effects compared with high dose combined pill.
High dose COCP can be given if there is no contraindications (Present or past Cardiovascular disease, focal migraine, liver disease, BP more than 160/100).100microgram ethynyl oestradiol with 250 microgram levenogestrel repeated in 12hrs can be offered.IUD is an option as long as it is fitted within 5 days of earliest ovulation.sceering for Chlamydia infection is important before Copper IUD insertion.

(c) Justify your follow-up arrangements and management during the follow-up visit [8 marks].
Follow up should be arranged within 3-4 wks of the treatment or earlier if she has any pain, bleeding or concerns. At follow up details of post treatment menstrual period should be documented
If she has menstruation future contraception must be discussed and previous failed contraception and compliance taken into consideration and suitable method of contraception should be given. Woman?s decision to use emergency contraception after full discussion backed up by information leaflet.
If Post coital contraception failed and preganancy suspected and diagnosed as any other unintended pregnancy. She may have an option of termination of pregnancy.
Woman\'s descion should be documented. If the she was offered any STD screening after unprotected sexual intercourse, the results should be discussed if necessary Patient should be referred to GU clinic.
Posted by Shankaralingaia N.
Mon Feb 4, 2008 07:55 pm
a)Before prescribing the medication I would like to know the date and duration since the sexual intercourse and the type of penentration whether oral,vaginal or anal.I Would also ask if she is in a stable relationship.
Menstrual history in terms of last menstrual period and whether her periods are regular is important.I would like to know if she has been pregnant before or if she has had any terminations.
Other information like whether she has been tested for sexually transmitted infection in the past and if her parents know this and would she want to tell them about it.
Information of any medical problems like diabetes,chronic illness,medication like antibiotics and immunosuppresants and any allergies is vital before prescribing.

b)The options depend on the duration since the time of intercourse.
Yuztpe method is using high doses of combined oral contraceptive pill taken 12hrs apart but not used in UK currently due to side effects.
If less than 3 days she can be given levenol 75mgs which has to be taken 12 hours apart or a single dose of 150mg tablets as soon as possible.If she vomits straight away she has to take another dose.Side effects are nausea and vomiting.
For upto 5 days we could insert a intrauterine contraceptive device(IUCD)can be fitted in.This prevents implantation.
These are very effective treatment and sooner the treatment taken the efficacy is better.

c)Follow up arrangement is made after her next periods to discuss contraception or if there is a delay in her periods as she could be pregnant.Report if any pregnancy symptoms develop.Counsel her that the tablets are not a method of contraception and should use other forms of long term contraception.IUCD could be used as a long term contraception.
At the follow up visit do a pregnancy test if her periods are delayed.If negative advice about different forms of contraception available.
Screen her for sexually transmitted infection and treat her accordingly with contact tracing.Advice in using barrier method to prevent them.
Information leaftlets about the contraception and STIs are given.
Posted by Dr seema jain J.
Mon Feb 4, 2008 08:06 pm
A 16 year old coming for emergency contraception is a challenging situation and needs to be dealt sensitively and in a nonjudgemental manner since a teenage pregnancy is not only a health issue,it is also a social issue.Apart from the time elapsed since the episode of sexual intercourse, the other important information I will ask is about her menstrual history. The date of her last period and period regularity will be inquired. I would also like to know whether she has been otherwise using regular contraception and what method of contraception she was following. Since she is an adolescent, I would ask her whether it is consensual sex or forced sex after taking her into confidence. I will also try to find out about any drug abuse, alcoholism or smoking and parental support I will reassure her that all the information will be kept confidential. I will ask her whether she has a single partner and also whether her partner has single or multiple partners. History of any sexually transmitted disease and treatment for the same will be inquired into. I will gently try to probe into her psychological status and knowledge of other contraceptive measures in an nonintrusive manner
The best option would be oral emergency contraception containing levonorgestrel single dose of 1.5 mg of levonogestrel or 0.75 mg levonorgestrel tablet which should be repeated after 12 hours.This will be a preferred method if she presents within 72 hours of unprotected sex because the efficacy is around 95percent though it can be given till 120 hours with proper counseling that its efficacy will decrease.The advantage of this method is that it does not have any absolute contraindication and does need any examination.Yuzpe?s regime is no longer followed.If she has a regular 28-30 day cycles and has had intercourse in the first 7days of her period,I will reassure her that the chances of pregnancy are negligible though even in this case its best to give emergency contraception after counseling. Though intrauterine contraception device is not the best option since she is nulliparous, but if she is not willing to use oral emergency contraception or if presents after 72hours,copper containing IUD can be considered if there is no active PID. .Mifepristone for emergency contraception is under research.
During the follow up visit, the main issue would be to find out whether a pregnancy has been averted and to counsel her regarding long term contraception and to see which contraceptive measure would best suit her.The follow up would be after 4-6 weeks during which she should have got her period.If it is found that she is pregnant then whether she wants to continue the pregnancy or not will be asked and managed accordingly.Though she is Frazer competent for contraception,she is a minor and her partner can be charged with rape.Such cases are best handled by judiciary. Since she is a teenage, my main aim would be to find out whether she has any social problem like illicit drug abuse, alcoholism, smoking and whether she is in a consensual or forced relationship. History of multiple sexual partners, any sexually transmitted disease would be delveed into.She will be referred to a GUM clinic if any STI is suspected for contact tracing and treatment. I will give her an idea regarding various modes of contraception and provide her with information leaflet regarding the same.If they are deemed compliant, use of condoms would be recommended for contraception. Important factors to be inquired into would be any family or personal history of vascular thromboembolism, family history of breast cancer. History of epilepsy and migraine will be asked. I would want to know whether she is taking any medication (which may include liver enzyme induces or antibiotics.)History of valvular heart disease and any valve replacement will be asked. If there are are no contradictions;hormonal contraception in form of oral,injectable,patch or implant may be offered. Since she is nulliparous, IUD would not be the best option but in case she is not fit or willing or has any contradiction to the above methods, IUD contraception may be offered after screening for Chlamydia.I would try to arrange this meeting with her partner and help them make the best decision..
Posted by Idris O.
Tue Feb 5, 2008 12:26 am
a) I would ask about her last menstrual period and whether her periods are regular because will affect effectiveness of any treatment offered.The date and the time of intercourse to presentation will determine if suitable for emergency postcoital contraception. Any other gynaecological problems like menorrhagia or dysmenorrhoea which also requires treatment. I would ask about her previous contraception and reasons for discontinuation. I would ask if this intercourse was with a regular partner or followed casual sexual intercourse .
History of previous STIs and treatment. Any previous pregnancy and the outcome. I would ask about medical problems like migraine or thromboembolism which are relative contra indication to combined pills. I would ask of symptoms of pregnancy like tiredness or early morning nausea and vomiting. Does she have result of pregnancy test.

b)The first option is Levonelle 2 ( two tablets of 1.5mg levonorgestrel) . This is effective up to 99% if taken within 72hours of unprotected intercourse. The earlier it is taken the more effective it is. The side effect include nausea, vomiting and breast tenderness. The dose should be repeated if she vomits within 4hours of taken the drug. The second option is the copper IUCD. This is also effective up to 99%. It can be used up to 5days following unprotected . It can also provide long term contraception if there are no contraindications like previous infection or menstrual problems like menorrhagia. The draw back is that she may require anaesthesia for its insertion . TheYuzpe regimen of combined oral contraception has gone out of favour because it is only 97% effective. It is also associated with troublesome side effects of nausea and vomiting . Mifepristone at a dose of 10mg is an unlicenced drug and more effective than levonelle for postcoital contraception. It can be taken up to 5days following unprotected intercourse.

c) She would be followed up within 2-3weeks of having emergency postcoital contraception. This is because her periods may be early or late. She would be seen earlier if she develops lower abdominal pain or vaginal bleeding. If she misses her period, a pregnancy test would be performed to confirm pregnancy. Opportunistic screening would be offered for STIs like chlamydia , gonococcal and hepatitis B. Her FBC, ABO blood group and rhesus would be determined as she may require antiD. A transvaginal scan would be performed to determine normal intrauterine location of the pregnancy or if it is an ectopic pregnancy. The gestational age of the pregnancy would also be determined. The option of treatment will be discussed with her. This includes continuing pregnancy or termination of pregnancy. If she wishes to continue with the pregnancy, she would be referred to ANC. If termination of pregnancy, this would be provided within 2weeks of the decision. She would be offered psychological counseling and social support to ensure there is no coercion and reduce the regret rate. The option of termination would be discussed with her. Medical termination is effective up to 15 weeks and is 85-95% effective. There is a risk of incomplete termination of pregnancy which may require surgical evacuation. The alternative is surgical termination of pregnancy which is suitable for gestation between 7-12 weeks. It may be done under general anaesthesia or sedation.It is associated with surgical complications of bleeding, infection, uterine perforation and injury to bowel or bladder. Contraception would be offered at the same time after the termination of the pregnancy.A follow up within 2-4weeks would be made to ensure good recovery post procedure. Psychological counseling and advice on safe sex would be offered.
Posted by PAUL A.
Tue Feb 5, 2008 03:18 pm
a) I would like to gather more information regarding time of unprotected sexual intercourse. If there were any previous episodes (1) of unprotected sex since her last menstrual period should be checked.History regarding her last menstrual period and cycle length (1) is important to asses her risk of pregnancy. Her risk of getting sexually transmitted infection should be assesed. Enquiry regarding partner should be made sensitively, if partner was stranger , new or long term partner number of partners . Her medical history should be checked especially hypertension, migraine focal migraine; family Hx of VTE, active liver disease , recent pelvic inflammatory disease (1) . Her drug history and if she had contraceptive pill in past should also be taken into account ? long-term contraceptive intentions .

Her options include levonelle do not use trade names 1500mg stat if episode happened not more than 72 hours ago (1) . It can be considered upto 96 hours but efficacy is poor. Antiemetic along with reduces risk of vomiting.It is simple method, doesnot involve examination, but efficacy declines with duration.
Intrauterine device other than mirena can be used if with in 5 days of ovulation or un protected intercourse (1) . This is highly effective and if patient wishes can be continued as followon contraceptive in a 16 year old nilliparous woman? . However it requires internal examination, can give discomfort during insertion and rare risk of perforation you were not asked to CRITICALLY evaluate . If she is at risk of infection how will you make this assessment and how accurate will you be? then antibiotic cover should be provided, otherwise risk of PID. If unfortunately patient is not eligible for any of these then she should be counselled regarding risk of pregnancy according to fertility period of her menstural cycle and advised to do pregnancy test if misses next period. However vaginal and endocervical swabs and antibiotics may be indicated if at risk of infection.

I would advise her that her period might be early or delayed if she had levonelle.I would advise to see her GP or family planning clinic around time when her next period is due to check pregnacy test , discuss swab results when were the swabs taken? What is the value of taking a swab say 6h after unprotected intercourse? and future contraception (1) . If pregnancy test is negative then to reassure with advice to repeat if still no period after a week. If pregnancy test is positive then her views regarding pregnancy (1) should be gathered, if she would continue or opt for termination.Appointment with counsellor should be considered. If she is unsure followup appointment in few days should be arrranged. If patient decides to have termination then she should be reffered at earliest and her blood group should be checked to asses need for anti-D. IF she decides to continue with pregnancy then USS to asses viability and site of pregnancy should be arranged and referal to antenatal clinic shouls be arranged.If swabs show sexually transmitted infection then empirical treatment and referal to GU clinic should be arranged to attain contact tracing and followup. Future contraception should be discussed and importance of safe sex what is safe sex? be discussed.

there are 2 parts to this question ? follow-up arrangements and management. You were asked to justify. When will you see her again (if at all) and why? What will you do when you see her and why? You have only considered what you will do if she had levonorgestrel. What if she had an IUCD?
Posted by PAUL A.
Tue Feb 5, 2008 03:19 pm
a) Detailed menstrual history (1) -Age at menarche, regularity of periods and LMP will be asked. Ask for complaints like vaginal discharge, post coital bleeding or lower abdominal pain suggesting PID (1) .

Sexual history like how many hours now since the sexual exposure, is the partner her only sexual contact, does she regularly have sex, and does this partner have any other sexual contacts (1) ? previous episodes . Does she feel coercised to have sex and was she offered money or gifts for the act and is she afraid of her partner. It is important to rule out sexual abuse. Though she is above age for consent for sex and is Frazer competent for requesting contraception, she is still a minor and her partner could be charged for rape if he is a major ? meaning You are venturing into deep water and will alienate the young woman early into the consultation. She may well tell you to mind your own business . Age of her partner should be asked.

I will take contraceptive history if any and her need in future (1) . I will ask her if she has knowledge of the contraceptive methods and STIs. I will enquire about her medical history and drug history?liver enzyme inducing drugs like phenytoin, carbamazepin, rifampicin which would require higher dose of LNG EC. contraindications to COCP
b) In Kwan and Ho method Levonorgestrel one step or Levonelle2 containing LNG 1.5mg is given ideally within 72 hrs of sex (1) for 84% effectivity in preventing pregnancy but it decreases to 63% effectivity not an English word. Efficacy when given from 72-120days days??/ . The EC can be repeated if she has further sexual exposure but Ideally she should be encouraged to follow regular contraception. There are no contraindications to this method. Advantages are it is single dose method, non-invasive, no risk of intrauterine infection and can be prescribed by GP, midwife without delay.

Cu IUD can be inserted within 5 days of sexual exposure or within 5 days of ovulation whichever is earlier (1) . The effectivity is 99% in preventing pregnancy. Risk of pregnancy varies in menstrual cycle and is 20-30% close to ovulation and this method is most effective if exposure has occurred during this period. It can be continued if she wants to continue the method in a 16 year old nullip?? Risk of infection and will protect her rest of the cycle. Does not need daily use of contraception, which is most useful if she has unplanned sexual exposures. Yuzpe\'s method is now not used due to less efficacy. Use of Mifepristone as Post coital contraception is under evaluation
c) She should followup after 1st menses or 3-6 weeks of IUD insertion (1) why? Justify . There is increased chance risk of infection within 20 days of insertion what about infection following unprotected intercourse? . I would explain to her the symptoms of pelvic infection and ask her to report if she has such symptoms, or is unable to feel threads suggesting expulsion or she misses a period suggesting pregnancy. If she gets pregnant there are chances it could be ectopic pregnancy though the risk of ectopic pregnancy is not increased due to IUD.Contraception lasts 5 years with Cu380A and after reviewing her risks of getting STI, I would enquire whether she would like to continue it.Cu IUD does not protect her against it so she would need concurrent use of condoms if at risk in a 16 year old nullip, you will remove the IUCD after her next period .

Following LNG one step, I would ask her to use condoms for rest of the cycle as she is not protected. She should follow up as soon as gets her period ? meaning? She should be followed up? or if she misses it. At the followup visit I will discuss various options of contraception with her (1) . No contraception is contraindicated based on her age alone and it depends on her life style, risk of pregnancy and STI.I would give her information booklets, website address like www.fpa.org.uk for more information and an appointment after she makes her decision.

what if she is pregnant?
Posted by PAUL A.
Tue Feb 5, 2008 03:21 pm
a)From the history, I need to know when the episode of unprotected intercourse occurred (1) . I will find out the date of the last menstrual period, length and regularity of the menstrual cycle. (1) This will enable me to determine the approximate time of ovulation and also whether there was a possibility that she may already have conceived in a previous cycle. I would enquire about previous episodes of unprotected intercourse, the number of sexual partners (1) and the presence of sexually transmitted infections such as Chlamydia do you expect her to know this? . A personal or family history of venous thrombolism or thrombophilias would increase her risk of developing thromboembolism and would affect the choice of emergency contraceptive it does not. Oestrogen-containing emergency contraceptives should no longer be used . Smoking will also have an impact how / why?? . A history of medication such as antibiotics or antiepileptic drugs is important because a higher dose of the hormonal emrgency contraceptive would be needed. I would also ask whether she had heart disease, since some conditions such as Eisenmenger\'s syndrome have a high incidence of maternal mortality and this would need to be considered in her follow up if she did conceive.

b) The intrauterine contraceptive device is an option for emergency contraception. It functions by preventing implantation. It may also have a toxic effect on sperm. It is beneficial because it can be effective up to 5 days after unprotected intercourse (1) will this be your first option in a 16 year old nillip? . In the presence of chlamydia how will you know when she presents? this can cause the infection to spread if untreated. The levonorgestrel pill is also effective oral form of emergency contraception. It is beneficial because it is effective if taken within 72 hours (1) of the unprotected intercourse. It is also good becuase it is not invasive such as the IUCD.

c) Follow up arrangements must be made because of the risk that she becomes pregnant what about risk of infection / long-term contraceptive needs? . This may be an intrauterine pregnancy or ectopic. The conception may be due to failure of the emergency contraception or she may have conceived in the previous cycle. The first visit should be approximately 2 weeks after the estimated date of ovulation typically 3 weeks after emergency contraception or as soon as possible after the next period .

In the follow up a pregnancy test must be done not if she had a period . If it is positive, an ultrasound scan would need to be done for location if you are seeing her 2 weeks after ovulation, will you expect to detect anything on scan? , dating and viability. If there is no intrauterine pregnancy identified then serial beta HCG\'s must be done to help determine the likelihood that the pregnancy is intrauterine or an ectopic pregnancy. If the pregnancy is intrauterine, then she should be referred for antenatal booking or termination of pregnancy depending on the patient\'s wishes. If the pregnancy is an ectopic, then mediacl treatment or laparscopic salpingectomy should be discussed based on the findings of the scan and level of serum beta HCG. The results of the vaginal and cervical swabs for infection must be reviewed if she presents say 6h after unprotected intercourse, how likely are you to detect infection? , since infections such as chlamydia can lead to significant tubal damage and subfertility, if the infection is not treated. A referral to the geniturinary clinc should be made for further assessment of sexually transmitted diseases and contact tracing. Advice on future contraception (1) and sexual health should be given.
Posted by PAUL A.
Tue Feb 5, 2008 03:22 pm
a.This patient is required emergency contraception (EC). Her last normal menstrual period is important information menstrual Hx should include cycle length . The last event of unprotected sexual intercourse (SI) should be obtained as well what about previous episodes? . Intrauterine contraceptive device (IUCD) is contraindicated for patient with history of recent sexual transmitted diseases or pelvic inflammatory diseases especially in the last 3 months so what history will you obtain from the patient? You are not answering the question . Family history of breast cancer or venous thrombo-embolism (VTE) should avoid the prescription of combined oestrogen and progestogen group a family history of breast cancer is not a contraindication to COCP . Current usage of enzyme inducing agent medication will require the patient to take higher dosing of EC. History of multiple sexual partners (1) should be asked as screening of STD should be carried out. Allergic history to copper or Wilson?s diseases will make IUCD become contraindicated. Her wishes for further contraception and her preference method of contraception (1) should be noted.
b.Option of EC include Yupze regime ( contain of ethinyloestradiol 100microgram and levonorgestrel 500microgram), this is no longer an acceptable option first dose is given within 24-72 hours of last unprotected SI and repeat another dose within 12 hours later. It has 77% of efficacy (if given within 24 hours of last unprotected coitus) but associated with vomiting and nausea or breast tenderness. Two doses of Levonorgestrel of 750microgram (1) ? single dose regimen?? , has better side effect with efficacy of 95% (first dose is within 24 of unprotedted coitus and second dose is after 12 hours later). Copper IUCD has less than 1 % of failure rate if it is inserted within 5 days of last unprotected SI or within 5 days of calculated ovulation period (1) . Mifepristone not licensed can be used up to five days of last unprotected SI with less side effect profile. Information leaflet should be given to the patient to enable inform decision.
c.She should be informed that the hormonal EC would cause a delay of period or abnormality bleeding. She should return earlier for pregnancy test if she has one week delayed of her expected menses or abnormal bleeding. STD screening should be arranged (1) if she has high risk behavior. She should be fully informed that IUCD will be removed (1) during her next period. Should she vomited after 2 to 3 hours of taking the hormonal EC, she should repeat another dose immediately. Prescription of anti-emetic is prudent to reduce vomiting or nausea. Termination of pregnancy can be discussed with the patient should she got pregnant discuss options, one of which is TOP . Future long term contraception (1) should be discussed to her to avoid unwanted pregnancy. Advice to reduce risk of STD (1) use of condoms or safe sex should be given to her if necessary. Written information and further follow-up should be provided.

Posted by PAUL A.
Tue Feb 5, 2008 03:22 pm
The main concerns are an unwanted pregnancy or contracting a sexually transmitted infection [STI]. I should ask about when that happened and whether there is previous episodes of unprotected intercourse in this cycle and when (1) . The date of her last menstrual period [LMP] and the regularity and length of her cycles (1) . I would like to ask about history of contraception and any associated complications, as well as the need for a contraception method (1) . I would like to ask about sexual history as number of sexual partners and a previous history of STI (1) . The medical history is also important as history of venous thrombo- embolism or focal migraine , as well as drug history like enzymes inducers (1) .
If there was less than 72 hours from the episode then she can use either the combined estrogen and progesterone [Yuzpe] should no longer be used , progesterone only, estrogen only should not be used and not licensed , mifepristone not licensed or the intra- uterine contraceptive device [IUCD]. Yuzpe can prevent 75% of pregnancies that would have occur that cycles, but associated with increased risks of side-effects especially nausea and vomiting. Progesterone and mifepristone are both more effective than Yuzpe with less side effects. With all these methods next period can be early, in time or delayed. They delay or prevent ovulation and there need to use barrier method during the rest of the period. The IUCD is almost effective in all cases, and can be used when more than 72 hours had passed, or till 5 days of calculated date of ovulation (1) . It can be used for longer contraception, but relatively contraindicated in nuliparous
A follow-up appointment at 3-4 weeks (1) should be advised. If missed period then pregnancy test should be requested. If positive she should be assured that there is no increase in risk of malformations, but if she want termination of the pregnancy then it will be arranged (1) . IUCD if not desired for longer period then it can be removed (1) should not be used long-term in a 16 year old nullip . Discuss future contraception (1) . To review the results of STI screening.
Posted by PAUL A.
Tue Feb 5, 2008 03:24 pm
a) A 16 year old girl must be given a non-judgemental, sensitive approach. She should be asked when and what time she had the episode of unprotected intercourse and whether there have been any previous episodes (1) , as emergency contraception isn\'t affective when it\'s been more than 5 days. She should also be asked when her last menstrual period was and what her cycle length (1) is and a pregancy test done if there is a possibility of this being positive.
Because she is underage is she below the age of consent? , sensitive enquiries should be made whether she gave consent to have intecourse, whether this is with a boyfriend and how old he is. She should also be asked whether either a parent or an adult she trusts is aware that she is sexually active. If she has had more episodes is she not as risk with just one episode? of unprotected intercourse, she is at risk of sexually transmitted disease, especially chlamydia.
Finally, she should be asked whether she has used contraception in the past and if she has, what the reason is she discontinued this (1) . A medical and drug history will show whether there are any contra-indications to certain types of contraception.

b) Levonelle is a high progesterone does not contain progesterone ? it contains a progestoGEN - levonorgestrel dose which can be given in a single dose or divided over two doses. A single dose gives higher compliance and only for that reason is more effective. It is effective in the first 72 hours following unprotected intercourse (1) and is more effective the sooner it is taken.
An intra-uterine contraceptive device is an effective method when inserted in the first 5 days following intercourse or 5 days of the most likely date of ovulation . it prevents implantation of the embryo in the endometrial cavity and does not prevent ectopic preganacies. It carries a risk of pelvic inflammatory disease if Chlamydia is allready present and for this reason cervical swabs should be taken and a single dose of 1 gram of azithromycin offered (1) . It is painfull to insert in a nullip and she can take analgesia following insertion to ease the pain. An advantage is that it also provides reliable, long-term contraception and can be left in-situ for up to 5 years will you do this in a 16 year old nullip? , or taken out any time sooner if no longer required. It needs to stay in for at least 2 weeks to provide the emergency contraception though. It may make her periods heavier and more painfull.
Information leaflets about themethod given should be provided and contact numbers in case she has any problems.

c) A follow-up appointment gives another opportunity when will you see her? That is the first part of the question to enquire after her social background and whether she is having intercourse with consent. This is also when contraception can be offered with written information on the various options available (1) . If she hasn\'t had a period since, a pregnancy test can be done with counselling if this is positive (1) . If she hasn\'t had swabs taken at the previous visit, these can be taken now (1) , as the prevalence of Chlamydia amongst sexually active teenagers in the UK is high and has long-term risks of PID, subfertility, chronic pain and ectopic pregancies. If swabs had been taken before, the results can be discussed and GUM referral and treatment offered. Condoms can be should be given to her and she should be encouraged to use these in addition to her contracetion (1) , to protect her form sexually transmitted disease. She should be encouraged to re-attend if another episode of unprotected intercourse happens in the future. Everything that has been done and said will remain confidential. Further follow-up will allow opportunity to ask about compliance with the methods used and any possible side-effects.

Posted by PAUL A.
Tue Feb 5, 2008 03:48 pm
I will ask how many hours have passed since she had sex ? previous episodes of unprotected intercourse? . I will also ask her last menstrual period ? cycle length to check if she has not already missed her period. I will enquire about her menstrual history if she has regular menstrual cycle to check the likelihood of ovulation. I will ask any history of sexually transmitted diseases (1) , any abnormal vaginal discharge, any treatment she is taking for any medical disease for example epilepsy. This will alter the dose of emergency contraception. I will ask if she has used any contraception before and any problems with different methods of contraception (1) . This will help in counseling her regarding regular method of contraception in future. I wiil ask her about use of condoms to prevent STDs. I will ask if her parents are aware that she is sexually active or not so that the medical staff will keep confidentiality.
Best option will be 1.5 mg of levonorgestrel as a single dose if she presents within 72 hours (1) of sexual intercourse. Other option is intrauterine contraceptive device but it is extremely difficult to insert in a 16 yrs old nulliparous woman when can this be used? Up to 5 days after most likely date of ovulation.
I will tell her that her expected period can be delayed by a few days because of hormonal emergency contraceptive but she should contact her gp if her period is delayed by more than 7 to 10 days. I will arrange a followup appointment in 2 weeks time to check if she is able to use a regular method of contraception most important thing will be to check that she is not pregnant or to advise regarding any problems that may arise during this period. On the other hand if emergency contraception fails, a followup appointment will help in discussing matters relatin to pregnancy (1) . I will discuss the options of continuing or termination of pregnancy, methods of termination and what it involves. This will be backed up by written information. In case she decides to continue with pregnancy she will be informed regarding social help if she needs and appropriate antenatal care will be arranged review after 3-4 weeks / as soon as possible after next period, check that she is not pregnant, remove IUCD if used, screen / review screening for STIs, discuss long-term contraception? .
Posted by PAUL A.
Tue Feb 5, 2008 03:49 pm
Eliciting the history should be done in a sensitive and non judgemental manner. She is assured that her responses are confidential.
It is important to determine how long ago the sexual act occureed ? previous episodes??. The nature of the sexual act and whether or not it was consensual should also be obtained. The date of her last normal menstrual period and whether or not she has regular menses should be determined (1) .
A prior history of contraceptive (1) use is elicited and if she has any concerns about contraceptive use should be addresses. A history of past or current sexuallt transmitted infections is important (1) . Age of coitarche and number of sexual partners you may need to make a judgement about using an IUCD, in rare cases for the long term are personal questions which are best avoided.
Use of enzyme inducing drugs eg antiepileptics is elicited. Any use of alcohol or illicit drugs that can potentilly lead to unsafe sexual practices is also important (1) .

b) The patient is presented with the options and allowed to decide in conjunction with the obstetrician is this an obstetric or a gynaecological problem? which is best for her.
One option is use of leonorgestrel 0.75mg taken orally 12 hours apart. The first dose must be taken within 72 hours of sex. It is associted with nausea and vomiting and an antiemetic can also be prescribed lower risk than oestrogen-containing preparations . This is 95% effective in preventing pregnancy. Alternatively a single dose of levonorgestrel can be taken within 72 hours os sex (1) .
The copper containing IUCD is the most effective form of emergency contraception. It can be used within 5 days of sex or 5 days within the earliest estimated date of ovulation (1) . Active PID is a contraindication to this method ? screen + prophylactic antibiotics .
Mifepristone is another alternative not licensed . Its efficacy rate is simplilar to that using levonorgestrel. Information leaflets should be given.

c) She is advised that if she vomits within 2 hours of taking the oral method she will need to take another dose. Use of enzyme inducing drugs will necessitate an increase in the dosage used. She is advised that her menses can be delayed following use of hormonal emergency contraception. A follow uo visit is scheduled for 4-6 weeks if you are seeing her mid-cycle and she is reviewed 6 weeks later, she could be 8 weeks pregnant .
At the follow up visit an enquiry is made about if she has menstruated. If not a sensitive UPT ?? is done. She is counseled about contraceptive methods (1) . She is encouraged to uise a barrier form of contraception to prevent STIs (1) in conjuction with any hormaonal method chosen. Chlamydia infection is very prevalent in sexually active teenagers and screening for chlamydia should be encouraged. Testing for other STIs eg HIV should also be discussed with her (1) .
Information leaflets are provided to her to supplement the discussion.
Posted by PAUL A.
Tue Feb 5, 2008 03:49 pm
(a) What information will you obtain from the history? [8 marks]
A detailed menstrual history what do you ask for when you take a detailed menstrual Hx? The examiner cannot assume that you know and timing of unprotected sexual intercourse ? previous episodes?? in relation to the current menstrual cycle and history of recent pelvic infection (1) should be elicited. Medical history is important to rule out contraindication for Emergency contraception particularly higher dose of COCP oestrogen-containing preparations should not be used . History of focal migraine and thromboembolism should be asked. Previous contraceptive history (1) including emergency contraception is useful to assess the patient compliance.

(b) Evaluate the options for emergency contraception in this patient [4 marks].
Progesterone only pill (Levonelle) this is NOT the progesterone-only pill is the current treatment of choice .0.75mg levenorgestrel taken 12 hr apart. This has fewer side effects compared with high dose combined pill (1) what about single dose regimen? .
High dose COCP should no longer be used can be given if there is no contraindications (Present or past Cardiovascular disease, focal migraine, liver disease, BP more than 160/100).100microgram ethynyl oestradiol with 250 microgram levenogestrel repeated in 12hrs can be offered.IUD is an option as long as it is fitted within 5 days of earliest ovulation (1) .sceering for Chlamydia infection is important before Copper IUD insertion (1) + prophylactic antibiotics .

(c) Justify your follow-up arrangements and management during the follow-up visit [8 marks].
Follow up should be arranged within 3-4 wks (1) of the treatment or earlier if she has any pain, bleeding or concerns. At follow up details of post treatment menstrual period should be documented
If she has menstruation future contraception must be discussed (1) and previous failed contraception and compliance taken into consideration and suitable method of contraception should be given. Woman?s decision to use emergency contraception after full discussion backed up by information leaflet. remove IUCD if used
If Post coital contraception failed and preganancy suspected and diagnosed (1) as any other unintended pregnancy. She may have an option of termination of pregnancy discuss options including TOP .
Woman\'s descion should be documented. If the she was offered any STD screening after unprotected sexual intercourse, the results should be discussed if necessary ? further screening. Tests taken a few hours after intercourse are unlikely to be informative Patient should be referred to GU clinic.
Posted by M M A.
Tue Feb 5, 2008 07:15 pm
a)
We inquire about duration since contact as emergency contraception act within limited time, we inquire also if this was an incidental episode or she has continuous relationship because this will help making good decision about type of contraception required.
We ask her about last LMP as she may be already pregnant also inquire about any medical diseases like liver disease, congenital heart disease which require special precaution before prescribing contraception.
We ask her about drug ingestion, smoking and alcohol intake also ask if her partner has other partners because this will increase her risk for acquiring STIs and this will affect her further management and advices. We try to deal with her in a sensitive non judgmental manner. History of previous pregnancy and termination also relevant and if there was any complications like perforation so as to shift toward hormonal contraception more than the use of IUDs.
History of violence also can be obtained.
We try also to assess her mental ability and whether she is competent to give consent or not and whether her family knows about her or not. She is reassured that her confidentiality will be preserved.

b)
Oral Levonorgestril tables ( two tablets as single dose) can be offered to her, it is effective contraception if taken within 72 hours from her episode, it is easy method with few side effect and can be used more than once during one menstrual cycle.

IUDs can be offered also , it is not considered as absolute contraindication in nullipara any more, it is also effective up to 5 days after episode. It can be left in utero for longer duration of contraception if she wish.

c)
Follow up appointment is given, cervical swab is adviced because her age put her at high risk of getting STIs, if the test is positive, we offer her antibiotic also we advice for referral for genitourinary clinic for contact tracing and management.

Her next cycle should be expected on its time, if she had delay of 7 days or more, or her menstruation is lighter than usual she should have a pregnancy test. If she is pregnant, we offer her options of termination or continuation of pregnancy +\\- adoption provided that she is fraser ruling competent [ understand our advices, she may continue to have relationship, advice her to inform her parents and treatment will be in her best interest].

If she is not pregnant and she wish to continue on contraception, we either offer her to continue to use IUCD and we should exclude partial or complete expulsion, or she can start regular hormonal contraception at her 5th day of the cycle and the IUD is removed provided that she has good compliance.
If she is smoker or drug abuser, we advice for cessation therapy, we can do screening for other diseases like hepatitis and HIV.
We provide patient information leaflet and contact information of support group.
We give her information also about risks of STIs and explain benefits of barrier methods. We advise her to avoid future unplanned pregnancies, emergency contraception can be prescribed in advanced if she is competent and had good compliance. We give her telephone numbers and contact details and encourage her to attend again in future if she need help or advice.


Posted by PAUL A.
Tue Feb 5, 2008 10:49 pm
a)Before prescribing the medication I would like to know the date and duration since the sexual intercourse ? previous episodes and the type of penentration whether oral,vaginal or anal.I Would also ask if she is in a stable relationship.
Menstrual history in terms of last menstrual period and whether her periods are regular i (1) s important.I would like to know if she has been pregnant before or if she has had any terminations.
Other information like whether she has been tested for sexually transmitted infection in the past and if her parents know this ?? value and would she want to tell them about it.
Information of any medical problems like diabetes,chronic illness,medication like antibiotics and immunosuppresants and any allergies is vital before prescribing.

b)The options depend on the duration since the time of intercourse.
Yuztpe method is using high doses of combined oral contraceptive pill taken 12hrs apart but not used in UK currently due to side effects why present this as an option? .
If less than 3 days she can be given levenol 75mgs ? dose which has to be taken 12 hours apart or a single dose of 150mg tablets as soon as possible.If she vomits straight away she has to take another dose.Side effects are nausea and vomiting.
For upto 5 days or 5 days after the most likely date of ovulation we could insert a intrauterine contraceptive device(IUCD)can be fitted in.This prevents implantation.
These are very effective treatment and sooner the treatment taken the efficacy is better.

c)Follow up arrangement is made after her next periods to discuss contraception or if there is a delay in her periods as she could be pregnant.Report if any pregnancy symptoms develop are you going to wait until she develops pregnancy symptoms? She should be seen as soon as possible after the next period or within 3-4 weeks .Counsel her that the tablets are not a method of contraception and should use other forms of long term contraception .IUCD could be used as a long term contraception ? in a 16 year old nullip?? .
At the follow up visit do a pregnancy test if her periods are delayed.If negative advice about different forms of contraception available (1) .
Screen her for sexually transmitted infection (1) and treat her accordingly with contact tracing.Advice in using barrier method to prevent them.
Information leaftlets about the contraception and STIs are given.
Posted by PAUL A.
Tue Feb 5, 2008 10:50 pm
A 16 year old coming for emergency contraception is a challenging situation and needs to be dealt sensitively and in a nonjudgemental manner since a teenage pregnancy is not only a health issue,it is also a social issue.Apart from the time elapsed since the episode of sexual intercourse ? previous episodes , the other important information I will ask is about her menstrual history. The date of her last period and period regularity will be inquired (1) . I would also like to know whether she has been otherwise using regular contraception and what method of contraception she was following (1) . Since she is an adolescent, I would ask her whether it is consensual sex or forced sex after taking her into confidence. I will also try to find out about any drug abuse, alcoholism (1) or smoking and parental support I will reassure her that all the information will be kept confidential. I will ask her whether she has a single partner and also whether her partner has single or multiple partners. History of any sexually transmitted disease (1) and treatment for the same will be inquired into. I will gently try to probe into her psychological status and knowledge of other contraceptive measures in an nonintrusive manner
The best option would be oral emergency contraception containing levonorgestrel single dose (1) of 1.5 mg of levonogestrel or 0.75 mg levonorgestrel tablet which should be repeated after 12 hours.This will be a preferred method if she presents within 72 hours of unprotected sex because the efficacy is around 95percent though it can be given till 120 hours with proper counseling that its efficacy will decrease.The advantage of this method is that it does not have any absolute contraindication and does need any examination.Yuzpe?s regime is no longer followed. If she has a regular 28-30 day cycles and has had intercourse in the first 7days of her period,I will reassure her that the chances of pregnancy are negligible though even in this case its best to give emergency contraception after counselling it is not appropriate to withhold emergency contraception if intercourse occurred in the first 7 days . Though intrauterine contraception device is not the best option since she is nulliparous, but if she is not willing to use oral emergency contraception or if presents after 72hours,copper containing IUD (1) ? screen for infection + prophylactic antibiotics can be considered if there is no active PID. .Mifepristone for emergency contraception is under research.
During the follow up visit when? , the main issue would be to find out whether a pregnancy has been averted and to counsel her regarding long term contraception and to see which contraceptive measure would best suit her.The follow up would be after 4-6 weeks if you see her 6 weeks later, she could be 8 weeks pregnant during which she should have got her period.If it is found that she is pregnant then whether she wants to continue the pregnancy or not will be asked you need to discuss options rather than simply ask her. She might not know what the options are and managed accordingly.Though she is Frazer competent for contraception,she is a minor and her partner can be charged with rape.Such cases are best handled by judiciary ?? meaning?? If she is pregnant at 16, will you call the police?? (-1) . Since she is a teenage, my main aim would be to find out whether she has any social problem like illicit drug abuse, alcoholism, smoking and whether she is in a consensual or forced relationship. History of multiple sexual partners, any sexually transmitted disease would be delveed into.She will be referred to a GUM clinic if any STI is suspected for contact tracing and treatment. I will give her an idea why just an idea? Why not detailed information? regarding various modes of contraception and provide her with information leaflet regarding the same. If they are deemed compliant, use of condoms would be recommended for contraception are condome a reliable method of contraception in a 16 year old?? (-1) . Important factors to be inquired into would be any family or personal history of vascular thromboembolism, family history of breast cancer. History of epilepsy and migraine will be asked. I would want to know whether she is taking any medication (which may include liver enzyme induces or antibiotics.)History of valvular heart disease and any valve replacement will be asked you should have optained this in (a) . If there are are no contradictions;hormonal contraception in form of oral,injectable,patch or implant may be offered. Since she is nulliparous, IUD would not be the best option but in case she is not fit or willing or has any contradiction to the above methods, IUD contraception may be offered after screening for Chlamydia.I would try to arrange this meeting with her partner and help them make the best decision..
Posted by Hala T.
Wed Feb 6, 2008 04:55 am
a)Information should include detailing of the last menstrual period. Enquiry should cover the most likely date of ovulation based on the LMP and the usual cycle length. Detailed history of timing of the sexual episode , and any previous episodes should be obtained.
I would ask her about history of ( STIs),symptoms of lower abdominal pain , postcoital pain, and abnormal vaginal discharge. I would ask her about any medical conditions such as focal migraine , drug history and allergy, or history of liver-enzyme inducing drugs .
I would ask her about family history of venous thromboembolism, liver dysfunction , and family or personal history of malabsorption syndromes such as ( Crohns?s disease ) which may reduce efficacy of oral EC ( emergency contraception). I would ask her sensitively about sexual history including presence of a new partner or more than partner .
b) A single oral 1.5 mg dose of levonorgestrel-only emergency contraceptive ( Levonelle one step ) is an option . It is more effective than ( combined oestrogen +progestogen which not licensed for use in UK now) and has fewer side effects. It should be administered as soon as possible within 72 hours after the unprotected sexual intercourse. Its efficacy is about 85% as oral EC. It has the same effectiveness as two doses 0.75 mg 12 hrs apart ,with no increase in the side effects. It has side effects such as nausea , vomiting ,breast tenderness and 16% bleeding disturbance which is unrelated to menstruation. Its efficacy may be reduced by hepatic dysfunction and severe malabsorption syndrome such as ( Crohn?s disease).
A copper IUD can be inserted up to 5 days after the episode of unprotected intercourse or the most likely date of ovulation .Prior to emergency IUD insertion ,she should be offered testing for Chlamydia Trachomatis , as a minimum testing . If the results of the testing are not available at the time of IUD insertion, the of prophylactic antibiotics (Zithromax) should be used as single dose. Nulliparity and young age are not contraindicated to IUD use. The benefits of IUD use outweigh risks ( WHO category 1 ; unrestricted use ). There may be a small increase of pelvic infection in the first 20 days following IUD insertion. IUD insertion may be difficult ,painful particularly in nulliparous woman .The efficacy of emergency IUD is 99%.. The failure rate of IUD for EC is < 1 % ( RCT ), and the risk of ectopic pregnancy is also very low.
c) She should be counseled and discussed about the failure rate of the regimens . Her attitude should be explored towards the possible failure of the regimen and continuation of pregnancy.
LVN EC ( 1.5 mg single dose ) does not provide a contraceptive cover for the remainder of the cycle, so, the practice of abstinence should be advised. An emergency IUD can be removed at any time after the next menstruation if no UPSI has occurred since menses or hormonal contraception was started within the first 5 days of that cycle.
She should be discussed about the long-term reversible methods of contraception ; such as IUD , IUS , Implants , which are more appropriate than COCP , especially if it is bearing in mind the difficulties in some young women have with compliance.
I would provide written information leaflet , and follow-up appointment within 3-4 weeks of EC treatment.
She should be offered to have pregnancy test in the appointment visit , if her menstruation is more than 7 days late ,or lighter than usual . If pregnancy is diagnosed , it should be managed as for any unintedended pregnancy; and termination of pregnancy is an option. If she opts to continue the pregnancy , she would be referred to continue the pregnancy with follow-up at the out-patient antenatal clinic. The possibility of the ectopic pregnancy in such woman should be taken into-account according to her clinical assessment .
If she has emergency IUD ,may choose to keep it as regular method of contraception. She should be advised to return 3-6 weeks for a check to exclude infection, perforation or expulsion.
Posted by Farina A.
Wed Feb 6, 2008 07:51 pm
History should be taken after obtaining a good rapport and ensuring her confidentiality. i would like to know about any previous pregnancy, timing and frequency of intercourse. Her menstrual cycle, its regularity and the LMP should be enquired as she may be pregnant before commencing emergency contraceptive. It is important know about the consent of the act, and the partner, weather known or unknown for medico legal implications. She should be asked about recreational drugs, substance misuse and alcohol ingestion for appropriate management. History of sexually transmitted diseases, its treatment and prevention is also important. I would like to know about any contraceptive measures she took in the past, its compliance and effectivity. Personal and family history of DVT and migrane is important for prescription of contraceptives. Her educational, socioeconomic status and competence for consent to treat should be assessed during history taking as it can effect compliance to the treatment, future contraception and medico legal aspects. Her views about involving a parent, guardian or a friend are noted.

Provided there is no contraindication and she presents immediately or within 72 hrs of unprotected intercourse, the contraceptive choice she has is 0.75 mg levonorgesteal 12 hrs apart or 1.2mg once. Side effects include nausea, vomiting how ever the side effect profile is better than combined estrogen and progesterone. Single dose regime is better tolerated and easy to take. The efficacy reduces after 72 hrs but is still effective. The combine regime has ethnyle eastradiol 100mcg and levonorgesteral 500mcg, to be taken 12 hrs apart, has side effects of nausea, vomiting, breast tenderness and headaches. Mifeprestone 600mg is one of the effective single dose therapy with minimum side effects and failure rate of less than 1%. Low doses 20mg are equally effective. Copper IUCD are effective up to 5 days of unprotected intercourse however caries risk of infection, bleeding and uterine cramps and may be unsuitable for nullipara. The advantage of IUCD is its continuation as a future contraception and absence of hormonal side effects.

Follow up is arranged after 3-4wks with a pregnancy test. Side effects are assessed and treated accordingly. Sexually transmitted diseases including HIV, Hep B and C should be screened. Partner notification is essential for prevention of future contracting of a STI. Use of condoms for prevention of STI should be advised. Future contraception should be discussed. Long acting progestational preparations are the most suitable for these young women. Ingectables are preferred over implants due to easy reversibility. In case of emergency contraceptive failure occurs, patient?s views about continuation and termination of pregnancy should be taken in account. Mode, timing and risks of TOP should be discussed in detail. Advice against unhealthy sexual behavior and substance misuse should be given. Information about STD, teenage pregnancies and its risk should be provided with. Opportunistic screening and vaccination for rubella and varcella zoster can be performed during this period.
Posted by PAUL A.
Thu Feb 7, 2008 04:20 pm
a) I would ask about her last menstrual period and whether her periods are regular (1) because will affect effectiveness of any treatment offered. The date and the time of intercourse to presentation ? meaning?? will determine if suitable for emergency postcoital contraception. Any other gynaecological problems like menorrhagia or dysmenorrhoea which also requires treatment. I would ask about her previous contraception (1) and reasons for discontinuation. I would ask if this intercourse was with a regular partner or followed casual sexual intercourse .
History of previous STIs (1) and treatment. Any previous pregnancy and the outcome. I would ask about medical problems like focal migraine or thromboembolism which are relative contra indication to combined pills (1) . I would ask of symptoms of pregnancy like tiredness or early morning nausea and vomiting. Does she have result of pregnancy test.

b)The first option is Levonelle 2 ( two tablets of 1.5mg 750mcg levonorgestrel) . This is effective up to 99% if taken within 72hours of unprotected intercourse. The earlier it is taken the more effective it is. The side effect include nausea, vomiting and breast tenderness. The dose should be repeated if she vomits within 4hours of taken the drug ? single dose regimen. The second option is the copper IUCD. This is also effective up to 99%. It can be used up to 5days following unprotected 5 days after most likely date of ovulation . It can also provide long term in a 16 year old nullip? contraception if there are no contraindications like previous infection or menstrual problems like menorrhagia. The draw back is that she may require anaesthesia for its insertion . TheYuzpe regimen of combined oral contraception has gone out of favour because it is only 97% effective. It is also associated with troublesome side effects of nausea and vomiting . Mifepristone at a dose of 10mg is an unlicenced drug and more effective than levonelle for postcoital contraception. It can be taken up to 5days following unprotected intercourse.

c) She would be followed up within 2-3weeks (1) of having emergency postcoital contraception. This is because her periods may be early or late because of risk of pregnancy / STIs and to discuss long-term contraception . She would be seen earlier if she develops lower abdominal pain or vaginal bleeding. If she misses her period, a pregnancy test would be performed to confirm pregnancy. Opportunistic screening would be offered for STIs like chlamydia , gonococcal and hepatitis B (1) . Her FBC, ABO blood group and rhesus would be determined as she may require antiD. A transvaginal scan would be performed to determine normal intrauterine location of the pregnancy or if it is an ectopic pregnancy. The gestational age of the pregnancy would also be determined. The option of treatment will be discussed with her. This includes continuing pregnancy or termination of pregnancy (1) . If she wishes to continue with the pregnancy, she would be referred to ANC. If termination of pregnancy, this would be provided within 2weeks of the decision. She would be offered psychological counseling and social support to ensure there is no coercion and reduce the regret rate. The option of termination would be discussed with her. Medical termination is effective up to 15 weeks and is 85-95% effective. There is a risk of incomplete termination of pregnancy which may require surgical evacuation. The alternative is surgical termination of pregnancy which is suitable for gestation between 7-12 weeks. It may be done under general anaesthesia or sedation.It is associated with surgical complications of bleeding, infection, uterine perforation and injury to bowel or bladder. Contraception would be offered at the same time after the termination of the pregnancy.A follow up within 2-4weeks would be made to ensure good recovery post procedure. Psychological counseling and advice on safe sex would be offered. it is not clear why you have focused on pregnancy / TOP. What if she is not pregnant? Remove IUCD if used, discuss long-term contraception

Posted by PAUL A.
Thu Feb 7, 2008 04:21 pm
a)
We inquire about duration since contact what does contact mean? Any previous episodes of unprotected intercourse?? as emergency contraception act within limited time, we inquire also if this was an incidental episode ? meaning?? or she has continuous relationship because this will help making good decision about type of contraception required.
We ask her about last LMP ? cycle length as she may be already pregnant also inquire about any medical diseases like liver disease, congenital heart disease which require special precaution before prescribing contraception.
We ask her about drug ingestion, smoking and alcohol intake (1) also ask if her partner has other partners because this will increase her risk for acquiring STIs (1) and this will affect her further management and advices. We try to deal with her in a sensitive non judgmental manner. History of previous pregnancy and termination also relevant and if there was any complications like perforation so as to shift toward hormonal contraception more than the use of IUDs.
History of violence also can be obtained.
We try also to assess her mental ability and whether she is competent to give consent consent to what? Sexual intercourse or contraception? You are not making yourself clear or not and whether her family knows about her or not ? meaning?? This statement is essentially meaningless in the context of the question . She is reassured that her confidentiality will be preserved.

b)
Oral Levonorgestril tables ( two tablets as single dose) can be offered to her, it is effective contraception if taken within 72 hours (1) from her episode, it is easy method with few side effect and can be used more than once during one menstrual cycle.

IUDs can be offered also , it is not considered as absolute contraindication in nullipara any more, it is also effective up to 5 days after episode or 5 days of the most likely date of ovulation . It can be left in utero for longer duration of contraception if she wish ? in a 16 year old nullip? .

c)
Follow up appointment is given when? , cervical swab is adviced because her age put her at high risk of getting STIs (1) , if the test is positive, we offer her antibiotic also we advice for referral for genitourinary clinic for contact tracing and management.

Her next cycle should be expected on its time, if she had delay of 7 days or more, or her menstruation is lighter than usual she should have a pregnancy test. If she is pregnant, we offer her options of termination or continuation of pregnancy +\\- adoption provided that she is fraser ruling competent ? relevance?? [ understand our advices advice (no s) , she may continue to have relationship, advice her to inform her parents and treatment which treatment will be in her best interest].

If she is not pregnant and she wish to continue on contraception, we either offer her to continue to use IUCD it should be removed in a 16 year old nullip unless there are exceptional circumstances and we should exclude partial or complete expulsion, or she can start regular hormonal contraception at her 5th day of the cycle do you normally recommend that women commence contraception on the 5th day of their cycle? (-1) and the IUD is removed provided that she has good compliance.
If she is smoker or drug abuser, we advice for cessation therapy, we can do screening for other diseases like hepatitis and HIV.
We provide patient information leaflet and contact information of support group which support group? .
We give her information also about risks of STIs and explain benefits of barrier methods (1) . We advise her to avoid future unplanned pregnancies, emergency contraception can be prescribed in advanced NO ? you have a responsibility to ensure that this is not needed. (-1) if she is competent and had good compliance. We give her telephone numbers and contact details and encourage her to attend again in future if she need help or advice.

You have not focused on the question and have lost marks for incorrect statements which are also irrelevant
Posted by PAUL A.
Thu Feb 7, 2008 04:23 pm
a)Information should include detailing of the last menstrual period. Enquiry should cover the most likely date of ovulation based on the LMP and the usual cycle length (1) . Detailed history of timing of the sexual episode , and any previous episodes should be obtained (1) .
I would ask her about history of ( STIs) (1) ,symptoms of lower abdominal pain , postcoital pain, and abnormal vaginal discharge. I would ask her about any medical conditions such as focal migraine , drug history and allergy, or history of liver-enzyme inducing drugs (1) .
I would ask her about family history of venous thromboembolism, liver dysfunction , and family or personal history of malabsorption syndromes such as ( Crohns?s disease ) which may reduce efficacy of oral EC ( emergency contraception). I would ask her sensitively about sexual history including presence of a new partner or more than partner (1) .
b) A single oral 1.5 mg dose of levonorgestrel-only emergency contraceptive ( Levonelle one step ) is an option . It is more effective than ( combined oestrogen +progestogen which not licensed for use in UK now) and has fewer side effects. It should be administered as soon as possible within 72 hours (1) after the unprotected sexual intercourse. Its efficacy is about 85% as oral EC. It has the same effectiveness as two doses 0.75 mg 12 hrs apart ,with no increase in the side effects. It has side effects such as nausea , vomiting ,breast tenderness and 16% bleeding disturbance which is unrelated to menstruation. Its efficacy may be reduced by hepatic dysfunction and severe malabsorption syndrome such as ( Crohn?s disease).
A copper IUD can be inserted up to 5 days after the episode of unprotected intercourse or the most likely date of ovulation (1) .Prior to emergency IUD insertion ,she should be offered testing for Chlamydia Trachomatis , as a minimum testing . If the results of the testing are not available at the time of IUD insertion, the of prophylactic antibiotics (Zithromax) (1) do not use trade names should be used as single dose. Nulliparity and young age are not contraindicated to IUD use. The benefits of IUD use outweigh risks ( WHO category 1 ; unrestricted use ). There may be a small increase of pelvic infection in the first 20 days following IUD insertion. IUD insertion may be difficult ,painful particularly in nulliparous woman .The efficacy of emergency IUD is 99%.. The failure rate of IUD for EC is < 1 % you are repeating yourself ? you already quoted a 99% efficacy = 1% failure rate ( RCT ), and the risk of ectopic pregnancy is also very low.
c) She should be counseled you are not answering the question. YOU WERE NOT ASKED ABOUT COUNSELLING and discussed about the failure rate of the regimens . Her attitude should be explored towards the possible failure of the regimen and continuation of pregnancy.
LVN EC ( 1.5 mg single dose ) does not provide a contraceptive cover for the remainder of the cycle, so, the practice of abstinence should be advised. An emergency IUD can be removed at any time after the next menstruation if no UPSI has occurred since menses or hormonal contraception was started within the first 5 days of that cycle.
She should be discussed about the long-term reversible methods of contraception ; such as IUD , IUS will you use these in a 16 year old nullip? , Implants , which are more appropriate than COCP on what basis? Have you encountered any 16 year old nullips with an IUCD? Have you encountered any 16 year old nullips taking COCP? Why, if IUCD is more appropriate? (-1) , especially if it is bearing in mind the difficulties in some young women have with compliance.
I would provide written information leaflet , and follow-up appointment within 3-4 weeks (1) this was the first part of the question of EC treatment.
She should be offered to have pregnancy test in the appointment visit , if her menstruation is more than 7 days late ,or lighter than usual . If pregnancy is diagnosed , it should be managed as for any unintedended pregnancy; and termination of pregnancy is an option (1) . If she opts to continue the pregnancy , she would be referred to continue the pregnancy with follow-up at the out-patient antenatal clinic. The possibility of the ectopic pregnancy in such woman should be taken into-account according to her clinical assessment .
If she has emergency IUD ,may choose to keep it as regular method of contraception not in a 16 year old nullip except in exceptional circumstances . She should be advised to return 3-6 weeks for a check to exclude infection, perforation or expulsion.

Posted by PAUL A.
Thu Feb 7, 2008 04:23 pm
History should be taken after obtaining a good rapport and ensuring her confidentiality. i would like to know about any previous pregnancy, timing and frequency of intercourse. Her menstrual cycle, its regularity and the LMP (1) should be enquired as she may be pregnant before commencing emergency contraceptive. It is important know about the consent of the act, and the partner, weather known or unknown for medico legal implications what are these?? . She should be asked about recreational drugs, substance misuse and alcohol ingestion (1) for appropriate management. History of sexually transmitted diseases (1) , its treatment and prevention is also important. I would like to know about any contraceptive measures she took in the past (1) , its compliance and effectivity. Personal and family history of DVT and focal migrane is important for prescription of contraceptives. Her educational, socioeconomic status ? relevance and competence for consent to treat should be assessed during history taking as it can effect compliance to the treatment, future contraception and medico legal aspects. Her views about involving a parent, guardian or a friend are noted.

Provided there is no contraindication what are the possible contraindications? and she presents immediately or within 72 hrs of unprotected intercourse, the contraceptive choice she has is 0.75 mg levonorgesteal 12 hrs apart or 1.2mg 1.5mg once. Side effects include nausea, vomiting how ever the side effect profile is better than combined estrogen and progesterone. Single dose regime is better tolerated and easy to take. The efficacy reduces after 72 hrs but is still effective ? meaning? What does effective mean? . The combine regime has ethnyle eastradiol 100mcg and levonorgesteral 500mcg, to be taken 12 hrs apart should no longer be used , has side effects of nausea, vomiting, breast tenderness and headaches. Mifeprestone 600mg is one of the effective single dose therapy with minimum side effects and failure rate of less than 1%. Low doses 20mg are equally effective not licensed . Copper IUCD are effective up to 5 days of unprotected intercourse or 5 days from most likely date of ovulation however caries risk of infection, bleeding and uterine cramps and may be unsuitable for nullipara. The advantage of IUCD is its continuation as a future contraception and absence of hormonal side effects.

Follow up is arranged after 3-4wks (1) with a pregnancy test even if she has a period?? . Side effects are assessed and treated accordingly which side-effects will you expect 3-4 weeks later?? . Sexually transmitted diseases including HIV, Hep B and C should be screened (1) . Partner notification is essential for prevention of future contracting of a STI. Use of condoms for prevention of STI should be advised (1) . Future contraception should be discussed. Long acting progestational preparations are the most suitable for these young women on what bases?? . Ingectables are preferred over implants due to easy reversibility is depot-provera easily reversible? How does this compare with taking out an implanon implant? (-1) . In case of emergency contraceptive failure occurs, patient?s views about continuation and termination of pregnancy should be taken in account (1) . Mode, timing and risks of TOP should be discussed in detail. Advice against unhealthy sexual behavior and substance misuse should be given. Information about STD, teenage pregnancies and its risk should be provided with. Opportunistic screening and vaccination for rubella and varcella zoster ? basis?? Not routine in the UK can be performed during this period.
Posted by Hala T.
Thu Feb 7, 2008 06:03 pm
Dear Dr. Paul :
Thanks for correcting my answer, but i\'d like to tell you that in the last (The Obstetrician & Gynaecologist Vol. 10 ,issue N0: 1 ) :
The NICE guidance emphasises that younger women should not be considered unsuitable for these methods : they can be used in nulliparous young women and there are no restrictions to the use of intrauterine devices (IUDs) or intrauterine systems ( IUSs) in adolescents. { page 25 }.
Regarding the contraceptive pill : It is the most commonly known to young women ,however ,the long-acting reversible methods may actually be more appropriate for teenagers. { page 26 }.
Regarding the injectable contraception : The young women will become anxious about amenorrhoea and suspect that they are pregnant unless they have been warned to expect this.
Also, Bearing in mind the difficulties some young women have with compliance , it is advisable to consider Longer-acting contraceptive methods . { page 26 }
Thank you very much .
Posted by M M A.
Thu Feb 7, 2008 06:52 pm
Please Dr Paul ,

FFPRHC Guidance on Emergency contraception(April 2006)state that {Advance provision of LNG can be offered to women to increase early use when required(Grade A)}.page 126

It also sate that [ Risk of sexually transmitted infections (STIs),
previous ectopic pregnancy, young age, and nulliparity are not contraindications to IUD use.] page 123

Also FSRH Guidance on Intrauterine Contraception(November 2007) put nulliparity in UKMEC category[1], ie: unrestricted use

but I am not sure whether this include teenage nulipara or not

I loss 2 marks with these items.

Can I have more clarification please?

Thank you.

Posted by Elizabeth  V.
Fri Feb 8, 2008 04:19 am
Emergency contraception is high dose hormonal contraception and is suitable only if used within 72 hrs of exposure.
A detailed history is esential to determine suitability for the same.
Details of her LMP (last menstrual period) and menstrual cycle should be enquired and if uncertain about pregnancy a urine pregnancy test should be done.Any history of abnormal vaginal bleeding or discharge,or history of multiple partners, should prompt a speculum examination and swabs to rule out pelvic infection.Details of the timing of last unprotected intercourse and history of any previous episodes should be enquired.The relevance of emergency contraception is lost if she has had multiple episodes in the same cycle.Specific enquiry regarding contraindications for hormonal emergency contraception should be done,such as migraine ,active liver disease,DVT,Cardiac disease,thrombophilia.
Medications are also of relevance as some enzyme inducing drugs are associated with increased failure rates of hormonal emergency contraception,due to rapid clearance of the drug.
Use of any contraception in the past as well as previous use of emergency contraception and any side effects with these can also be elicited.
The options for emergency contraception that are available are
High dose estrogen -which is not prefferred due to severe nausea and vomiting associated with it.
Yuzpe regime -which uses 100mcg of ethinyl estradiol(EE)+500mcg of levonorgestrel(LNG)x2 doses.associated with nausea and vomiting,failure rate of 3.2.
Ho & Kwan Regime - which uses 750 mcg of LNG x2 doses 12 hrs apart.Less side effects and failure rate of 1.1.
High dose progestrone ,where the two doses are combined to a single dose of 1.5mg .
Mefipristone 600mg ,single dose is associated with no pregnancy.

These regimens should be administered within 72 hrs of exposure.
IUCD is another option,which is suitable upto 5 days after exposure ,associated witha very low failure rate of 0.1.How ever this not the method of choice in nulliparous and also in the presence of vaginal infection

A follow up should be organised at the time of of anticipated menstrual period, to ensure a normal flow and success of the emergency contraception.This visit also gives an opportunity to discuss future contraception such as barrier method ,combined oral contraceptive pill,implants or injectables.The risks and benefits associated with each method should be discussed .What ever the method choosen ,the addition of barrier contraception to it should be recommended for added protection against STI.
This review also helps to discuss the results of any swabs taken and implement adequate treatment,and referral to the GUM clinic.
In the event of a missed cycle patient should be councelled on the possibility of a failure and investigations to confirm pregnancy should be initiated.

Posted by PAUL A.
Sat Feb 9, 2008 03:05 pm
Dear Dr. Paul :
Thanks for correcting my answer, but i\'d like to tell you that in the last (The Obstetrician & Gynaecologist Vol. 10 ,issue N0: 1 ) :
The NICE guidance emphasises that younger women should not be considered unsuitable for these methods : they can be used in nulliparous young women and there are no restrictions to the use of intrauterine devices (IUDs) or intrauterine systems ( IUSs) in adolescents. { page 25 }.
Regarding the contraceptive pill : It is the most commonly known to young women ,however ,the long-acting reversible methods may actually be more appropriate for teenagers. { page 26 }.
Regarding the injectable contraception : The young women will become anxious about amenorrhoea and suspect that they are pregnant how does the use of the IUS or depot help this? unless they have been warned to expect this.
Also, Bearing in mind the difficulties some young women have with compliance , it is advisable to consider Longer-acting contraceptive methods . { page 26 }

The question is not a test of your knowledge of the guidelines but how you can apply these guidelines to a specific situation. You have quoted the guidelines correctly above, but in your answer, you state:

such as IUD , IUS , Implants , which are more appropriate than COCP , You have repaced \'may be\' with \'are\' and this makes all the difference. There is no evidence / reason to assume that these ARE more appropriate. NICE is stating that these options should be considered. You are stating that these should be FIRST LINE and that is incorrect.

You need to look at the specific clinical situation and if her life-style indicates their use then they should be used. However, the generalisation that long-acting contraceptives are more appropriate for young women is incorrect


Thank you very much .

Posted by PAUL A.
Sat Feb 9, 2008 03:22 pm
FFPRHC Guidance on Emergency contraception(April 2006)state that {Advance provision of LNG can be offered to women to increase early use when required(Grade A)}.page 126

Again, the question is not a test of your knowledge of guidelines but your ability to apply that knowledge. How will you protect a 16 year old from STIs if she has a supply of pills she can simply take after her next episode of unprotected intercourse? For the majority, access is not a problem. How do you encourage the use of long-term contraception while providing the option of repeated self-administration of emergency contraception? The guidelines are not wrong but cannot be applied as a blanket policy

It also sate that [ Risk of sexually transmitted infections (STIs),
previous ectopic pregnancy, young age, and nulliparity are not contraindications to IUD use.] page 123

Also FSRH Guidance on Intrauterine Contraception(November 2007) put nulliparity in UKMEC category[1], ie: unrestricted use

but I am not sure whether this include teenage nulipara or not

Young age, nulliparity and risk of STI on their own are not contra-indications. This does not imply that an IUCD can be used without restriction in a 16 year old nullipara whose life-style puts her at high risk of STIs. The question tests your clinical judgment and your judgment will be questioned if you used an IUCD in this situation without demonstrating that other options were unsuitable and she developed a complication
I loss 2 marks with these items.

Can I have more clarification please?

Thank you.
Posted by M M A.
Sat Feb 9, 2008 04:17 pm

Dear Dr paul,

Thank you for your explanation and for your largeheartedness.
Posted by PAUL A.
Mon Feb 11, 2008 01:04 am
Emergency contraception is high dose hormonal contraception and is suitable only if used within 72 hrs of exposure this is not HISTORY and is a waste of time & space .
A detailed history is esential to determine suitability for the same.
Details of her LMP (last menstrual period) and menstrual cycle should be enquired (1) and if uncertain about pregnancy a urine pregnancy test should be done.Any history of abnormal vaginal bleeding or discharge,or history of multiple partners, should prompt a speculum examination and swabs to rule out pelvic infection.Details of the timing of last unprotected intercourse and history of any previous episodes should be enquired (1) . The relevance of emergency contraception is lost if she has had multiple episodes in the same cycle why should it?? . Specific enquiry regarding contraindications for hormonal emergency contraception should be done,such as migraine ,active liver disease,DVT,Cardiac disease,thrombophilia these are not contraindications .
Medications are also of relevance as some enzyme inducing drugs are associated with increased failure rates of hormonal emergency contraception,due to rapid clearance of the drug.
Use of any contraception in the past as well as previous use of emergency contraception and any side effects with these can also be elicited (1) .
The options for emergency contraception that are available are
High dose estrogen NOT USED -which is not prefferred due to severe nausea and vomiting associated with it.
Yuzpe regime -which uses 100mcg of ethinyl estradiol(EE)+500mcg of levonorgestrel(LNG)x2 doses NO LONGER USED .associated with nausea and vomiting,failure rate of 3.2.
Ho & Kwan Regime - which uses 750 mcg of LNG x2 doses 12 hrs apart.Less side effects and failure rate of 1.1 1.1 what? .
High dose progestrone ,where the two doses are combined to a single dose of 1.5mg this sentence has no meaning .
Mefipristone 600mg ,single dose is associated with no pregnancy not licensed .

These regimens should be administered within 72 hrs of exposure.
IUCD is another option,which is suitable upto 5 days after exposure or 5 days of the most likely date of ovulation ,associated witha very low failure rate of 0.1 0.1 what???? .How ever this not the method of choice in nulliparous and also in the presence of vaginal infection

A follow up should be organised at the time of of anticipated menstrual period, to ensure a normal flow and success of the emergency contraception within 3-4 weeks or after next period .This visit also gives an opportunity to discuss future contraception (1) such as barrier method ,combined oral contraceptive pill,implants or injectables.The risks and benefits associated with each method should be discussed .What ever the method choosen ,the addition of barrier contraception to it should be recommended for added protection against STI (1) .
This review also helps to discuss the results of any swabs taken and implement adequate treatment,and referral to the GUM clinic (1) .
In the event of a missed cycle patient should be councelled on the possibility of a failure and investigations to confirm pregnancy should be initiated what if she is pregnant? .
Posted by PAUL A.
Mon Feb 11, 2008 01:10 am
A good candidate should

(a)

? Obtain detailed menstrual history (1)
? Obtain gynaecological history including history of STIs (1)
? Obtain detailed sexual history (2) :
1) Date / time of unprotected sexual intercourse
2) Any previous episodes of unprotected intercourse
3) Identify associated factors like use of alcohol / drugs
3) Number of sexual partners

? Obtain contraceptive history ? previous use of contraception (including sheath) and compliance / side-effects (1)
? Identify future contraceptive intentions (1)
? Identify potential contra-indications to future hormonal contraceptives ? focal migraine, family / personal Hx of VTE, active liver disease (1)

(b) With respect to options for emergency contraception

? If within 72h of unprotected intercourse, levonorgestrel-only emergency contraceptive would be most appropriate. Discuss single dose regimen (2)
? If over 72h but less than 5 days from episode of unprotected intercourse (or less than 5 days from the most likely date of ovulation) then copper IUCD would be most appropriate (1)
? Know the importance of screening for STIs + prophylactic antibiotics if IUCD is inserted (1)

(c) With respect to follow-up arrangements

? Know that there is a risk of pregnancy & STI and a need to ensure adequate long-term contraception (1)
? Know that the woman should be reviewed within 3 weeks or as soon as possible after her next period (1)
? Discuss long-term contraceptive options (1)
? If an IUCD had been inserted, it should be removed if not required for long-term contraception (1) .
? Review screening for STI results and offer further screening (1)
? Discuss use of sheath to prevent STIs (1)
? Pregnancy test if missed period. Discuss options if positive pregnancy test (1)
s Posted by PAUL A.
Mon May 7, 2012 01:39 am

s