Contraception in the

Emergency Room
Veronica M. Alvarez-Galiana, MD, MSEd
Emory Gyn/Ob PGY3
No financial disclosures
Objectives

• Review background information

• Discuss available resources
• Review basics of emergency contraception,
non-emergent contraception and LARCs
• Case based discussions
• Questions
 Background

Unintended Pregnancy Rate

= 50%
60%
Unintended Pregnancy
• Low birth weight, late prenatal care, and
alcohol and tobacco use during pregnancy
• Limitations on educational achievement and
economic difficulties Gipson et al. 2008
 Emergency Contraception (EC)

1,000 80
Combined estrogen-
progestin method
20
Progestin-only method 10
Copper IUD 1
Raymond et al. 2007
 Contraception
Access to non-emergent contraception and LARC methods
may also help decrease the unintended pregnancy rate

Affordable Care Act  No copay for contraception

Increase in contraception use, especially LARCs
Slight but significant decrease in unintended pregnancy and
teen pregnancy rates

Thaxton & Espey, 2017

 EC in the emergency room
• Reproductively aged women = 2 most common group to visit ED
nd

• Unique opportunity to assess risk and provide access

50-70%
40% Failed
have to counsel or provide
prescribed EC
EC to sexual assault victims
22% had heard of copper IUD used as EC
have prescribed EC
70-80%
Barriers: Lack of follow-up,<time, resources
5 times per year
Concern about birth defects & discouraging regular birth control

LIles et al. 2015; Chung-Park, 2008; Goyal et al., 2009; Patel et al., 2013; Batur et al., 2016
contraception in the emergency room
60% never provided Rx for non-
emergent contraception

86% refer for management

2/3 Rx for 1-3 months

3% Rx for the entire year

never provided depo provera,
>90% the implant or IUDs in the ED LIles et al. 2015
resources available to ER providers
• Smart phone apps
• US MEC (Medical Eligibility Criteria)
• SPR (Selected Practice Recommendations)
• Family Planning at Grady and EUHM
• Can call for curbside consult or formal consult
• Same day appointments available in Family Planning clinic
• Teen clinic: M, W afternoon, Saturday morning walk-ins
• Phone number: (404) 616-3678
• Managing Contraception handbook
• Flyers around the ED – coming soon
• Order set – coming soon
Smart phone apps: CDC MEC and SPR
Download now!
Category 1: no restriction

Category 2: benefits > risks

Category 3: risks > benefits

Category 4: unacceptable
Emergency contraception (EC)
• can offer to any woman of reproductive age (13-50)
• 2 easy questions to remember when assessing if someone
is eligible for emergency contraception:

Have you had sex in the last 5 days?

Do you want to get pregnant?

If they answer yes to the first and no to the second, you

can offer them EC if they are not using any other reliable
form of birth control ACOG, 2015
Common misconceptions regarding EC
Emergency contraception can cause a miscarriage/abortion
• EC will not cause prevention of implantation of a
fertilized egg nor will it cause a miscarriage
• EC causes no harm to an established pregnancy or
developing embryo
Emergency contraception encourages risky sexual behavior
Emergency contraception increases unintended pregnancy
• These statements are not supported by numerous
studies including RCTs
ACOG, 2015
Common misconceptions regarding EC
Women with certain medical conditions cannot receive EC
• False. There are no conditions where the risks of EC
outweigh the benefits
EC can only be given once per menstrual cycle
• False.
I have to do a pregnancy test first and pelvic exam in order
to give someone EC
• False. According to ACOG, even a negative pregnancy
test is not necessary before prescription of EC
• No clinical examination is necessary prior to providing EC
ACOG, 2015
 Types of EC

M • Copper IUD
O
S
T

E
• Ulipristal
F
F

• Levonorgestrel
E
C
T
I
V
E
• Combined estrogen-progesterone

ACOG, 2015
 Types of EC

• Copper IUD
• Most effective EC in preventing pregnancy
• Prevents fertilization by affecting sperm viability and
function
• Non-hormonal
• Contraindicated in those with current PID
• Pros: Most effective, lasts up to 12 years
• Cons: Has to be placed by provider in clinic
ACOG, 2015
 Types of EC

• Ulipristal acetate 30mg (ella)

• Second most effective
• Selective progesterone receptor modulator
• Prevents or delays ovulation
• Side effects: nausea, headache
• Pros: effective up to 5 days, pill form
• Cons: requires prescription, may not work as well in
obese women, have to wait 5 days before starting long
term hormonal contraception
ACOG, 2015
 Types of EC

• Levonorgestrel 1.5mg (Plan B)

• Third most effective and most common method used
• FDA approved for up to 72 hrs after unprotected sex,
however studies demonstrate lasting effect after 120hrs
• Also works by inhibiting/delaying ovulation
• Pros: available over the counter (but can also Rx); can
start using long term contraception immediately after
• Cons: not as effective as ella or copper IUD; may also be
less effective in obese women ACOG, 2015
 Types of EC

• Combined oral contraceptive method

• Least effective method however still prevents about
74% of expected pregnancies
• Many combined methods available
• Side effects: nausea, headache
• Pros: Patient may already have pills available if taking
combined contraception pills; can continue taking pills
for long term contraception
• Cons: side effects are usually worse; requires RxACOG, 2015
Non-emergent contraception
• Think about offering long term birth control if you are
providing a patient with emergency contraception
• Types of long term contraception:
• LARCs – Copper IUD, LNG IUD, Nexplanon implant
• Injectable – Depo provera
• Combined contraception – pill, patch, ring
• Progesterone only pill
• If patient is interested in LARC or injectable, can place
referral for family planning and/or call clinic to see if
patient can be seen for a same day appointment
Long-acting reversible contraception (LARC)
• Nexplanon implant (most effective method – 0.5 in 1000)
• Contains etonogestrel (progesterone)
• Implant is placed in upper arm by provider
• Lasts up to 4 years; can be removed at any time
• Can cause irregular bleeding or amenorrhea
• Levonorgestrel IUD (Mirena or Liletta) – 2 in 1000
• Placed by provider in clinic
• Can last up to 7 years
• Can cause irregular bleeding or amenorrhea
• Copper IUD – 8 in 1000
• Non-hormonal
• Can last up to 12 years
• No irregular bleeding but can cause heavier cycles
 Injectable contraception

• Depo provera – 60 in 1000 pregnancies per year

• Medoxyprogesterone acetate (progesterone)
• Injection placed in upper arm every 3 months
• Side effects: irregular bleeding, amenorrhea, weight gain
• Pros: hormonal effect lasts up to 3 months
• Cons: have to come in to receive injection; also can delay
fertility for up to 1 year
 Combined hormonal contraception
• Pill, patch, ring – 90 in 1000 pregnancies per year
• Pill has many different combinations; Ortho tri cyclen,
mononessa commonly used
• Patch – ortho evra; Ring – NuvaRing
• Contraindicated in smokers > 35, uncontrolled HTN, history
of DVT, other vascular associated conditions, liver dz
• Certain medications may reduce their effectiveness
• Side effects: nausea, headache, breast tenderness
• Pros: commonly used; can help regulate cycle
• Cons: have to take pill every day, change patch every week,
change ring every 3 weeks. Require Rx
 Progesterone only pills
• Norethindrone – likely higher than 90 in 1000
• Also known as the “minipill” and Micronor 0.35mg
• Have to take at the same time every day to remain effective
• Option for patients who are breast feeding or otherwise
have a contraindication for using combined methods
• Side effects: irregular bleeding
• Pros: do not pose same risks as COCs
• Cons: have to take at the same time every day; not as
effective as other methods
• Can consider using this as a bridge to a LARC or other long
term method
 Case #1
• 18 yo with sickle cell disease presents to the ED with
vaginitis of one week duration. She had unprotected sex 3
days ago with a new partner. She takes hydroxyurea. Exam
demonstrates purulent discharge from os. She otherwise
feels well, is afebrile, and has a normal WBC count.

Besides treatment for her current condition, what else can

you offer her at this time?

Which method(s) would be contraindicated?

 Case #2

• 36 yo woman with history of DVT during previous

pregnancy presents to the ED for leg pain. She is worried
she has another DVT. Doppler studies are negative and she
otherwise is doing well. She is sexually active but does not
use contraception consistently and would like to avoid
pregnancy. She smokes cigarettes, 1 PPD. UPT negative.

What else do you need to know to offer EC?

How would you counsel this patient on her options for
long term contraception?
 Case #3
• 23 yo presents to EUHM s/p spontaneous abortion,
confirmed on exam and ultrasound. This had been an
unplanned but desired pregnancy. She is unsure if she
wants to try again and is interested in contraception. She
takes topiramate for seizure prophylaxis. After counseling
her on options, she is most interested in the pill (CHC).

Would this be the best method for this patient?

How would you counsel this patient on pregnancy
prevention should she choose to use the pill (CHC)?
 Case #4
• 31 yo comes to the ED s/p assault. She has a PMH of DM2,
obesity (BMI 35) and HTN (controlled). She is worried she
will get pregnant because she’s been skipping a few days
of her birth control pill.

What can you offer this patient?

How do you counsel her regarding emergency
contraception options?
What long term contraceptive options would be best in
her case and why?
Questions and Comments
 Summary and Take Aways

• You have the unique opportunity to offer EC and contraception to

reproductively aged women
• Ask the 2 questions: Have you had unprotected sex in the last 5 days? Do
you want to get pregnant?
• Use the CDC MEC/SPR app to help you!
• Place Family Planning referrals or call 404-616-3678 and ask to see if the
patient can be seen same day
• Consider prescribing non-emergent/long term contraception for patients
you offer EC to. Don’t be afraid to give them refills for an entire year.
 References
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2007;109:181–188.
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