A 19-year-old comes to see you because she found a tear in her diaphragm contraceptive device. She had intercourse with her boyfriend only once (the previous day) since the diaphragm insertion. She is worried about unwanted pregnancy.
What is an appropriate action?
Correct Answer D:
Emergency contraception, the so-called morning-after pill, consists of hormones or drugs that affect hormones. It is used within 72 hours after one act of unprotected sexual intercourse or after one occasion when a contraceptive method fails (for example, when a condom breaks).
Emergency contraception decreases the chance of pregnancy after one act of unprotected intercourse, including when the act occurs near the time the egg is released (ovulation) - when conception is most likely. Near ovulation, the chance of pregnancy is about 8% without contraception. The sooner emergency contraception is taken, the more likely it is to be effective.
Levonorgestrel is a progestin often taken in lower doses for contraception, is most commonly used. Usually, one dose is taken by mouth, followed by another dose 12 hours later. If the first dose is taken within 72 hours of intercourse, the chance of pregnancy decreases by almost 90%. If the first dose is taken within 24 hours of intercourse, the chance decreases by about 95%.
A 20-year-old single white female who is a patient of yours was raped in her apartment at 7:00 a.m. today. She is brought to your office at 9:00 a.m. for assessment and treatment. Despite having occasional intercourse with her boyfriend, she has never used any type of contraceptive. Their last intercourse was approximately 1 week ago and the boyfriend has been out of town on business since then. The patient has a history of irregular periods and her last normal period was approximately 2 1/2 weeks ago. You note live sperm on a wet mount. In addition to many other issues that must be addressed at this visit, the patient asks about emergency contraception.
Which one of the following would be accurate advice to the patient regarding this topic?
Correct Answer A: An FDA Advisory Committee has recommended over-the-counter marketing of Plan B, an emergency contraceptive package that contains two 0.75-mg tablets of levonorgestrel to be taken 12 hours apart. Plan B is one of the two FDA approved products for this indication. The Preven emergency contraceptive kit includes four tablets, each containing 0.25 mg of levonorgestrel and 50 mg of ethinyl estradiol; these are taken two at a time 12 hours apart. In a randomized, controlled trial comparing the single versus combined estrogen/progestin, the single-drug regimen was shown to be more effective. Pregnancy occurred in 11 of 976 women (1.1%) given levonorgestrel alone, and in 31 of 979 (3.2%) given ethinyl estradiol plus levonorgestrel. The proportion of pregnancies prevented, compared to the expected number without treatment, was 85% with levonorgestrel and 57% with the combination. In both regimens, the interval between individual doses is 12 hours. In this case, emergency contraception may be appropriate in the face of a possible pregnancy from previous consensual intercourse. Emergency contraception has not been found to interfere with an established post-implantation pregnancy. Furthermore, no fetal malformations have been reported as a results of the unsuccessful use of high-dose oral contraceptives for emergency contraception.
A 25-year-old female has unprotected intercourse and chooses to take Plan B (two 0.75 mg tablets of levonorgestrel, taken 12 hours apart) as a form of emergency contraception.
Plan B has been shown to:
Correct Answer A:
Emergency contraception with Plan B has been available for several years. It has been shown to prevent pregnancy primarily, or perhaps exclusively, by delaying or inhibiting ovulation.
→ Plan B does not protect against sexually transmitted diseases (choice B).
→ It is not recommended as routine contraception (choice C); failure rates tend to accumulate over time.
→ It is not teratogenic (choice D) to a developing fetus.
→ It is effective when used up to 72 hours after unprotected intercourse (choice E) (other studies have demonstrated effectiveness at 5 days also), but the longer the patient waits to take the first dose, the more its effectiveness wanes.
You are asked to see a young woman in the Emergency Department after an alleged sexual assault that occurred today. She is an otherwise healthy 28 years old. A serum pregnancy test is negative. Her menstrual cycle is regular, every 28 days, and her last period was 14 days ago. She is not currently on contraception and desires to minimize her chance of becoming pregnant from this episode.
Of the following, the best option is:
Correct Answer B:
Currently, postcoital birth control can be done either with an IUD or with hormonal therapy. With OCPs, you need to give two doses, each of at least 100 µg of ethinyl estradiol (Emergency Contraceptive Pill - Ovral). Less than 2% of women will become pregnant with this dose (prevents 75% of expected pregnancies), and it can be given up to 72 hours after coitus. DES has a slightly higher success rate, but due to the significant side effect rate, compliance with this regimen is much less, making is less effective. An IUD is an option if there is no risk for sexually transmitted diseases, so it is not indicated after a sexual assault. Some countries also use two doses of 0.75 mg levonorgestrel, which has a similar success rate to the Emergency Contraceptive Pill (Ovral) regimen. Note that the clinical pregnancy rate of unprotected midcycle coitus is about 7%.
→ IUDs can be used for emergency postcoital contraception, but are not indicated when the risk for a sexually transmitted disease is present.
→ A minimum of 100 µg of ethinyl estradiol in two divided doses needs to be given.
→ Significant side effects (nausea) make compliance with this regimen much less, making it less effective.
→ At this point, the fertilized ovum is still within the fallopian tube.
Which one of the following hormones is responsible for the development of milk producing alveolar cells in breast tissue during pregnancy?
During pregnancy, breast size increases, as epithelial cells of the alveoli differentiate into secretory cells for milk production.
Progesterone (choice B) released by the corpus luteum, stimulates proliferation of glandular tissue by increasing the development of milk producing alveolar cells.
→ Oxytocin (choice A) via the suckling reflex causes the contraction of the smooth-muscle cells in the ducts to eject the milk from the nipple.
→ Prolactin (choice C) is the primary hormone responsible for stimulating alveolar cells to produce milk. During pregnancy, high levels of progesterone inhibit prolactin from milk synthesis. Therefore the role of progesterone and prolactin should not be confused as the first stimulates to development of glands while the latter make the glands produce milk. The expulsion of the placenta at delivery initiates milk production and causes the drop in circulating estrogen and progesterone.
→ Estrogen (choice D) released from the ovarian follicle, promotes growth ducts. During pregnancy estrogen antagonizes the positive effect of prolactin on milk production.
→ Human placental lactogen (choice E) is chemically similar to the growth hormone and prolactin. It antagonizes the cellular action of insulin, decreasing insulin utilization, thereby contributing to the predisposition of pregnancy to glucose intolerance and diabetes.
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