Emergency contraception consultation — structured SAQ (15 marks)

(a) Three emergency contraception options in order of efficacy (3 marks)

One mark per option, with dose and time window. [1][6][7][8]

• Copper intrauterine device (Cu-IUD) — inserted within 120 hours (5 days) of unprotected intercourse. Single insertion procedure. Most effective option. Can be left in situ for ongoing contraception (typical duration around 10 years for the CuT 380A device).[7][8]
• Ulipristal acetate (UPA) 30 mg orally — single dose within 120 hours (5 days) of unprotected intercourse. Selective progesterone receptor modulator with delayed ovulation even in the late follicular phase.[1][2]
• Levonorgestrel (LNG) 1.5 mg orally — single dose within 72 hours (3 days) of unprotected intercourse, with pregnancy rates rising on days 4 to 5 according to the Cochrane 2019 review.[1]

(b) Recommended regimen with evidence-based justification (3 marks)

Marks for recommendation and for the trial-level evidence. [2][8]

• Recommendation: Insert a Cu-IUD today if she consents, given her presentation at 14 hours post-UPI (well within 5 days), day 12 of cycle, and BMI 28. The Cu-IUD is the most effective EC across the full 5-day window.[7][8]
• Evidence: Turok 2013 (Hum Reprod) reported zero pregnancies in 1 771 Cu-IUD users followed up at one month — the contemporary evidence supporting Cu-IUD as the most effective EC. Cleland 2012 systematic review of 7 034 women found a pregnancy rate of 0.09% across 42 studies.[7][8]
• Alternative evidence: If she declines the Cu-IUD, offer UPA 30 mg orally. Brache 2013 pooled analysis showed UPA delays follicular rupture by 5 days or more in 58.8% of cycles with leading follicle of 18 mm or more, versus 14.6% for LNG — UPA is the more effective oral EC, particularly relevant in the late follicular phase.[2]

(c) Counselling for ongoing contraception using WHO MEC (5 marks)

Marks for MEC framework, fertility preference assessment, method options and bridging. [5][6]

• Apply the WHO Medical Eligibility Criteria: she is 27, nulliparous, BMI 28, regular periods, no migraine, non-smoker, no drug interactions — all three LARC methods (ENG implant, 52 mg LNG-IUS, Cu-IUD) are MEC Category 1; CHC is Category 1; POP is Category 1.[5][6]
• Identify pregnancy intention and adherence: she tells you she misses the pill 3 to 4 times per month — this identifies her as a candidate for a user-independent method (LARC), because the Curtis 2024 SPR shows CHC and POP both have typical-use failure rates around 7 per 100 versus under 1 per 100 for LARC.[6]
• Lead with LARC first: ENG implant up to 5 years (FDA 2026), 52 mg LNG-IUS up to 8 years for contraception, Cu-IUD around 10 years. Discuss the bleeding profile for each (irregular spotting on implant; spotting then amenorrhoea on LNG-IUS; heavier monthly menses on Cu-IUD).[6]
• Same-day bridge: if she chooses a Cu-IUD for ongoing contraception and accepts it as her EC, she is protected immediately. If she chooses an LNG-IUS today, it cannot be inserted today because of UPA if used; she should return for insertion in the next 5 days with a backup method. If she chooses the implant (Nexplanon), wait at least 5 days after UPA — for LNG or combined oestrogen-progestin ECPs, no wait needed and the implant can be placed the same day.[6]
• Document: record the EC administered, the chosen ongoing method, the alternative declined, the side-effect counselling and the follow-up plan (3 to 4-week pregnancy test).[6]

(d) Vomiting within 1 hour of oral EC (2 marks)

One mark for recognising the risk and one for the management. [6]

• Recognise the problem: vomiting within 3 hours of oral EC means the dose has not been reliably absorbed; a repeat dose is required.[6]
• Manage: offer an antiemetic (e.g. ondansetron 4 mg orally); repeat the full dose of UPA or LNG once vomiting is controlled; if the first method was UPA, she can repeat with the same; if LNG, she can repeat the same dose. The Cu-IUD is the alternative if oral medication is not tolerated.[6]

(e) Positive pregnancy test at 4 weeks — next step (2 marks)

One mark for diagnostic next steps and one for management. [9][6]

• Document: confirm urine pregnancy test with serum β-hCG and order a transvaginal ultrasound to localise the pregnancy (intrauterine vs ectopic vs pregnancy of unknown location). If a Cu-IUD was used as EC, image the device in the cavity. Consider the patient presenting with a true method failure (rare with Cu-IUD EC).[9]
• Manage: if intrauterine pregnancy and Cu-IUD strings visible — offer to remove the Cu-IUD (removing an intrauterine device in early pregnancy reduces the risk of miscarriage, preterm birth and septic complications). If ectopic, treat with methotrexate or surgery per local protocol. Counsel on pregnancy options (continuation or termination) regardless of device status. Report EC failure for pharmacovigilance if relevant.[6][9]