Emergency Medicine

WOMEN’S MEDICINE CRISES

390 Obstetric and Gynaecological Emergencies

2 Post-coital ‘morning after’ pill

This may be used up to 72 h after unprotected intercourse. Taking the dose as

soon as possible increases the efficacy.

(i) Give levonorgestrel 1.5 mg as a single dose

(a) do not prescribe in women with undiagnosed vaginal

bleeding, breast cancer or severe liver disease

(b) give 2.25 mg levonorgestrel (1.5 mg taken immediately and

750 g taken 12 hours later) in patients taking enzyme-

inducing drugs such as carbamazepine, rifampicin, phenytoin

and phenobarbitone (phenobarbital).

(ii) Give a repeat levonorgestrel dose if vomiting occurs within 2

hours, with an antiemetic such as metoclopramide 10–20 mg i.v.

or domperidone 20 mg orally.

(iii) Explain to the patient that:

(a) her next period may be early or late

(b) a barrier method of contraception must be used until her

next period

(c) there is an increased risk of ectopic pregnancy so she should

seek medical advice immediately if abdominal pain occurs.

(iv) Refer all patients for follow-up to their general practitioner (GP)

or a family planning clinic to check that:

(a) the pregnancy test is negative 3–4 weeks later

(b) there is no ectopic pregnancy

(c) the patient receives proper contraceptive advice for the

future.

Missed oral contraceptive pill

Usually a frantic call on the telephone requests advice on what to do following a

missed oral contraceptive pill. The critical time for loss of contraceptive protec-

tion is at the beginning or end of the menstrual cycle, due to extension of the

‘pill-free’ interval.

1 Combined oral contraceptive pill

(i) Up to 12 hours late: Take the missed pill and carry on as usual.

(ii) Over 12 hours late:

(a) continue normal pill taking, but for the next 7 days either

abstain from sex or use an alternative barrier method of

contraception such as the condom

(b) start the next packet immediately the present one is over,

if these 7 days run beyond the end of the packet; i.e. no gap

between packets

• this will mean that no period may occur until the end of two
  packets
  (c) miss out the seven inactive pills if the everyday pills are the
  ones being taken