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Guideline Summary
Guideline Title
Emergency contraception.
Bibliographic Source(s)
Dunn S, Guilbert E. Emergency contraception. J Obstet Gynaecol Can. 2012 Sep;34(9):870-8. [73 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Unintended pregnancy

Guideline Category
Counseling
Evaluation
Management
Clinical Specialty
Emergency Medicine
Family Practice
Nursing
Obstetrics and Gynecology
Preventive Medicine
Intended Users
Advanced Practice Nurses
Health Care Providers
Nurses
Physician Assistants
Physicians
Guideline Objective(s)

To review current knowledge about emergency contraception (EC), including available options, their modes of action, efficacy, safety, and the effective provision of EC within a practice setting

Target Population

Women at risk of unintended pregnancy

Interventions and Practices Considered
  1. Hormonal methods, also known as emergency contraceptive pills
  2. Post-coital insertion of a copper intrauterine device
Major Outcomes Considered
  • Efficacy in terms of reduction in risk of pregnancy
  • Safety
  • Side effects of methods for emergency contraception (EC)
  • Effect of the means of access to EC on its appropriate use and the use of consistent contraception

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Studies published in English between January 1998 and March 2010 were retrieved though searches of Medline and the Cochrane Database, using appropriate key words (emergency contraception, post-coital contraception, emergency contraceptive pills, post-coital copper IUD). Clinical guidelines and position papers developed by health or family planning organizations were also reviewed.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Quality of Evidence Assessment*

I: Evidence obtained from at least one properly randomized controlled trial.

II-1: Evidence from well-designed controlled trials without randomization.

II-2: Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more than one centre or research group.

II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

*Adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care.

Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

The studies reviewed were classified according to criteria described by the Canadian Task Force on Preventive Health Care, and the recommendations for practice were ranked according to this classification.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Classification of Recommendations†

A. There is good evidence to recommend the clinical preventive action.

B. There is fair evidence to recommend the clinical preventive action.

C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making.

D. There is fair evidence to recommend against the clinical preventive action.

E. There is good evidence to recommend against the clinical preventive action.

L. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making.

†Adapted from the Classification of Recommendations criteria described in The Canadian Task Force on Preventive Health Care.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

This clinical practice guideline has been prepared by the Social and Sexual Issues Committee, reviewed by the Clinical Practice Gynaecology Committee and the Family Practice Advisory Committee, and approved by the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.

Recommendations

Major Recommendations

The quality of evidence (I-III) and classification of recommendations (A-L) are defined at the end of the "Major Recommendations" field.

Summary Statements

  1. Hormonal emergency contraception may be effective if used up to 5 days after unprotected intercourse. (II-2)
  2. The earlier hormonal emergency contraception is used, the more effective it is. (II-2)
  3. A copper intrauterine device (IUD) can be effective emergency contraception if used within 7 days after intercourse. (II-2)
  4. Levonorgestrel emergency contraception regimens are more effective and cause fewer side effects than the Yuzpe regimen. (I)
  5. Levonorgestrel emergency contraception single dose (1.5 mg) and the 2-dose levonorgestrel regimen (0.75 mg 12 hours apart) have similar efficacy with no difference in side effects. (I)
  6. Of the hormonal emergency contraception regimens available in Canada, levonorgestrel-only is the drug of choice. (I)
  7. A pregnancy that results from failure of emergency contraception need not be terminated (I)

Recommendations

  1. Emergency contraception should be used as soon as possible after unprotected sexual intercourse. (II-2A)
  2. Emergency contraception should be offered to women if unprotected intercourse has occurred within the time it is known to be effective (5 days for hormonal methods and up to 7 days for a copper IUD). (II-2B)
  3. Women should be evaluated for pregnancy if menses have not begun within 21 days following emergency contraception treatment. (III-A)
  4. During physician visits for periodic health examinations or reproductive health concerns, any woman in the reproductive age group who has not been sterilized may be counselled about emergency contraception in advance with detailed information about how and when to use it. (III-C)

Definitions:

Quality of Evidence Assessment*

I: Evidence obtained from at least one properly randomized controlled trial.

II-1: Evidence from well-designed controlled trials without randomization.

II-2: Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more than one centre or research group.

II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

*Adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care.

Classification of Recommendations†

A. There is good evidence to recommend the clinical preventive action.

B. There is fair evidence to recommend the clinical preventive action.

C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making.

D. There is fair evidence to recommend against the clinical preventive action.

E. There is good evidence to recommend against the clinical preventive action.

L. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making.

†Adapted from the Classification of Recommendations criteria described in The Canadian Task Force on Preventive Health Care.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

These guidelines are intended to help reduce unintended pregnancies by increasing awareness and appropriate use of emergency contraception (EC).

Potential Harms

Women should be informed about the potential side effects and potential failure of emergency contraception (EC) and should be advised that hormonal EC will not prevent pregnancy from unprotected intercourse in the days or weeks following treatment.

Side Effects

  • The 2-dose levonorgestrel regimen has a significantly lower incidence than the Yuzpe regimen of nausea (23.1% vs. 50.5%), vomiting (5.6% vs. 18.8%), dizziness (11.2% vs. 16.7%), and fatigue (16.9% vs. 28.5%). In the studies comparing the 2-dose levonorgestrel regimen with the 1 double-dose regimen, the occurrence of side effects was similar.
  • An antiemetic has been demonstrated to reduce the risk of nausea by 27% and vomiting by 64% when taken 1 hour before the first dose of the Yuzpe regimen. Expert opinion suggests that if the woman vomits within the first 2 hours after taking hormonal EC, the dose should be repeated and consideration should be given to vaginal administration of the medication.
  • Possible complications of the post-coital copper intrauterine device (IUD) include pelvic pain, abnormal bleeding, pelvic infection, uterine perforation, and expulsion.

Contraindications

Contraindications

There are no absolute contraindications to the use of emergency hormonal contraception except known pregnancy, and this is only because it is ineffective.

Qualifying Statements

Qualifying Statements

This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Timeliness

Identifying Information and Availability

Bibliographic Source(s)
Dunn S, Guilbert E. Emergency contraception. J Obstet Gynaecol Can. 2012 Sep;34(9):870-8. [73 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2012 Sep
Guideline Developer(s)
Society of Obstetricians and Gynaecologists of Canada - Medical Specialty Society
Source(s) of Funding

Society of Obstetricians and Gynaecologists of Canada

Guideline Committee

Social and Sexual Issues Committee

Composition of Group That Authored the Guideline

Principal Authors: Sheila Dunn, MD, Toronto ON; Édith Guilbert, MD, Quebec QC

Social Sexual Issues Committee Members: Margaret Burnett, MD (Chair), Winnipeg MB; Anjali Aggarwal, MD, Toronto ON; Jeanne Bernardin, MD, Moncton NB; Virginia Clark, MD, Golden BC; Victoria Davis, MD, Scarborough ON; Jeffrey Dempster, MD, Halifax NS; William Fisher, PhD, London ON; Karen MacKinnon, RN, PhD, Victoria BC; Rosana Pellizzari, MD, Peterborough ON; Viola Polomeno, RN, PhD, Ottawa ON; Maegan Rutherford, MD, Halifax NS; Jeanelle Sabourin, MD, Edmonton AB; Vyta Senikas, MD, Ottawa ON; Marie-Soleil Wagner, MD, Montreal QC

Financial Disclosures/Conflicts of Interest

Disclosure statements have been received from all members of the committee.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Society of Obstetricians and Gynaecologists of Canada Web site External Web Site Policy. Also available in French from the SOGC Web site External Web Site Policy.

Print copies: Available from the Society of Obstetricians and Gynaecologists of Canada, La société des obstétriciens et gynécologues du Canada (SOGC) 780 promenade Echo Drive Ottawa, ON K1S 5R7 (Canada); Phone: 1-800-561-2416.

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on November 19, 2012. The information was verified by the guideline developer on December 18, 2012.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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