emergency contraception
Doctor Information
Miranda Kirk, age 23
Current medical problems:
Asthma - well controlled
Past medical history:
Nil
Medication:
Clenil 50 microgram one puff Bd
Salbutamol 100 microgram PRN
Allergic to Penicillin
Current medical problems:
Asthma - well controlled
Past medical history:
Nil
Medication:
Clenil 50 microgram one puff Bd
Salbutamol 100 microgram PRN
Allergic to Penicillin
Patient Information
Miranda Kirk, age 23
Opening Line: I think I need the morning after pill
History: You went out on saturday night (3 nights ago), and met a really nice bloke. You ended up going home with him and having sex. You did use a condom but you think it might have split. There is no way you want to get pregnant. You are also really anxious about the possibility of picking up an infection (although do not mention your anxiety surrounding infection, unless asked about your concerns by the doctor)
If asked only: You are not on regular contraception because you used to always forget to take your pill. You don't make a habit of going out and sleeping with strangers, in fact this is the first time you have done that and are very ashamed of yourself. On saturday you had normal vaginal sex. Your last period was 8 days ago and it was normal. No abnormal vaginal discharge, no bleeding between periods. Your last sexual partner before this guy was a boyfriend when you were 19. You did not feel pressured at the time. Your last period was 2 weeks ago. You know very little about your sexual partner 3 days ago, except that he is a British White male, in his mid 20s.
Your underlying concern is not so much pregnancy but picking up an infection. You have no abnormal discharge, nor pain down below, but you have heard about HIV through your reading, and want to make sure you don't have that today. You have heard about a 'clinic' you could go to get tested, but it's in town, and you don't want to go in case one of your friends sees you going in. You would like the doctor to do the testing for you.
Social History: You are in your second year of dentistry at Leeds University, and live with your best friend Clare. You don't smoke, but do drink alcohol on nights out - usually 4 or 5 vodka and cokes.
Past History
Asthma
Medication
Clenil 50microgram one puff twice daily
Salbutamol as required
No known allergies
Ideas: You need the morning after pill, and you want to make sure you don't have an infection
Concerns: you are worried about picking up HIV!
Expectations: the pill is 100% effective and the doctor will have no problem giving you the tablet, the doctor will check for a HIV infection today as you are anxious
If the doctor explains why going to the clinic in town may be better, I.e. More thorough testing, contact tracing. And the fact that it's completely confidential, then you could be convinced to go. If the doctor offers to do the testing in house then you would be happy with that too.
As for long term contraception, if offered by the doctor you will decline today, as you are in "no fit mood to discuss that today" due to your anxiety about the HIV infection.
Opening Line: I think I need the morning after pill
History: You went out on saturday night (3 nights ago), and met a really nice bloke. You ended up going home with him and having sex. You did use a condom but you think it might have split. There is no way you want to get pregnant. You are also really anxious about the possibility of picking up an infection (although do not mention your anxiety surrounding infection, unless asked about your concerns by the doctor)
If asked only: You are not on regular contraception because you used to always forget to take your pill. You don't make a habit of going out and sleeping with strangers, in fact this is the first time you have done that and are very ashamed of yourself. On saturday you had normal vaginal sex. Your last period was 8 days ago and it was normal. No abnormal vaginal discharge, no bleeding between periods. Your last sexual partner before this guy was a boyfriend when you were 19. You did not feel pressured at the time. Your last period was 2 weeks ago. You know very little about your sexual partner 3 days ago, except that he is a British White male, in his mid 20s.
Your underlying concern is not so much pregnancy but picking up an infection. You have no abnormal discharge, nor pain down below, but you have heard about HIV through your reading, and want to make sure you don't have that today. You have heard about a 'clinic' you could go to get tested, but it's in town, and you don't want to go in case one of your friends sees you going in. You would like the doctor to do the testing for you.
Social History: You are in your second year of dentistry at Leeds University, and live with your best friend Clare. You don't smoke, but do drink alcohol on nights out - usually 4 or 5 vodka and cokes.
Past History
Asthma
Medication
Clenil 50microgram one puff twice daily
Salbutamol as required
No known allergies
Ideas: You need the morning after pill, and you want to make sure you don't have an infection
Concerns: you are worried about picking up HIV!
Expectations: the pill is 100% effective and the doctor will have no problem giving you the tablet, the doctor will check for a HIV infection today as you are anxious
If the doctor explains why going to the clinic in town may be better, I.e. More thorough testing, contact tracing. And the fact that it's completely confidential, then you could be convinced to go. If the doctor offers to do the testing in house then you would be happy with that too.
As for long term contraception, if offered by the doctor you will decline today, as you are in "no fit mood to discuss that today" due to your anxiety about the HIV infection.
Examination Findings
Pulse 89
Blood pressure 119/78
BMI 22
Afebrile
Blood pressure 119/78
BMI 22
Afebrile
Mark scheme
Data Gathering
|
Positive indicators
Takes full sexual and contraceptive history Assesses risk for pregnancy and STI Appropriate examination |
Negative indicators
Inadequate sexual and contraceptive history No risk assessment for pregnancy/STI Does not examine |
Clinical Management Skills
|
Positive indicators
Accurate diagnosis Discussion of all three options, weighs up risks/benefits of each Shared management plan Advises sexual health screening |
Negative indicators
Unsure if emergency contraception required Does not discuss contraceptive options Makes decisions for patient Fails to advise on sexual health screening |
Inter Personal Skills
|
Positive Indicators
Shared management plan Identifies agenda and health beliefs Sympathetic and non judgemental approach |
Negative Indicators
Makes assumptions and fails to share options Does not identify health beliefs and agenda Judgmental, does not show sympathy |
Management
This case is testing your knowledge of emergency contraception (EC)
EC should be used to prevent unwanted pregnancy following unprotected sexual intercourse (UPSI) or contraceptive failure, however it is not a method of termination of pregnancy.
Three methods are currently available:
Levonorgestrel: this is a progesterone only pill that works by inhibiting ovulation until sperm in the reproductive tract have lost their viability
Ullipristal: a selective progesterone modulator pill that works by inhibiting or delaying ovulation
Copper intrauterine device: this is a copper coil which has a toxic effect on sperm and interferes with implantation
There is a limited timeframe to use all the types of emergency contraception.
Levonorgestrel can be taken up to 72 hours after UPSI, and can be used more than once in the same cycle. If the woman vomits within 2 hours, she requires a second dose. It is less effective in women taking enzyme-inducing medication, in which case specialist advice should be sought. It can be bought from a pharmacy for £25 without prescription.
Ullipristal, also called Ella1 is licensed for use up to 120 hours after UPSI and should not be used more than once in the same cycle. Caution is advised in asthmatics as it can trigger bronchspasm, and once again a repeat dose is required if the woman vomits within 3 hours of taking the tablet.
Copper IUD is the most effective form of EC, and can be left in situ for ongoing contraception. However it is easily removal, at which time fertility returns to normal. The coil can be inserted up to 120 hours after UPSI, or within 5 days of the earliest time you could have released an egg ( I.e. up to day 19 in a 28 day cycle). Unfortunately it is less readily available that the tablet EC, and often is only performed at sexual health clinics. Once inserted, it can also cause irregular (often heavy) bleeding, which usually settles after 3-6 months. There is a 2/100 risk of uterine perforation.
With any form of EC, advised your patient to still perform a pregnancy test if their next period is delayed, or if they have any symptoms of pregnancy. Encourage them to attend for sexual health screening, and to consider long term contraceptive methods.
There is a second element to this case, and that is regarding the risk of STIs. It would be best if she is concerned to go to a gum clinic. They often have access to more rapid testing, and better tests for diagnosing infections quicker. They also have the ability to perform contact tracing, and to treat some of the more complex cases. Some gp practices are now beginning to offer some of the same services, especially practices associated with universities.
As for HIV testing, The current test for HIV infection combines HIV antibody and p24 antigen tests for both species of HIV. The period during which HIV antibody tests are negative lasts up to 3 months. The p24 antigen test usually detects HIV infection much earlier than HIV antibody tests (from about 2 weeks), but can still take up to 3 months to become positive. To be confident that negative tests accurately exclude HIV infection, the tests need to be repeated 3 months after exposure. There are also home testing kits based on saliva samples, however they re more likely to be affected by the seroconversion window, and therefore ideally need to be taken or repeated 3 months after exposure.
As for chlamydia, one can be tested soon after intercourse, with either a swab or a urine sample if a symptomatic, however if taken before two weeks, It may need repeating due to the incubation period. The same goes for gonorrhoea, however urine tests for gonorrhoea are less accurate in women, so a swab is usually best.
EC should be used to prevent unwanted pregnancy following unprotected sexual intercourse (UPSI) or contraceptive failure, however it is not a method of termination of pregnancy.
Three methods are currently available:
Levonorgestrel: this is a progesterone only pill that works by inhibiting ovulation until sperm in the reproductive tract have lost their viability
Ullipristal: a selective progesterone modulator pill that works by inhibiting or delaying ovulation
Copper intrauterine device: this is a copper coil which has a toxic effect on sperm and interferes with implantation
There is a limited timeframe to use all the types of emergency contraception.
Levonorgestrel can be taken up to 72 hours after UPSI, and can be used more than once in the same cycle. If the woman vomits within 2 hours, she requires a second dose. It is less effective in women taking enzyme-inducing medication, in which case specialist advice should be sought. It can be bought from a pharmacy for £25 without prescription.
Ullipristal, also called Ella1 is licensed for use up to 120 hours after UPSI and should not be used more than once in the same cycle. Caution is advised in asthmatics as it can trigger bronchspasm, and once again a repeat dose is required if the woman vomits within 3 hours of taking the tablet.
Copper IUD is the most effective form of EC, and can be left in situ for ongoing contraception. However it is easily removal, at which time fertility returns to normal. The coil can be inserted up to 120 hours after UPSI, or within 5 days of the earliest time you could have released an egg ( I.e. up to day 19 in a 28 day cycle). Unfortunately it is less readily available that the tablet EC, and often is only performed at sexual health clinics. Once inserted, it can also cause irregular (often heavy) bleeding, which usually settles after 3-6 months. There is a 2/100 risk of uterine perforation.
With any form of EC, advised your patient to still perform a pregnancy test if their next period is delayed, or if they have any symptoms of pregnancy. Encourage them to attend for sexual health screening, and to consider long term contraceptive methods.
There is a second element to this case, and that is regarding the risk of STIs. It would be best if she is concerned to go to a gum clinic. They often have access to more rapid testing, and better tests for diagnosing infections quicker. They also have the ability to perform contact tracing, and to treat some of the more complex cases. Some gp practices are now beginning to offer some of the same services, especially practices associated with universities.
As for HIV testing, The current test for HIV infection combines HIV antibody and p24 antigen tests for both species of HIV. The period during which HIV antibody tests are negative lasts up to 3 months. The p24 antigen test usually detects HIV infection much earlier than HIV antibody tests (from about 2 weeks), but can still take up to 3 months to become positive. To be confident that negative tests accurately exclude HIV infection, the tests need to be repeated 3 months after exposure. There are also home testing kits based on saliva samples, however they re more likely to be affected by the seroconversion window, and therefore ideally need to be taken or repeated 3 months after exposure.
As for chlamydia, one can be tested soon after intercourse, with either a swab or a urine sample if a symptomatic, however if taken before two weeks, It may need repeating due to the incubation period. The same goes for gonorrhoea, however urine tests for gonorrhoea are less accurate in women, so a swab is usually best.