A 24-year-old woman comes to the office for emergency contraception. The patient had unprotected intercourse with her boyfriend 2 nights ago after a condom broke. She is not using any form of contraception other than condoms with spermicide. Her last menstrual period was 2 weeks ago. The patient has no medical problems and has had no surgeries. She takes no daily medications and does not use tobacco, alcohol, or illicit drugs.
Vital signs are normal. BMI is 26 kg/m². On speculum examination, there is a mucopurulent discharge at the cervical os; no vaginal bleeding is noted. The uterus is small and mobile. There are no adnexal masses or tenderness.
Urine pregnancy test is negative.
Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

11ec193a_97d6_8ad3_853d_6bd613664974_MD0002_00 Emergency contraception (postcoital contraception) is indicated in patients with recent unprotected intercourse who do not want to become pregnant. In patients close to ovulation, the probability of pregnancy is as high as 30%. Emergency contraception works by either delaying ovulation (eg, oral contraceptives, levonorgestrel) or inhibiting fertilization (eg, copper-containing intrauterine device [IUD]). The contraception should be provided as soon as possible as efficacy decreases with time after intercourse. The most effective emergency contraceptive is a copper-containing IUD, which is 99% effective in preventing pregnancy and can be placed up to 120 hours after intercourse. However, the copper-containing IUD is contraindicated in patients with acute cervicitis or active pelvic infection due to the risk of ascending infection (ie, pelvic inflammatory disease) (Choice B). Therefore, in this patient with mucopurulent cervical discharge suggestive of acute cervicitis, the best option is a single dose of oral levonorgestrel (ie, Plan B) due to its high efficacy (85% preventive), availability, ease of use, and low side-effect profile. Levonorgestrel should be given within 72 hours of unprotected intercourse. mucopurulent cervical discharge (Choice A) A high-dose regimen of oral contraceptives is a second-line option for emergency contraception due to a higher risk of failure and often intolerable side effects (eg, persistent nausea). (Choice C) The etonogestrel subcutaneous implant is a long-acting, reversible contraceptive. This implant has a slow onset of action (up to 7 days after insertion) and is therefore not a form of emergency contraception. (Choice E) Methotrexate is indicated in the management of hemodynamically stable patients with ectopic pregnancies. Although methotrexate can cause fetal demise and spontaneous abortion, it is not currently indicated for pregnancy prevention or termination. Educational objective: Emergency contraception should be provided as soon as possible in patients who had unprotected intercourse. First-line options include the copper-containing intrauterine device and oral levonorgestrel pill. __________ References: Practice bulletin no. 152: emergency contraception. (http://www.ncbi.nlm.nih.gov/pubmed/26287787) Emergency contraception. (http://www.ncbi.nlm.nih.gov/pubmed/27261868)

A 24-Year-Old Woman Comes to the Office for Emergency Contraception