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Old 11-30-2011
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ObGyn Unprotected Coitus; How to manage?

A 20-year-old college student comes to the student health clinic concerned that she may be pregnant. She states that she has had a steady boyfriend for the last 2 years and that they regularly use condoms for birth control. Last night the condom broke, however, and the patient is extremely worried that she may have become pregnant. Although she has mixed feelings about terminating an advanced pregnancy, she is not opposed to terminating an early pregnancy, and wants to know if she can take an “abortion pill” that she has heard about in the news. Her last menstrual period was 14 days ago, and her last gynecologic examination, which included a negative Pap smear, was 10 months ago. She has no previous illnesses and has a negative review of systems. She does not smoke, drinks only rarely, and does not use any illicit substances. Vital signs are: temperature 37.0 C (98.6 F), blood pressure 118/78 mm Hg, pulse 72/min, and respirations 20/min. Physical examination is unremarkable. A urine pregnancy test is negative. Given her request, which of the following is the most appropriate management?

A. Explain that no legal treatment is available and refer her to Planned Parenthood
B. Explain that no treatment is necessary given the negative urine pregnancy test
C. Explain that no treatment is necessary; given the timing of unprotected coitus there is a low risk for pregnancy
D. Prescribe a daily oral contraceptive pill
E. Prescribe ethinyl estradiol and levonorgestrel to be taken twice, 12 hours apart
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Old 11-30-2011
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C. Explain that no treatment is necessary; given the timing of unprotected coitus there is a low risk for pregnancy ?
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Old 11-30-2011
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E.

Prescribe ethinyl estradiol and levonorgestrel to be taken twice, 12 hours apart
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Old 12-01-2011
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E. Prescribe ethinyl estradiol and levonorgestrel to be taken twice, 12 hours apart


I would go with this as the timing is more likely to have more chances of pregnancy and it could be a false negative test result
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Old 12-01-2011
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i would go with E.
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Old 12-01-2011
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The correct answer is E. A double dose of oral contraceptive pills can significantly reduce the risk for pregnancy and is considered an effective postcoital contraceptive. It is believed to inhibit implantation, though the exact mechanism is not clear. The pills should be spaced by 12 hours and administered within 72 hours of coitus.
There are a variety of legal options; no longer is emergency contraception the domain of special providers (choice A). There are now a variety of FDA-approved hormonal combinations for emergency contraception. Additionally, mifepristone (RU486) is now available, as are copper intrauterine devices that prevent implantation if used within 72 hours of coitus.
A pregnancy test (choice B) should be performed to establish that there is no prior pregnancy, as there is a theoretic (and unproven) risk that emergency contraception can be a teratogen. A urine pregnancy test will not be positive the day after unprotected sex, as there is no increase in b-HCG levels before implantation.
The timing of intercourse (choice C) should not be used to gauge pregnancy risk, nor should it be used as a birth control method by a couple who does not wish to have children. Furthermore, this patient is mid-cycle, increasing her risk for pregnancy.
A daily oral contraceptive pill (choice D) does not provide adequate doses to prevent pregnancy. A double dose needs to be given. This patient may, however, wish to consider oral contraceptive pills or transdermal patches if she does not feel comfortable with the risk for condom rupture (though pills and patches also have a low but measurable failure rate).
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Old 12-01-2011
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ya E
doubel dose ...
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