Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So if you're ready, let's jump right in.

When advising a patient on the use of emergency contraception (EC) with levonorgestrel (LNG), which of the following is correct? And I'm going to use some terms here: Emergency contraception is often abbreviated E.C. Levonorgestrel, a progestin, is often abbreviated LNG.

A. If pregnancy does occur post LNG EC use, a teratogenic pattern in the offspring has been noted 
 
B. EC with LNG must be used within 12 hours after unprotected heterosexual vaginal intercourse to provide EC benefit.  
 
C. LNG EC’s use is limited due to a number of common contraindications.  
 
D. LNG EC use does not result in the interruption of an established pregnancy. 

Where do we start?  

 First, determine what kind of a question this is. And given we're being asked to advise a patient about a medication, this would need an intervention or plan question. Let's look at the background here. Emergency contraception, again, abbreviated EC is used post heterosexual intercourse to help minimize the risk of unintended pregnancy when a contraceptive method fails or is not used. It's a highly effective method of minimizing the number of unintended pregnancies.  

Knowledge of and access to emergency contraception is an important part of comprehensive health care, as this modality reduces the risk of pregnancy by 75% or more. There are many options available for EC, including oral levonorgestrel, as mentioned here and available over the counter as well as ulipristal, brand name Ella, and copper containing IUD insertion. The latter two options, the ulipristal and the IUD are prescription only.  

The IUD insertion is highly effective as EC, requires a skilled provider for insertion, also provides ongoing contraception. If a copper containing IUD is not used for EC, another effective form of ongoing contraception should be offered. EC should also always be offered post sexual assault.  

 Let's take a look at the options. And to recap with the question, when advising a patient on the use of emergency contraception with  levonorgestrel, which of the following is correct? 

A. If pregnancy does occur with post LNG EC use, a teratogenic pattern in the offspring has been noted. 

 This is not correct. Keep in mind, when is EC taken? It is taken prior to a pregnancy being established. If a woman takes LNG EC and does become pregnant, the medication has been excreted prior to the fertilized ovum implantation, which is not for a number of days after the egg is fertilized. In addition, LNG is a progestin, a drug class that's not known to be a fetal teratogen even when taken in the presence of an established pregnancy.  

Option B. EC LNG must be used within 12 hours after unprotected heterosexual vaginal intercourse to provide EC benefit.  This is also not correct. The FDA labeling for this EC form advises that it should be used within 72 hours post unprotected heterosexual intercourse. Though it likely has some impact on pregnancy reduction beyond this time frame. However, we need to keep this in mind — earlier beats better. The earlier that LNG is taken as a form of emergency contraception post intercourse, the more likely it is to be effective in preventing a pregnancy. 

C. LNG EC’s use is limited due to a number of common contraindications. 

This is also incorrect. When used as EC, LNG has very few contraindications. Indeed, when LNG issues as a contraceptive method, ditto, very few contraindications. And in fact, LNG EC, as I mentioned earlier, is actually sold over the counter. And when a med is sold over the counter, keep in mind the two main reasons for that. One, the patient can diagnose themselves with their condition. Obviously, the patient can assess being in need of emergency contraception. They don't need a health care provider or a special test to do that. And two, the medication, the product tends to be quite safe to use.  

Let's take a look then at option D. LNG EC use does not result in the interruption of an established pregnancy. This is our correct answer. The most likely mechanism of action to reduce pregnancy risk with a progestin only EC form like LNG is by inhibiting or delaying ovulation or impairing ovum or sperm transport. And I always feel like when I say this next sentence, like a fifth grade science teacher, but the idea behind impairing ovum or sperm transport is by slowing down the transport of either of the ovum or the sperm that the two don't meet in the fallopian tubes and therefore the egg never gets fertilized. This form of EC is unlikely to prevent pregnancy by impeding the implantation of a fertilized ovum.  

Take home message: Counseling about medication use is an important part of the NP role. To be an effective communicator about drug therapy, you must know how the medication works, its effectiveness, contraindications and, of course, its indications.  

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