Management of Condom Rupture During Intercourse (2 Hours Prior)

1. Initial Assessment

• Last menstrual period (LMP) - to determine cycle phase and baseline pregnancy risk
• Regular menstrual cycle? - irregular cycles change the pregnancy risk window
• Time since intercourse - confirmed at 2 hours (well within all EC windows)
• Any existing pregnancy? - EC is not effective if already pregnant but is not harmful
• Contraindications to hormonal EC (rare - mainly active liver disease for combined pills; levonorgestrel has no absolute contraindications)
• STI risk - any concern for STI exposure? Inquire about partner's STI status
• Ongoing contraceptive plan - what method were they using besides condoms?

2. Emergency Contraception Options

Option A: Levonorgestrel (Preferred Oral Option in India)

• 1.5 mg single dose (one tablet) as soon as possible, OR
• 0.75 mg + 0.75 mg - first dose immediately, second dose 12 hours later

Option B: Ulipristal Acetate (Ella)

• 30 mg single tablet, prescription only
• Effective up to 120 hours from intercourse
• More effective than levonorgestrel near the time of ovulation
• Comparable to levonorgestrel at 2 hours post-intercourse
• Odds of pregnancy 65% lower in the first 24 hours vs. levonorgestrel's ~42% reduction

Option C: Combined OCP (Yuzpe Regimen)

• 100 mcg ethinyl estradiol + 0.5-1.0 mg levonorgestrel within 72 hours, repeated 12 hours later
• Alternatively: 4 tablets of a 30-35 mcg EE pill within 72 hours + 4 tablets 12 hours later
• Largely fallen out of favor due to high rates of nausea/vomiting (50.5% vs. 23.1% with LNG alone) and lower efficacy
• Still an option if other methods are unavailable

Option D: Copper IUD - Most Effective Method

• Efficacy: ~100% when inserted within 5 days (up to 7 days with near-100% efficacy)
• Works by inhibiting sperm function, inhibiting fertilized egg transport, and likely inhibiting implantation
• Does NOT terminate an established pregnancy
• Additional benefit: Provides long-term contraception (up to 10 years)
• Risk of uterine perforation: 1/1,000
• Associated with uterine cramping and may increase menstrual flow
• Requires a provider visit - but given the couple is already at the OPD, this is feasible

Note: Nine times more women choose oral EC over the copper IUD despite the IUD's superior efficacy. Counsel the couple on this option, especially if they want long-term contraception.

3. Mechanism of Action Clarification (Counseling Point)

• Emergency contraception is NOT an abortion pill. Both levonorgestrel and ulipristal delay or inhibit ovulation. The copper IUD prevents fertilization.
• None of these methods terminate an established pregnancy.
• If EC fails and pregnancy occurs, there is no evidence of fetal harm.

4. STI Risk Assessment and Prophylaxis

• Inquire about risk of HIV, chlamydia, gonorrhea, hepatitis B
• If HIV exposure risk is present and within 72 hours - refer urgently for HIV Post-Exposure Prophylaxis (PEP)
• If risk of other STIs (gonorrhea, chlamydia) - consider testing and/or empirical treatment
• Advise use of correct condom technique going forward

5. Follow-Up Instructions for the Couple

6. Ongoing Contraception Counseling

• Discuss reliable regular contraception - combined OCPs, POPs, DMPA injection, implant, IUD
• Educate on correct condom use technique (proper sizing, lubrication, checking expiry, pinching the tip, leaving space at the end)
• Condoms should be continued even with another method for dual protection against both pregnancy and STIs
• Discuss that EC is an emergency backup - not for routine use

Summary Decision Guide