Emergency contraception and abortion

Modalities and Clinical Selection

1. Copper Intrauterine Device (Cu-IUD):
   • The Gold Standard: Efficacy exceeds 99.9% (failure rate $< 0.1\%$).
   • Timeframe: Can be inserted up to 120 hours (5 days) after UPSI, or up to 5 days after the earliest calculated day of ovulation.
   • Advantages: Independent of body weight or BMI; provides immediate, highly effective ongoing contraception for 5 to 10 years.
2. Ulipristal Acetate 30 mg oral (EllaOne):
   • Timeframe: Licensed for oral administration up to 120 hours (5 days) post-UPSI.
   • Mechanism: A selective progesterone receptor modulator (SPRM). Binds with high affinity to progesterone receptors, delaying follicular development and postponing ovulation by at least 5 days, even after the luteinizing hormone (LH) surge has commenced (up until the LH peak).

• Weight and oral EC: Higher weight/BMI may reduce effectiveness of oral EC, including ulipristal. A copper IUD is the most effective option and is not known to lose efficacy with body weight. Discuss timing, suitability and access without denying oral treatment when an IUD cannot be provided.
  • Further exposure: Oral EC does not protect later intercourse. Repeat treatment may be appropriate after a new exposure, accounting for ulipristal–progestogen interactions and copper-IUD suitability.

1. Levonorgestrel 1.5 mg oral (Postinor-1, Norlevo):
   • Timeframe: Licensed for administration up to 72 hours (3 days) post-UPSI (efficacy declines rapidly over time; minimal efficacy between 72 and 120 hours).
   • Mechanism: Delays or inhibits ovulation by blunting the LH surge; ineffective once the LH surge has begun.
   • Body Weight Impact: Efficacy is significantly reduced in individuals weighing $> 70\text{ kg}$ or with $BMI > 30\text{ kg/m}^2$. In this cohort, Cu-IUD is first-line; if unavailable or declined, ulipristal is preferred. If levonorgestrel must be used, Australian guidelines recommend doubling the dose to 3 mg oral (two 1.5 mg tablets).
   • Ongoing Contraception: Regular hormonal contraception can be started immediately ("quick-start"), requiring barrier protection for the next 7 days.

Pregnancy Termination in Australia

Legal Framework

Abortion has been decriminalized across all Australian States and Territories, transitioning termination of pregnancy from criminal law into mainstream public healthcare. Gestational limits for termination on request vary by state (generally up to 16 to 24 weeks' gestation). Beyond these statutory thresholds, termination requires clinical review and approval by two independent medical practitioners based on medical, physical, or psychosocial grounds. Healthcare practitioners with a conscientious objection are legally and ethically obligated to disclose their objection immediately and refer the patient without delay to an accessible, non-objecting practitioner or service.

Medical Termination of Pregnancy (MTOP)

In Australia, MTOP is approved and subsidized on the Pharmaceutical Benefits Scheme (PBS) under the MS-2 Step regimen for pregnancies up to 9 weeks (63 days) of gestation.

• Step 1: Mifepristone 200 mg orally:
  • A potent synthetic competitive antiprogestogen with anti-glucocorticoid actions.
  • Binds uterine progesterone receptors, blocking progesterone action. This leads to decidual degeneration, detachment of the gestational sac, cervical softening, and sensitization of the myometrium to exogenous prostaglandins.
• Step 2: Misoprostol 800 mcg buccally (36 to 48 hours later):
  • A synthetic prostaglandin $E_1$ analogue.
  • Stimulates powerful myometrial contractions and cervical dilatation, expelling the products of conception.
• Clinical Course & Complications: Vaginal bleeding and uterine cramping typically begin 1 to 4 hours post-misoprostol, accompanied by the passage of blood clots and the gestational sac. Common self-limiting side effects include nausea, vomiting, diarrhoea, headache, chills, and transient low-grade fever ($< 38^\circ\text{C}$). Red-flag symptoms requiring urgent emergency assessment include soaking more than two maximal sanitary pads per hour for two consecutive hours, severe unremitting pelvic pain, foul-smelling vaginal discharge, or persistent fever $\ge 38^\circ\text{C}$ lasting $> 24\text{ hours}$ after misoprostol.
• Completion follow-up: MS-2 Step product information requires review 14–21 days after mifepristone. Confirm completion with the agreed clinical, serum hCG or ultrasound pathway; earlier serum sampling can support this. Persistent pain, fever, heavy bleeding or ongoing pregnancy symptoms need earlier assessment.

Surgical Termination of Pregnancy (STOP)

• In the first trimester, performed via suction aspiration curettage under local anaesthesia with conscious sedation or general anaesthesia. Preoperative cervical priming with misoprostol ($400\text{ mcg}$ buccally 2 to 3 hours pre-procedure) softens the cervix and decreases procedural trauma.

• In the second trimester, performed via dilatation and evacuation (D&E) or medical induction.

• Abortion and anti-D: RANZCOG’s updated abortion guideline does not require routine RhD testing for medical or surgical abortion up to 10 weeks. Use current gestation-specific guidance after that point; 250 IU is not the correct dose for every gestation, and after 12 weeks the usual NBA dose is 625 IU. Miscarriage and ectopic pregnancy have separate prophylaxis indications.

• Post-abortion contraception: Many methods can begin promptly. Giving DMPA on the mifepristone day may slightly increase ongoing-pregnancy risk, which should be explained; timing after misoprostol is another option. Follow-up includes the service’s low-sensitivity pregnancy-test or other completion protocol.

Clinical comparison: Comparison of Emergency Contraceptive Modalities

• Mechanism: Copper Intrauterine Device (Cu-IUD): Sterile inflammatory reaction toxic to sperm; prevents fertilization & implantation; Ulipristal Acetate (EllaOne): Selective progesterone receptor modulator; delays LH surge and follicle rupture; Levonorgestrel (Postinor-1 / Norlevo): Progestogen; delays LH surge and follicle rupture only prior to onset of LH surge
• Licensed Timeframe: Copper Intrauterine Device (Cu-IUD): Up to 120 hours (5 days) post-UPSI or 5 days post-ovulation; Ulipristal Acetate (EllaOne): Up to 120 hours (5 days) post-UPSI; Levonorgestrel (Postinor-1 / Norlevo): Up to 72 hours (3 days) post-UPSI
• Comparative Efficacy: Copper Intrauterine Device (Cu-IUD): $> 99.9\%$ (highest of all methods); Ulipristal Acetate (EllaOne): High (superior to levonorgestrel); Levonorgestrel (Postinor-1 / Norlevo): Moderate; declines rapidly over time
• Impact of High BMI: Copper Intrauterine Device (Cu-IUD): No reduction in efficacy ($BMI > 30\text{ kg/m}^2$); Ulipristal Acetate (EllaOne): Maintained efficacy in overweight/obesity; Levonorgestrel (Postinor-1 / Norlevo): Reduced efficacy if weight $> 70\text{ kg}$ or $BMI > 30$ (double dose to 3 mg)
• Hormonal Quick-Start: Copper Intrauterine Device (Cu-IUD): Not applicable (non-hormonal); Ulipristal Acetate (EllaOne): Must wait 5 full days before starting hormonal contraception; Levonorgestrel (Postinor-1 / Norlevo): Can quick-start hormonal contraception immediately
• Barrier Protection Period: Copper Intrauterine Device (Cu-IUD): None required (immediate ongoing contraception); Ulipristal Acetate (EllaOne): Condoms required for 12 days (5-day wait + 7 days of pills); Levonorgestrel (Postinor-1 / Norlevo): Condoms required for 7 consecutive days
• Ongoing Contraception: Copper Intrauterine Device (Cu-IUD): Yes, provides 5 to 10 years of ongoing contraception; Ulipristal Acetate (EllaOne): No; provides no ongoing post-coital protection; Levonorgestrel (Postinor-1 / Norlevo): No; provides no ongoing post-coital protection

Primary references (checked 7 October 2026): Australian combined-pill flowchart; RANZCOG abortion guideline.

MS-2 Step product information specifies the approved regimen and follow-up.