A 31-year-old married woman presents to the family planning clinic 96 hours after a condom rupture during intercourse. She is concerned about an unplanned pregnancy. Her last menstrual period was 12 days ago with a regular 30-day cycle. Vital signs are stable, and general examination is unremarkable. She has no history of thromboembolism, migraine with aura, or smoking. What is the most appropriate management for this patient?

Explanation

## Emergency Contraception Beyond 72 Hours: Copper IUD **Key Point:** At 96 hours (4 days) post-intercourse, levonorgestrel is no longer effective. The copper intrauterine device (IUD) becomes the **only viable emergency contraceptive option**. ### Timeline of Emergency Contraceptive Efficacy | Method | Effective Window | Efficacy | Mechanism | |---|---|---|---| | **Levonorgestrel** | 0–72 hours | 95% (at 24h) → 58% (at 72h) | Ovulation inhibition | | **Copper IUD** | 0–120 hours (5 days) | >99% | Spermicide + endometrial inflammation | | **Mifepristone** | 0–72 hours | ~98% | Progesterone antagonist (not approved in India for EC) | **High-Yield:** The **copper IUD is the most effective emergency contraceptive** available, with efficacy >99%, and can be inserted up to **5 days** after intercourse. ### Why Copper IUD at 96 Hours? 1. **Levonorgestrel is ineffective** beyond 72 hours; at 96 hours, it provides minimal benefit 2. **Copper IUD mechanism** is independent of cycle timing: - Creates a hostile intrauterine environment - Impairs sperm motility and fertilization - Triggers inflammatory response preventing implantation 3. **This patient is a candidate:** - No contraindications (no history of STI, thromboembolism, or cardiac disease) - Nulliparity is NOT a contraindication for emergency IUD use - Regular cycle (predictable ovulation timing) ### Copper IUD as Emergency Contraception **Advantages:** - Highest efficacy (>99%) - Works up to 120 hours post-intercourse - Can be left in place for 10 years of contraception - No hormonal side effects - Immediately reversible **Insertion Requirements:** - Must be inserted by trained provider (gynecologist/trained health worker) - Aseptic technique essential - Baseline pregnancy test (negative in this case) - Screening for STI if high-risk **Clinical Pearl:** The copper IUD is **superior to any hormonal emergency contraceptive** in terms of efficacy and extended window of opportunity. It should be offered to all women presenting beyond 72 hours or when hormonal methods are contraindicated. **Mnemonic:** **COPPER-5** = Copper IUD effective up to 5 days (120 hours) [cite:Park 26e Ch 6; WHO Emergency Contraception Guidelines 2022]