A 28-year-old woman presents to the emergency department 36 hours after unprotected intercourse. She has no contraindications to any form of emergency contraception. Regarding the options available to her, all of the following are acceptable EXCEPT:

Explanation

## Emergency Contraception at 36 Hours Post-Coitus ### Clinical Scenario The patient presents at 36 hours post-unprotected intercourse, which falls within the efficacy window of multiple EC methods. The question asks which option is **NOT acceptable** in the Indian context. ### Analysis of Each Option #### Option A: Levonorgestrel 1.5 mg (single dose) - **Acceptable.** Levonorgestrel is effective within 72 hours of intercourse. - At 36 hours, the patient is well within the optimal window. - Dose: 1.5 mg as a single dose or 0.75 mg × 2 doses, 12 hours apart. - Mechanism: Delays or inhibits ovulation. - [cite:Park 26e Ch 23] #### Option B: Mifepristone 10 mg (single dose) - **NOT ACCEPTABLE in India.** This is the answer. - Mifepristone is **not approved for emergency contraception in India**. - It is used for medical abortion (typically 200 mg dose) in countries where approved, not as a routine EC agent. - Not included in Indian guidelines (FOGSI, ICOG) for emergency contraception. - Offering this would be outside standard of care in India. #### Option C: Ulipristal acetate 30 mg (single dose) - **Acceptable.** Ulipristal acetate is a selective progesterone receptor modulator. - Effective up to 120 hours (5 days) post-coitus; at 36 hours, well within window. - More effective than levonorgestrel, especially in the 72–120 hour window. - Single dose: 30 mg. - [cite:Park 26e Ch 23] #### Option D: Copper IUD insertion - **Acceptable.** Cu-IUD is the most effective EC method. - Efficacy >99% when inserted within 5 days (120 hours) of unprotected intercourse. - At 36 hours, patient is well within the window. - Can be left in situ for 10 years as long-term contraception. - [cite:Park 26e Ch 23] ### High-Yield EC Methods in India | Method | Dose | Timing | Efficacy | Status in India | | --- | --- | --- | --- | --- | | Levonorgestrel | 1.5 mg single dose | ≤72 hrs | 60–90% | **Approved, widely available** | | Ulipristal acetate | 30 mg single dose | ≤120 hrs | >95% | **Approved, increasingly available** | | Cu-IUD | Insertion | ≤5 days (120 hrs) | >99% | **Gold standard, approved** | | Mifepristone | 10–25 mg | ≤120 hrs | >95% | **NOT approved for EC in India** | **Key Point:** Mifepristone is used for medical abortion in countries where it is approved, not as a routine emergency contraceptive. In India, it is not part of the standard EC armamentarium. ### Clinical Pearl When counseling a patient on EC options in India at 36 hours post-coitus: - **First-line:** Levonorgestrel (accessible, affordable) or Cu-IUD (most effective) - **Alternative:** Ulipristal acetate (if available and cost is not a barrier) - **Never offer:** Mifepristone for EC (not approved; abortifacient; outside guidelines) **Warning:** Confusing mifepristone (abortion pill) with emergency contraception is a common trap. They are distinct interventions with different indications, doses, and legal status in India.