CPPE on EHC

[johnep]

Local PCT is instituting PGD for EHC and I am required to produce a certificate from CPPE that I have passed the test in the booklet.

When I was at uni only hormone available was stilboestrol and OC a long way ahead in the future.

Having a problem with some of the questions:

1) 26 yr old with 35 day cycle exposed to risk on day 12. Is there a significant risk of pregnancy.?
2)30 yr old with 25 day cycle exposed to risk on day 12. Risk of pregnancy.?
3) Woman took Logynon 12 hours late but upsi in between. Risk of pregnancy?
4) Woman forgot micronor yesterday morning but had upsi last night.
Risk of pregnancy?

Must say that usually I would give Levonelle to all four to prevent anxiety.
What is official ruling.?

5) Lady on Epilim. Not specifically mentioned, but usually I refer all epileptics.
Is there a particular interaction of importance.

Only anticonvulsants we had in the old days were Pot Brom and phenobarbitone. Epanutin looked on as great advance.

6) Levonorgestrol increases risk of DVT.? I would say no unless took frequently.
Am I correct?

7) If hormonal cover compromised, extra precautions for 14 days. I usually say for rest of month. Correct advice?

I need to pass these questions as I am OOH locum and get more than my fair share of EHC requests, particular on a BHM and the girl is on the edge of 72 hours, and has no money!

thanks in advance,

johnep

[Titch]

1) 26 yr old with 35 day cycle exposed to risk on day 12. Is there a significant risk of pregnancy.?

Ovulation tends to occur 12-14 days before next period expected - something to do with 2nd half of cycle being fairly constant length.

So if 35 day cycle - would expect ovulation to be on day 21-23 so no significant risk

2)30 yr old with 25 day cycle exposed to risk on day 12. Risk of pregnancy.?

As above rule - would expect ovulation to be on day 11-13 so high risk of pregnancy

3) Woman took Logynon 12 hours late but upsi in between. Risk of pregnancy?

Rule says can be up to 12 hours late so I would say ok and negligible risk

In practice I would probably supply to reassure her.

4) Woman forgot micronor yesterday morning but had upsi last night.
Risk of pregnancy?

Micronor POP so only 3 hour window - needs EHC as high risk. Gets cover back after about 2 days of POP from 1st dose after missed dose but for safety would advise 1 week of precautions.

Must say that usually I would give Levonelle to all four to prevent anxiety.
What is official ruling.?

I agree - if woman happy to take - what's the harm in supplying.

Our PGD official rule is if in doubt and no contra-indication then supply.

5) Lady on Epilim. Not specifically mentioned, but usually I refer all epileptics.
Is there a particular interaction of importance.

Not that I'm aware of - not an enzyme inducer (is it?)
Our PGD does cover double dose for woman on certain drugs.

6) Levonorgestrol increases risk of DVT.? I would say no unless took frequently.
Am I correct?

Think it's oestrogen that increases DVT risk so no risk as no oestrogen. If taken regularly could upset natural hormone levels and potentially cause a risk. Pretty sure POP can be used in people with DVT risk on COC so by same logic Levonelle no risk.

7) If hormonal cover compromised, extra precautions for 14 days. I usually say for rest of month. Correct advice?

Assuming by hormonal cover you mean missed pill or D/V or antibiotics or such like.
COC - additional precautions until has taken 7 consecutive pills. If pack finishes start next immediately and have no break.
POP - additional precautions until has taken 2 consecutive pills. Personally tend to still say 7 days then don't have to remember 2 different timescales!!

Exception to above is if on antibiotics - need precautions until finished antibiotics plus 7 days after and start next pack immediately if finish during that time.

I need to pass these questions as I am OOH locum and get more than my fair share of EHC requests, particular on a BHM and the girl is on the edge of 72 hours, and has no money!

Good on you Johnep - been in that situation so many times. I just wish more companies would prioritise installing consultation area so can supply via PGD - our PCT specifies must have private area as per defination for MUR and so frustrating that I am trained but pharmacy premises unsuitable.


Only other thing I would add as not covered in Schering training or CPPE. Latest research suggests Levonelle main action is by preventing LH surge. So if someone with 28 day cycle presents on day 10-16 then LH surge may have already happened and so taking Levonelle will do nothing.
Our PGD now amended so we have to encourage client to attend for coil fitting but we still supply EHC and stress that it is an "emergency measure" and so not guaranteed to work at any point!

Oh and risk of vomiting after is virtually zero but still best to tell them!

[Pharmanaut]

Originally Posted by Titch

Oh and risk of vomiting after is virtually zero but still best to tell them!

Looks like it is worth doing a flow chart of all that information.
Anyone good at flow charts?

[Titch]

Will have a go tomorrow.

Got electronic copies of most of PGD info so can cut n paste lots of the text info.

Sorry to sound like an idiot but can I post a flow chart to the forum? Step by step instructions would be appreciated.

By the way - can you tell I went to a contraception update meeting this week - room full of practice nurses and me the "ringer".
Nurse doing talk tried to make out that if taking St Johns Wort probably not much of an issue with any of the pills available - had to open mouth at that point and explain basic pharmacokinetics to all of them!!

[Pharmanaut]

Originally Posted by Titch

Will have a go tomorrow.

Got electronic copies of most of PGD info so can cut n paste lots of the text info.

Sorry to sound like an idiot but can I post a flow chart to the forum? Step by step instructions would be appreciated.

By the way - can you tell I went to a contraception update meeting this week - room full of practice nurses and me the "ringer".
Nurse doing talk tried to make out that if taking St Johns Wort probably not much of an issue with any of the pills available - had to open mouth at that point and explain basic pharmacokinetics to all of them!!

Nice one.
St Johns Wort - not exactly standardised so hard to predict what effect it has as a weak MAOI or a CYP3A4 inducer.

[Titch]

Appreciate that hard to predict but nurse was impying that because it's OTC and not an official medicine it didn't matter.

[Pharmanaut]

Originally Posted by Titch

Appreciate that hard to predict but nurse was impying that because it's OTC and not an official medicine it didn't matter.

... ah yes, I get it now.

[kemzero]

Originally Posted by Titch

Will have a go tomorrow.



By the way - can you tell I went to a contraception update meeting this week - room full of practice nurses and me the "ringer".
Nurse doing talk tried to make out that if taking St Johns Wort probably not much of an issue with any of the pills available - had to open mouth at that point and explain basic pharmacokinetics to all of them!!

Good on yer Titch.....way to go!
I do think that some practice nurses don't have a good knowledge of pharmacology