What is the recommended emergency contraception for a female patient of childbearing age with iron deficiency anemia, gastrointestinal problems, and impaired renal function?

Emergency Contraception for Women with Iron Deficiency Anemia, GI Problems, and Renal Impairment

Ulipristal acetate (ella) 30 mg as a single oral dose is the recommended emergency contraception for this patient, as it is effective up to 120 hours after unprotected intercourse and does not require dose adjustment for renal impairment. 1

Primary Recommendation: Ulipristal Acetate

• Ulipristal acetate 30 mg should be administered as a single oral dose within 120 hours (5 days) of unprotected intercourse, with efficacy maintained across all time intervals from 0-120 hours post-intercourse 1
• The observed pregnancy rate with ulipristal acetate is 2.2% when taken 48-120 hours after intercourse and 1.9% when taken 0-72 hours after intercourse, representing statistically significant reductions from expected pregnancy rates 1
• No dose adjustment is required for renal impairment, making it particularly suitable for this patient 1

Why Ulipristal Acetate is Preferred in This Clinical Context

Gastrointestinal Considerations

• Ulipristal acetate is a single-dose oral medication, minimizing GI exposure compared to multi-dose regimens 1
• The patient's existing GI problems make oral iron supplementation poorly tolerated, but a single dose of emergency contraception is manageable 2
• Unlike chronic iron therapy which causes high rates of GI side effects with ferrous salts, a single emergency contraception dose poses minimal additional GI burden 2

Renal Function Considerations

• Ulipristal acetate does not require dose modification in patients with impaired renal function, unlike some other medications that require adjustment 1
• This is critical as the patient has documented renal impairment, and avoiding medications requiring renal dose adjustment reduces complexity and potential toxicity 2

Iron Deficiency Anemia Considerations

• Emergency contraception itself does not worsen iron deficiency anemia 1
• Preventing unintended pregnancy is crucial in this patient, as pregnancy would dramatically increase iron requirements threefold during the second and third trimesters (to approximately 5.0 mg iron/day), which this patient cannot meet given her existing iron deficiency 3
• Pregnancy in the setting of pre-existing iron deficiency increases risk for preterm delivery and low-birthweight babies 3

Efficacy Across BMI Categories

• For women with BMI ≤30 kg/m², ulipristal acetate maintains excellent efficacy 1
• For women with BMI >30 kg/m² (16% of study subjects), the observed pregnancy rate was 3.1%, which was not significantly reduced compared to expected rates, indicating reduced efficacy in obese women 1
• If this patient has BMI >30 kg/m², consider copper intrauterine device (IUD) as the most effective emergency contraception option regardless of BMI, though this requires procedural placement 1

Administration and Follow-Up

• Confirm negative pregnancy test before administering ulipristal acetate 1
• Administer 30 mg orally as soon as possible after unprotected intercourse, up to 120 hours 1
• Counsel the patient that ulipristal acetate may alter the timing of her next menstrual period 1
• If vomiting occurs within 3 hours of taking the dose, repeat the dose 1

Critical Pitfall to Avoid

• Do not delay emergency contraception to "optimize" iron status first—the window for effective emergency contraception is time-sensitive (120 hours), and pregnancy would worsen her iron deficiency far more than the current state 3, 1
• Do not use hormonal contraceptives containing estrogen/progestin as emergency contraception in this patient, as ulipristal acetate has superior efficacy in the 72-120 hour window 1

Concurrent Management of Iron Deficiency

• While addressing emergency contraception, initiate treatment for iron deficiency anemia with 60-120 mg elemental iron daily, though GI side effects may limit oral tolerance 4
• Consider intravenous iron (such as iron sucrose) given her GI problems and renal impairment, as IV iron avoids GI absorption issues and is preferred in patients with chronic kidney disease 5, 2
• Heavy menstrual bleeding affects 10% of women of childbearing age and is a major risk factor for recurrent iron deficiency—consider gynecologic referral for menorrhagia evaluation and hormonal management to reduce future blood loss 5, 4