Ectopic pregnancy following

levonorgestrel emergency
contraception: a case report
introduction
postcoital
contraception

preventing
unwanted
pregnancy safe
(8%-11%) Levonorgestrel
(LNG)

better
effective
tolerated
Case report

25-year-old nulliparous woman

with acute onset of pain in her lower abdomen

• Urine pregnancy test (+), Menstrual cycle:30

days
• Last menstrual period was 6 weeks prior to
presentation.
• She had light vaginal bleeding 2 weeks earlier,
which was interpreted by her as menses,
following which spotting persisted
• She was in good general health with no long-
term medical problems and in a stable
relationship, using a barrier method of
contraception.
Case report

25-year-old nulliparous woman

with acute onset of pain in her lower abdomen

 She did give a history of a ruptured condom

approximately 10 days after her last normal
period and took two doses of 750 mcg of LNG,
12 h apart.
 The levonorgestrel tablets were purchased at a local
pharmacy, and the first dose was administered within
12 h of intercourse.
 There was no history of repeat unprotected
intercourse, no risk factors for ectopic
pregnancy were identified.
Case report
examination

25-year-old nulliparous woman

with acute onset of pain in her lower abdomen
 Vital signs were stable
 There was mild tenderness in the suprapubic area
 Pelvic examination showed the uterus was of
nongravid size, and bilateral fornices were tender.
 A transvaginal sonogram revealed no gestational sac
in the endometrial cavity, with no adnexal mass and
minimal free fluid in the pelvis.
 Serum β-hCG was 3816.8 mIU/mL
Case report

25-year-old nulliparous woman

with acute onset of pain in her lower abdomen
 A diagnosis of ectopic pregnancy was made
 she was administered 65 mg methotrexate (im)
 She was sent home with instructions to report back in 4
days for assessment and repeat β-hCG estimation.
 Four days later, she complained of severe abdominal pain
and was mildly tachycardic on examination, and there
was significant free fluid in the pelvis on
ultrasonography.
 Her β- hCG level had risen to 4305.6 mIU/mL.
Case report

25-year-old nulliparous woman

with acute onset of pain in her lower abdomen
 A diagnosis of ruptured ectopic pregnancy was made and
she underwent laparoscopy.
 Per-operative findings revealed a right ampullary
ruptured ectopic with hemoperitoneum of 300 mL, and
right salpingectomy was performed.
 The postoperative period was uneventful, and she was
discharged home the following day.
 synthetic progestin analogue
licensed for use as EC in India since 2001 and available over-the-counter 2005

effectiveness vary with the ciliary dysfunction and altered

phase in menstrual cycle tubal motility secondary to
high progestin levels.

Follicular phase
interferes with the ovulatory process by
the occurrence of EC in the
inhibiting the LH surge
event of contraceptive failure
LNG after LH surge (Paltieli Y, 2000)

failures of EC method
(Croxattoa, 2004 and Marions, 2002)
A single dose of 750 mcg could be Two doses of 750 mcg
an effective alternative to
the standard regimen.

The advantage would be a lower High serum level of

serum level of progestin 30–40 ng/mL
(5–10 ng/mL)
(Johansson et al, 2002)
(Changhai,1991)

lessen the effect on tubal motility & risk of ectopic gestation.

 Levonorgestrel
(LNG)

Apart from timing in relation to the

menstrual cycle and the dose administered
↓
the other factor appears to be the time elapsed between
first dose administered and act of unprotected intercourse
↓
pregnancy rates increased from:
0.5% when treatment was given within the first 12-h period after intercourse
to 4.1% when it was given within the sixth 12-h period (61–72 h).

(Piaggio, 1999)
Cases of ectopic pregnancy

A further three cases of ectopic pregnancy:

•Following LNG EC use in the peri- and postovulatory phase of cycle.
•Concluded that if the risk of ectopic pregnancy is increased upon
failure of EC, it is more likely to do so when LNG is administered
in the peri- and postovulatory period.

(Sheffer-Mimouni et al,2003)

Jian & Linan and Basu & Candelier reported two and one case of
ectopic pregnancy, respectively, following over the counter use of LNG
as an ECP in women otherwise at low risk for ectopic pregnancy.

(Jian, 2003 and Basu, 2005)

Cases of ectopic pregnancy

Retrospective questionnaire:
•A total of 73 ongoing pregnancies were reported among an estimated
total of 2569 prescriptions.
•Out of the 73, three (4.1%) were ectopic pregnancies.
•No information on phase of menstrual cycle, timing of initiation of
LNG or presence of pre-existing risk factors for ectopic pregnancy
was mentioned.
(Gainer, 2001)

The first reported case of nontubal ectopic pregnancy following

failure of postcoital contraception with LNG:
•Occurred at the site of a previous caesarean section scar in the
absence of any tubal pathology and was managed conservatively.
•No mention of timing of administration ormenstrual phase

(Fabunmi and Perks, 2002)

Conclusion

•Ectopic pregnancy following use of levonorgestrel as EC is a well

known risk.

•In spite of prompt use (within 12 h of intercourse) in the correct phase

of cycle (preovulatory) in a woman with no pre-existing risk factors for
ectopic gestation, LNG failure resulted in an ectopic pregnancy.

•All physicians should be alert to this possibility, and public awareness

spread regarding the need to contact health personnel in case of
amenorrhea/ menstrual abnormality or pain in the abdomen following
use, so that availability without prescription does not translate into
unmonitored use.