Ectopic pregnancy with postcoital

contraception a case report

A. Basu and C. K. Candelier
Department of Obstetrics and Gynaecology, Stepping Hill Hospital,
Stockport, Cheshire, UK
Presenter
Dr. Cordova Arridho
Moderator
Dr. Hj. Hartati, SpOG(K)

Introduction

The incidence
of ectopic
pregnancy
continues to
increase.

Levonelle-2 is a
relatively new
drug
introduced in
the UK for
postcoital
contraception

In the UK, there

have been twelve
reported cases of
ectopic pregnancy
associated with
Levonelle-2 so far.

There was
reported a case
of ectopic
pregnancy
related to
Levonelle-2 use

CASE REPORT

A 27-year
woman, para 3
+3 Examinded
by her general
practitioner
(GP) for
postcoital
contraception
within 72 hours
of unprotected
intercourse.

GP prescribed
Levonelle-2 and
she tolerated
the medication
well. She
denied any
menstrual
irregularities or
unprotected
intercourse in
the preceding
month.

She returned to
her GP 4 weeks
later with a
positive
pregnancy test.
She had slight
vaginal
bleeding and
some lower
abdominal
pain.

The pain in her

lower abdomen
was crampy in
nature, radiating
to her back and
had been there
for the previous
45 days. She
also mentioned a
brownish vaginal
discharge, which
had been present
for nearly a week.

LMP
Reproductiv
e
Parity
contraceptio
n

about 4 weeks earlier, was unusually light and

had lasted only a day.

Her usual cycles were 23 days every 28

days.

she had had three vaginal deliveries,

Two miscarriages and an uncomplicated termination of
pregnancy.

never used any contraception as her partner was away

a lot.
Her last smear, performed 2 years earlier, was negative.

Examinations
hemodynamically stable with a pulse rate of 95/m and BP
115/95 mmHg. There was a degree of suprapubic
tenderness, without any rebound tenderness or guarding. An
internal examination was unremarkable

a quantitative serum b-human chorionic gonadotrophin: The

b-hCG was reported as 2900 IU/l. a repeat serum b-hCG was
4600 IU/l.

ultrasound scan of the pelvis. The uterus was noted to be

empty with endometrial thickening. The right ovary was
normal and a collapsed corpus luteum was found on the left
ovary. There was no free fluid in the pelvis

Treatment
At laparoscopy, there was a small degree of
haemoperitoneum. Both ovaries were normal
and an unruptured ectopic pregnancy was
found in the ampullary region of the left
Fallopian tube. A laparoscopic total left
salpingectomy
was
carried
out
with
peritoneal lavage. Postoperative recovery
was satisfactory and the patient was allowed
home the following day. A serum b-hCG level

 Histology of the tube confirmed the presence of a

gestational sac containing first-trimester chorionic
villi and placental site trophoblast. There were no
features to suggest chronic salpingitis and there
were no other abnormalities.

DISCUSSION
There has been a four-fold increase in the incidence of
ectopic pregnancy in the UK in the last two decades.
According to the Confidential Enquiry into Maternal Deaths,
there were 12 deaths from ectopic pregnancy in the last
triennia for which data are published (199496).
The risk factors for ectopic pregnancy include

previous ectopic pregnancy,

previous tubal surgery,
documented tubal pathology,
intrauterine contraceptive device use
in vitro fertilization with embryo transfer.

Factors that do not affect

ectopic pregnancy are:
previous termination of pregnancy
or a previous Caesarean section.
It has also been said that previous
oral contraceptive use does not
affect ectopic pregnancy.

Studies in the United States

have demonstrated that a
large number of ectopic
pregnancies occur when a
pregnancy occurs while the
woman is on progesteroneonly contraceptives. It is
probably because the
progesterone-only
contraceptives limit the
propulsive effect of the tube
at the ampullary region, thus
trapping the fertilized ovum.

Levonelle-2
Levonelle-2 is a progesterone-only preparation conmprising two
tablets of 750 mg of levonorgestrel. It acts as a postcoital
contraceptive when the two tablets are taken 12 hours apart, with
the first tablet being taken within 72 hours of unprotected
intercourse.
According to the product information leaflet, Levonelle-2 prevents
nearly 85% of expected pregnancies. it is thought to work by a
combination of ovulation inhibition, prevention of fertilization of the
released ovum and inhibition of implantation.
According to the information provided by the manufacturers, the
reported incidence of ectopic pregnancy with Levonelle/Levonelle-2
use is less than 1 : 10 000 (i.e. very rare). However, there have been
12 reports of ectopic pregnancy in the UK following the use of
levonorgestrel emergency contraception.

CONCLUSION
Ectopic pregnancy is frequently misdiagnosed at the initial visit despite
technological advances. Nevertheless, laparoscopic salpingectomy is now
the surgical treatment of choice for tubal ectopic pregnancy, with a final
treatment rate of 95% and a low rate for further surgical complication.

Histology confirms the diagnosis. However, in the absence of any

macroscopic pathology or known predisposing factor(s), ectopic
pregnancy is believed to be the result of endothelial tubal damage
secondary to salpingitis. Loss of ciliation is frequently found or there is
histological evidence of previous salpingitis. In this case, there was no
evidence of any tubal pathology on histology. A cause for ectopic
pregnancy could have been the progesterone effect of Levonelle-2, which
slows the rate of intratubal migration of the fertilized ovum.

THANK
YOU...