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Case of ectopic pregnancy after postcoital contraception with ethinyloestradiol-levonorgestrel.

A 34-year old para 0+1 requesting postcoital treatment 34 hours afer a single episode of unprotected intercourse on day 12 of her menstrual cycle had a history of salpingitis at age 20 and termination of pregnancy at 24. Vaginal examination showed no abnormality. She was given a combination of .1 mg ethinylestradiol and .5 mg levonorgestrel according to the Yuzpe regimen. She did not experience nausea or vomiting. At follow-up 4 weeks later she reported an episode of light vaginal bleeding which began 12 days after treatment and lasted for 8 days. 4 days afer the bleeding she began bleeding again and experienced severe lower abdominal pain. Vaginal examination in an emergency room showed no mass or tenderness and she was discharged with no arrangement for follow-up. The pelvic pain persisted and when she was again seen 32 days after the original treatment there was a tender left adnexal mass about 3 cm in diameter. A left tubal pregnancy was diagnosed at laparoscopy. The tube was distended with a hemosalpinx complicating a preexisting hydrosalpinx along with a small hemoperitoneum. The right tube and ovary were normal. A left salpingectomy was done and the patient made an uneventful recovery. Because the Yuzpe regimen is thought to act primarily at the uterine level rather than to inhibit ovulation an ectopic pregnancy is more likely when the treatment fails especially if there is preexisting tubal damage. The total number of ectopic pregnancies observed is roughly equal to what would be expected if no contraception had been used. Patients requesting postcoital treatment should be warned of the need for prompt examination if they develop severe pelvic pain. The history of previous tubal pregnancy should be a strong contraindication to postcoital treatment until more is known about the causative relation between postcoital hormonal treatment and ectopic pregnancy.