Intended for healthcare professionals

Rapid response to:

Clinical Review

Contraception for women: an evidence based overview

BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b2895 (Published 07 August 2009) Cite this as: BMJ 2009;339:b2895

Rapid Response:

Ectopic pregnancy after Progesterone only Emergency Contraception

Dear Editor,

In their evidence-based review on contraception in women the authors
state that combined oral contraceptives, progestogen-only pills,
mifepristone, and copper bearing intrauterine devices may be used for
emergency contraception (1). A recent cochrane review showed that
levonorgestrel-only emergency contraceptive was more effective and better
tolerated than the combined oral contraceptive (2). I would like to raise
the awareness of risk of ectopic pregnancy in those taking emergency
contraception (including progestogen-only pills).

Progesterone only emergency contraceptive pill (POEC) in the form of
levonorgesterol is one of the common modes of emergency contraception
which provides women with safe means of preventing pregnancy following
unprotected sexual intercourse or potential contraceptive failure.
Levonorgesterol inhibits or delays ovulation and alters tubal motility by
decreasing peristalsis and reducing fimbrial beating (3). POEC was first
licensed for use in the UK in 1999 and became available over the counter
from January 2001 allowing easier access (4).

Ectopic pregnancy can be an unwanted complication as a result of
emergency contraception. Ectopic pregnancies are reported in about 10% of
the pregnancies in emergency contraceptives with oestrogen (5). Ectopic
pregnancies are also reported with other forms of emergency contraception.
Five cases of ectopic pregnancy (three cases after mifepristone, two cases
after split-dose of levonorgestrel) were identified among 45,842 women
(2). Twelve cases of ectopic pregnancy (out of a total of 201 unintended
pregnancies) have been reported to the Committee on Safety of Medicines
following failure of POECs (6). In 2006, I saw a 21 year old woman with a
ruptured tubal ectopic pregnancy two weeks after use of emergency
contraception in the form of a single dose of levonorgestrel (1.5gm) which
was purchased over the counter.

The above reports and my anecdotal experience highlight the need to
maintain extra vigilance for ectopic pregnancy in women who have a
positive pregnancy test and have used emergency contraception recently.

References

(1)Amy JJ, Tripathi V. Contraception for women: an evidence based
overview. BMJ 2009 Aug 7;339:b2895. doi: 10.1136/bmj.b2895.

(2)Cheng L, Gülmezoglu AM, van Oel CJ, Piaggio G, Ezcurra E, van Look
PF. Interventions for emergency contraception. Cochrane Database Syst Rev
2007;(4):CD001324.

(3)Faculty of Family Planning and Reproductive Health Care Clinical
Effectiveness Unit. FFPRHC Guidance: emergency contraception (April 2003).
J Fam Plann Reprod Health Care 2003; 29: 9-16.

(4)Camp SL, Wilkerson DS, Raine TR. The benefits and risks of over-
the-counter availability of levonorgestrel emergency contraception.
Contraception 2003; 68: 309-17.

(5)Van Look PF, von Hertzen H. Emergency contraception. Br Med Bull
1993; 49: 158-70.

(6)Woolley J. Levonelle/Levonelle-2 emergency contraception: new
advice. CMO’s Update 35, January 2003: 9

Competing interests:
None declared

Competing interests: No competing interests

27 September 2009
Puneet Arora
Registrar
Department of Obstetrics & Gynaecology, Hope Hospital, Salford