Ectopic pregnancy with use of progestin-only injectables and contraceptive implants: a systematic review

Long-Acting Reversible Etonogestrel Subdermal Implant in Adolescents

Several effective contraceptive options are available for use by adolescents, including the long-acting reversible subdermal implant and intrauterine devices, which provide a high level of convenience, privacy, and effectiveness for an adolescent. Knowledge of all the effective birth control methods is essential for the pediatrician to be able to provide effective contraceptive counseling for an adolescent. An approach to counseling using a reproductive justice framework, which allows the provider and adolescent patient to engage in shared decision-making, is described. This article focuses on the long-acting reversible etonogestrel (ENG) subdermal implant for adolescents. The ENG implant is labeled for preventing pregnancy by suppressing ovulation. The ENG implant may also have a role in ameliorating dysmenorrhea and heavy menstrual bleeding. Postlabeling studies indicate that the ENG implant is effective for up to 5 years, although the device's labeling states effectivenessup to 3 years. The main contraindication to using the ENG implant is pregnancy itself. Safe initiation of the ENG implant is described, including an approach to determine whether an adolescent is pregnant. The main adverse effect of the ENG implant is an unpredictable bleeding pattern that is most often ameliorated by use of nonsteroidal anti-inflammatory medications, as well as estrogen, if not contraindicated for the patient. Details of the insertion and removal procedures, including potential complications, are described to enable the pediatrician to provide effective anticipatory guidance for the adolescent.

Diagnosis of Intrauterine Pregnancy Despite the Presence of Etonogestrel Implant

While contraception is an important method to avoid pregnancy, it is not always effective. Our case details a 33-year-old-female with an etonogestrel implant who presented to the emergency department (ED) with a two-week history of vomiting and abdominal pain. Pelvic and transvaginal ultrasound confirmed a single, live intrauterine pregnancy. Our case serves as a reminder that ED providers should have a high index of suspicion for pregnancy in clinically relevant scenarios, despite contraceptive methods, until the appropriate confirmatory diagnostic evaluation for pregnancy is completed.

BRCA mutation carriers' perception about benefits and risks associated with combined hormonal contraceptives use

OBJECTIVE

To evaluate the actual perceptions about combined hormonal contraceptives (CHCs) use in BRCA mutation carriers in comparison to women from the general population.

METHODS

This was a cross-sectional, observational study involving two Italian referral centres for hereditary cancers. An identical questionnaire investigating how CHC use could affect the risk of developing some types of cancer, specific diseases, and symptoms was administered to 85 BRCA mutation carriers and 85 healthy women without this genetic mutation (control group). Women's perceptions were evaluated using specific questions and Likert scales (-5 to +5).

RESULTS

Perceptions about the effects of CHC use on developing specific diseases and symptoms did not differ between BRCA mutation carriers and controls. Conversely, the protective effects of CHC use on colorectal (p = .02), uterine body (p = .01) and ovarian (p = .01) cancers were unknown by BRCA mutation carriers. Moreover, BRCA mutation carriers recognised the association between CHC use and a higher risk of breast (p = .0008) and uterine cervix cancer (p = .007).

CONCLUSIONS

Investing time and effort in transmitting the correct key messages about oncological risk related to CHC use could potentially increase their use in BRCA mutation carriers.

Method of Hormonal Contraception and Protective Effects Against Ectopic Pregnancy

The risk of ectopic pregnancy was higher in women using low-dose hormonal intrauterine devices (13.5 mg levonorgestrel) than in women using other types of hormonal contraception

OBJECTIVE:

METHOD:

RESULTS:

CONCLUSION:

Ectopic pregnancy with etonogestrel implant

The etonogestrel implant is the most effective contraceptive available. We report a case of ectopic pregnancy in a woman who had an etonogestrel implant inserted 15 months ago and the effective concentration of the implant was within normal limits.

Contraception after pregnancy

Whatever the outcome, pregnancy provides the opportunity to offer effective contraception to couples motivated to avoid another pregnancy. This narrative review summarizes the evidence for health providers, drawing attention to current guidelines on which contraceptive methods can be used, and when they should be started after pregnancy, whatever its outcome. Fertility returns within 1 month of the end of pregnancy unless breastfeeding occurs. Breastfeeding, which itself suppresses fertility after childbirth, influences both when contraception should start and what methods can be used. Without breastfeeding, effective contraception should be started as soon as possible if another pregnancy is to be avoided. Interpregnancy intervals of at least 6 months after miscarriage and 1-2 years after childbirth have long been recommended by the World Health Organization in order to reduce the chance of adverse pregnancy outcome. Recent research suggests that this may not be necessary, at least for healthy women <35 years old. Most contraceptive methods can be used after pregnancy regardless of the outcome. Because of an increased risk of venous thromboembolism associated with estrogen-containing contraceptives, initiation of these methods should be delayed until 6 weeks after childbirth. More research is required to settle the questions over the use of combined hormonal contraception during breastfeeding, the use of injectable progestin-only contraceptives before 6 weeks after childbirth, and the use of both hormonal and intrauterine contraception after gestational trophoblastic disease. The potential impact on the risk of ectopic pregnancy of certain contraceptive methods often confuses healthcare providers. The challenges involved in providing effective, seamless service provision of contraception after pregnancy are numerous, even in industrialized countries. Nevertheless, the clear benefits demonstrate that it is worth the effort.

Helping patients select long-acting reversible contraceptives

To reduce the rate of unintended pregnancies, patients should select a contraceptive option that fits their needs and lifestyle. Long-acting reversible contraceptives (LARCs) are a relatively safe and effective option. This article outlines the characteristics of available LARCs and identifies the appropriate method for specific patient populations.

Long-acting reversible contraceptives: Addressing adolescents' barriers to use

NPs caring for adolescent females have an opportunity to reduce US teen pregnancy rates through unbiased counseling on contraception options, including highly effective long-acting reversible methods. Intrauterine devices and subdermal implants are safe, effective contraception options for adolescents, but their rates of use remain low among this patient population. This article discusses current adolescent contraceptive practices, barriers to access, and current recommendations for long-acting reversible contraceptive use.

Levonorgestrel intrauterine contraceptive systems (13.5 mg and 52 mg) and risk of ectopic pregnancy

INTRODUCTION

The objective was to investigate the Pearl index for ectopic pregnancy in women using the levonorgestrel intrauterine system (LNG-IUS) at the time of conception.

MATERIAL AND METHODS

This was a substudy of a hospital-based historical cohort including women with an ectopic pregnancy diagnosed in 4 referral hospitals in Stockholm, Sweden between December 2013 and April 2017. Study participants and type of contraception at time of conception were identified through the electronic medical chart system. Cases were defined as women with LNG-IUS 13.5 or 52 mg in situ at the time of diagnosis of ectopic pregnancy who had their LNG-IUS inserted 1 January 2014 or later. Outcome was defined as the incidence rate for ectopic pregnancy during use per 100 woman-years (Pearl index) with 95% confidence interval (95% CI).

RESULTS

The study includes 35 cases with LNG-IUS 13.5 mg and 13 cases with LNG-IUS 52 mg, which occurred in 18 488 (13.5 mg) and 50 246 (52 mg) exposed woman-years. Pearl index for ectopic pregnancy was estimated at 0.19 (95% CI 0.15-0.28) for LNG-IUS 13.5 mg and to 0.006 (95% CI 0.00-0.01) for LNG-IUS 52 mg. The most cases for the LNG-IUS 13.5 mg (n = 26; 74%) occurred during the first year of use with a corresponding Pearl index at 0.23 (95% CI 0.14-0.35).

CONCLUSIONS

The absolute risk of ectopic pregnancy during the use of LNG-IUS remains low. Our method may underestimate as well as overestimate the Pearl index for ectopic pregnancy. The findings underline the importance of identifying risk factors for ectopic pregnancy at insertion, and to rule out ectopic pregnancy for all women presenting with abdominal discomfort during the use of LNG-IUS. Longer observation periods and prospective studies in a general population are a priority for further research.

Ruptured Ectopic Pregnancy in the Presence of an Intrauterine Device

Ruptured ectopic pregnancy is the leading cause of first trimester maternal mortality. The diagnosis of ectopic pregnancy should always be suspected in patients with abdominal pain, vaginal bleeding or syncope. While the use of an intrauterine device (IUD) markedly reduces the incidence of intrauterine pregnancy, it does not confer equal protection from the risk of ectopic pregnancy. In this report we discuss the case of a female patient who presented with a ruptured ectopic pregnancy and hemoperitoneum despite a correctly positioned IUD.

Levonorgestrel only emergency contraceptive use and risk of ectopic pregnancy in Eldoret Kenya: a case-control study

INTRODUCTION

ectopic pregnancy is one of the causes of maternal morbidity and mortality in sub-Saharan Africa. Levonorgestrel (LNG) only emergency contraceptive pill is a well-established emergency contraceptive pill that is administered within 72 hours after unprotected intercourse. This study aimed at determining whether or not there is a significant association between levonorgestrel emergency contraceptive use and the occurrence of ectopic pregnancy.

METHODS

case-control (1:3) study among 79 women with ectopic pregnancy (cases) matched against 237 women without (controls) at Moi Teaching and Referral Hospital in Eldoret, Kenya; Sociodemographic and clinical data were collected using a questionnaire. Association between ectopic pregnancy and LNG-EC was assessed using Pearson chi-square test. The relationship between outcome and exposure (while adjusting for confounders) was assessed using logistic regression model.

RESULTS

The mean age was 27.15 years. Both cases and controls were similar by age (p = 0.990), educational level (p = 0.850), marital status (p = 0.559), employment status (p = 0.186) and parity (p = 0.999). Seventy-eight (24.7%) participants had a history of miscarriage. A higher proportion of the cases had history of using LNG-EC compared to the controls (32.9% vs. 7.2%, p < 0.001). The use of LNG-EC portended more than nine times increased odds of ectopic pregnancy compared to other contraceptive methods {OR = 9.34 (95% CI: 3.9 - 16.0)}.

CONCLUSION

levonorgestrel only emergency contraceptive use was associated with ectopic pregnancy. One of the limitations of this study is that we could not control for all confounders of ectopic pregnancy.

Occurrence of anembryonic pregnancy with use of levonorgestrel subdermal implant (JADELLE®): a case report

BACKGROUND

Progestin-only subdermal implants are one of the most effective contraceptive methods. Anembryonic pregnancy is not reported as a possible outcome in cases of contraceptive failure of these products. We present a rare case of anembryonic pregnancy occurring in a woman with levonorgestrel-releasing implant (JADELLE®).

CASE PRESENTATION

A 31-year-old Cameroonian (black African) housewife with a JADELLE® implant for 13 months, consulted at our hospital for a 1-month history of pelvic pain, prolonged menstrual bleeding, and spotting. She had a last normal menstrual period 8 weeks 1 day prior to presentation. On examination, there was suprapubic tenderness and blood trickling from her cervix. Despite a negative qualitative urine pregnancy test, an empty intrauterine gestational sac with mean sac diameter of 28 mm was visualized on pelvic ultrasound. Dilation and curettage with suction was done and she had complete relief from symptoms.

CONCLUSION

This case report highlights the possibility of anembryonic pregnancy occurring in women using the levonorgestrel-releasing subdermal implant (JADELLE®).

[Safety profile of etonogestrel contraceptive implant (Nexplanon® and Implanon®) reported in France]

OBJECTIVES

The aim of the study was to assess the incidence of adverse effects (AE) reported with etonogestrel contraceptive implant in France (Implanon^® and Nexplanon^®).

MATERIALS AND METHODS

All cases of AE or unintended pregnancies reported to health authorities or to the firm were analyzed.

RESULTS

During 10 years, 5433 AE and 789 unintended pregnancies were reported. Only 388 (7 %) were serious. There were 1137 reports of difficulties to remove, failure to locate or migration, 430 of insertion difficulties and 203 of deformation or expulsion of the implant. Among other AE, the most common were 1694 gynecological AE, 524 skin reactions and 437 metabolic AE. Since the marketing of Nexplanon^® which causes less deep insertions, the incidence of migrations, removal or insertion difficulties has decreased overall (0.92 vs. 1.31/1000 patients), particularly the incidence of removal difficulties, location failures or migrations (0.12 vs 1.01/1000). The infrequent but serious AE were infectious complications at the implant site and pregnancies. When the circumstances of the pregnancy were known, the contraceptive failure was due to the apparent inefficiency of the implant (n=224), to a technique failure (n=203) or to a drug-drug interaction (n=59).

CONCLUSION

This study confirms that AE of this implant are frequent but not serious, except for the pregnancies. The incidence of complications related to insertion decreased with Nexplanon^®. Among other preventable AE, unintended pregnancies due to a drug-drug interaction would require to be better known by the practitioner.