Ruptured ectopic pregnancy with normally implanted Levonorgestrel Intrauterine System

Introduction: Ectopic pregnancy is the implantation and development of the blastocyst outside the endometrial lining of the uterine cavity. In patients with intrauterine hormonal contraception, the pregnancy rate is less than 1%. One of the potential complications of ectopic pregnancy is a ruptured pregnancy, with a high maternal mortality rate. Objective: To report a rare case of ectopic pregnancy in a patient with a normally implanted levonorgestrel intrauterine system. Methodology: This is a descriptive observational study based on the analysis of the patient's medical record and literature review. Results: A 28-year-old woman with a history of previous cesarean delivery and who had been using a levonorgestrel-releasing intrauterine device (Mirena) for 4 years, came to the gynecological clinic due to bright red bleeding for 15 days. On speculum examination: cervix visualized, no ectopia, bleeding from the fundus and from the external orifice. Vaginal examination: thick, posterior and infertile cervix. Quantitative Beta-HCG of 1507. The transvaginal ultrasound showed a normoimplanted (SIU), a retro-verso-flexed uterus with a uterine volume of 43.3 cm3, a heterogeneous and hypoechoic oval image with a cystic area in between and no flow on Doppler, located adjacent to the left adnexal region measuring 2.0 x 1.8 x 1.5 cm. The correlation between the imaging findings and the quantitative beta-HCG value confirmed the diagnosis of ectopic pregnancy. The patient was then given intramuscular methotrexate at a dose of 50mg/m2 without any complications. After 2 days, the patient returned complaining of abdominal pain in the lower abdomen radiating to the vaginal canal, associated with moderate vaginal bleeding. On physical examination: the patient was sweating, tachycardic and hypotensive. The abdomen was painful on deep and superficial palpation and there was sudden decompression. Speculum examination showed bleeding from the fundus and discharge from the external orifice. Due to the clinical alterations and the patient's physical examination, surgical treatment was chosen due to the possibility of a ruptured ectopic pregnancy. Exploratory laparotomy was performed. A moderate amount of blood was found in the cavity and a ruptured ectopic pregnancy was visualized in the left fallopian tube, and due to this finding, a left salpingectomy was performed. Post-operatively, the patient was hemodynamically stable, with no complaints of pain, and was discharged within a few days. Conclusion: Despite the hormonal intrauterine device having a Pearl index of 0.9%, our case portrayed a pregnancy, rare in this situation, which evolved without complications for the patient.