Journal of Women's Health Care
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Clinical Study of Ectopic Pregnancy in Nepal

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Introduction

An ectopic pregnancy is one in which the fertilized ovum is implanted and develops outside the normal endometrial cavity [1]. It complicates 1% of all pregnancies and is one of the leading causes of the maternal morbidity and mortality especially in low income countries [2,3]. About 95% of ectopic pregnancies are tubal in origin. Rarely, it occurs in the ovary, rudimentary hom of a bicornuate uterus and the cervix [4]. The classical clinical triad of amenorrhea, bleeding per vaginum and lower abdominal pain is present in less than 50% of cases [5].In a reproductive aged woman presenting with acute abdomen, ectopic pregnancy should always be considered. The modality of treatment depends on the clinical state of the patient, serum ẞ-HCG level, USG findings and desire for future fertility (Table 1).

Table 1: Ectopic pregnancy in relation to age.

An ectopic pregnancy has received a great deal of attention in present day due to its association with fertility [6]. Ectopic pregnancy is on the rise, likely contributions being increasing incidence of sexually transmitted infections, ovulation inducing drugs, abdomino-pelvic surgeries and intrauterine contraceptive device use [7,8].However, ectopic pregnancy related deaths are decreasing owing to early diagnosis and prompt management. Delay or error in diagnosis makes a ruptured ectopic pregnancy still a common occurrence in our setting (Table 2).

Table 2: Distribution of cases according to parity.

Nepal has a highest number of recorded maternal deaths. In Nepal, pregnant women don’t seek early antenatal care due to various financial and geographical constraints because of which most cases of ectopic pregnancies remain undiagnosed till it ruptures. The late presentation of a woman in hypovolemic shock to a health facility due to ruptured ectopic is a common finding. These women have massive hemorrhage requiring multiple units of blood transfusion and some succumb to death due to unavailability of blood products and expert health professionals as well as delayed arrival to the health facility. Despite advances in the technology to diagnose ectopic pregnancy at an early stage, diagnostic dilemma still prevails due to varied presentation. The aim of this study is to see the trend of ectopic pregnancy in a tertiary hospital, demographic profile of such patients, identify the risk factors and morbidity.

Methodology

This observational retrospective study was carried out in Gandaki Medical College Teaching Hospital over a period of one years between May 1, 2019 to April 30, 2020. It is a tertiary care center which caters to patients from nearby districts and hospitals. The diagnosis of ectopic pregnancy was made mainly by history-taking, clinical physical examination, laboratory (urine pregnancy test/ serum beta HCG), and radiological (ultrasound) investigations. All ectopic pregnancy cases were identified from the gynecology ward and OT records and information on the socio-demographics, clinical presentations, intraoperative findings and outcome of surgery were all gathered and recorded in a predesigned proforma. The total number of deliveries during this period was obtained from the labour ward registers. Data were analyzed using descriptive statistics (Figure 1).

Figure 1. Clinical features
In present study, abdominal pain and amenorrhea was present in 100% and 72.7% cases respectively which represents the most common symptoms in a woman with ectopic pregnancy.

Results

In the present study, which was conducted during a period of one year from May 1, 2019 to April 30, 2020 at Gandaki medical college and teaching hospital, Pokhara, the total number of deliveries was 2086 and the total confirmed cases of ectopic pregnancy was 33, giving an incidence of 1.5% or 15 per 1000 deliveries (Tables 3-7).

Table 3: Duration of amenorrhea.

Table 4: Distribution of cases according to risk factor.

Table 5: Site of ectopic pregnancy.

Table 6: Management of ectopic pregnancy.

Table 7: Hemoperitoneum.

Discussion

The incidence of ectopic pregnancy in this present study was 15 per 1000 deliveries which is comparable to the reported incidence in various publications.

Most common age group in this study was 21-25 years and 31- 35 years. This could be because women are most fertile in the age group 21-25 years. Kaveri Shaw et al.in their study found that the common age group for ectopic pregnancy was 31-35 years similar to this study [9]. It could be explained by the fact that the incidence of pelvic inflammatory diseases and medical termination of pregnancies is high in this age group.

The present study depicts that the incidence was higher in multigravida (81.8%) as compared to the primigravida (18.2%) with similar results in study carried out by Poonam et al. [10]. The higher incidence of ectopic in multigravida is probably due to frequent use of emergency pills, previous abortions and infection.

36.36% of ectopic pregnancies had gestational age more than 8 weeks in contrast to study done by Manthan Patel which showed the frequent occurrence of ectopic pregnancies between 6-8 weeks [11].In our setting, most women don’t attend the antenatal clinic once pregnancy is diagnosed, so the presentation is rather late with rupture as an outcome and consequent maternal morbidity.

Medical termination of pregnancy and emergency contraception were the major risk factors associated with ectopic pregnancy in the present study. Eight cases (24.24%) of ectopic pregnancy gave history of medical abortion while 6 cases (18.2%) gave history of emergency contraception. Similar result noting abortion as the most common risk factor was given by Shukla et al. [12]. The easy availability of abortifacient drugs as well as unawareness regarding family planning measures make women susceptible to ruptured ectopic pregnancy in our setting. 15.15% of cases didn’t have obvious cause for ectopic pregnancy.

All the patients in the study (100%) had abdominal pain as a major symptom which were of varying intensity and it was one of the reasons for attendance to the hospital. The next frequent symptom was amenorrhea which was present in 72.7% of the patients. Vaginal bleeding was present in 45.4% of the total cases. All these findings were consistent with the study done by Nahar et al. [13].

The incidence of tubal pregnancy was in 96.9% of the total cases as quoted in most of the literature. Ampulla of the fallopian tube was commonly involved in 13 (58.9%) cases in the present study which is same as studies fromKhaleeque et al. [14]. It was followed by isthmus that was involved in 30.3% of the cases. Ovarian ectopic was present in 3.03% of the cases. The incidence of isthmic and ovarian ectopic coincided with study by Kaveri Shaw et al. [9].

Surgery was the mainstay of management in all the cases (100%) partly because most patients presented with rupture and partly because surgery still remains the method of choice in a developing country like Nepal. The method of choice in a developing country like Nepal. The most commonly done surgery in 78.77% of patients was open unilateral salphingectomy which was similar to study done by Yakasai et al.19 (89.10%) [15]. Salphingo-oopherectomy was required in 18.2% of case which was more in comparison to study done by Rajendra Wakankar and Kshama Kedar [16]. One patient was managed successfully with laparoscopic salpingectomy [17].

75.75% of cases had hemoperitoneum of more than 1000 ml intraoperatively suggesting that majority of patients presented with rupture. These patients required blood transfusion intraoperatively as well as postoperatively. Kaveri Shaw et al. in their study noted that 50%, 36.36% and 13.63%of the total cases had hemoperitoneum between 101-500ml, 1000ml or less and less than 100ml respectively [9].

Conclusion

Worldwide, ectopic pregnancy continues to be a significant health problem. Unsupervised use of abortifacient drugs and emergency contraceptive pills has resulted in a significant surge in the incidence of ectopic pregnancy. Also, it remains one of the major reasons for a reproductive aged woman undergoing surgery in her lifetime. So the general public should be made aware about risk factors of ectopic pregnancy and counselled regarding early care seeking behavior as soon as pregnancy is diagnosed.

Source of Funding

None

Conflict of Interest

None

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