Introduction

An ectopic pregnancy occurs when a fertilized ovum implants outside normal uterine cavity.

The cardinal rule in the evaluation of early pregnancies with bleeding, especially in early 1^st trimester, is to have a high index of suspicion for an ectopic pregnancy.2

Over 95% of ectopic pregnancies occur in fallopian tube’s various segments. The ampulla [70%] is most frequent site followed by isthmus[12%], fimbrial[11%], interstitial[2%].1

Non tubal ectopic pregnancies comprise the remaining 5% and implant in ovary, peritoneal cavity, cervix, prior cesarean scar.1

Ocassionally, a multifetal pregnancy contains one conceptus with normal uterine implantation and the other implanted ectopically-Heterotopic pregnancy. 1

The classic triad of ectopic pregnancy is Amenorrhoea that is followed by Abdominal pain and Vaginal bleeding.

‘When in doubt, do it’ was indeed standard teaching in the management of ectopic pregnancy until the development and easy availability of serum beta-hcg testing, transvaginal ultrasound and laparoscopy. With highly sensitive urine pregnancy tests, if the test is positive and the uterus is empty on ultrasound, a diagnosis of ectopic pregnancy should be made unless proved otherwise.3

Because of the ready availability of both pregnancy test and the ultrasound, a number of ectopic pregnancies are now diagnosed even before any symptoms occur or at a very early stage with mild bleeding and discomfort and stable haemodynamic condition. This has opened up the possibility of treating ectopic pregnancies medically without the need for surgery.3

Ultrasound criteria of an ectopic gestation include failure to visualise an intrauterine pregnancy at a serum beta-hCG level greater than 1500 units, visualisation of an extrauterine gestation sac with or without a living embryo, a nonspecific, variably vascular, variably tender adnexal mass and free fluid in the pelvis.3

Aim of the Study

To study and analyse ectopic pregnancies in a tertiary care centre in one year.

Objectives

To determine the

Materials and Methods

Retrospective analysis of ectopic pregnancy was done in Gandhi hospital, Secunderabad from October 2021 to September 2022{1 year duration} with a sample of 97 cases of suspected ectopic pregnancy observed and treated, out of total 11252 pregnant women admitted, are included in this study.

Age, parity, risk factors, clinical features, ultrasonography findings, mode of management, need for blood transfusions were noted.

Main outcome measures studied were incidence, risk factors, clinical presentation, management, morbidity and mortality.

Results

During the study period of 1 year, there were 11252 pregnant women admitted in the hospital and out of 97 suspected ectopic pregnancies 90 cases were found to have ectopic pregnancy giving the incidence of 0.8%(8 per 1000 pregnancies). 4 cases were found to have ovarian cyst, 1 case was found to have ovarian torsion and 2 cases were found to have negative laparotomy.

Majority of the patients (87 5% belonged to the age group of 20-30years.

In this study 77.4% were multigravida and 22.6% were Primigravida.

In present study multiparity (50.5%) appears to be a most common risk factor.

In the present study the triad of amenorrhoea, pain abdomen, bleeding pv was seen in 69% of cases.

Out of 96 cases managed surgically, ultrasonography findings of 87(90.6%) cases correlated with laparotomy findings. In remaining 9(9.3%) cases there was a disparity between ultrasonography and laparotomy findings (Table 5).

UPT was positive in all ectopic pregnancies.

False positive UPT was observed in 7 cases.

50%(1) cases of isthmic ectopic pregnancies, 30.7%(5) cases of cornual ectopic pregnancies, 26.6%(4) cases of fimbrial ectopic pregnancies, 20.7%(11) cases of ampullary ectopic pregnancies were presented with severe anaemia. P-value for the (Table 6) comparision is 0.68 which is statistically non significant.

Among 97 suspected ectopic pregnancies, intraoperatively, 89(92.7%) cases were found to have ectopic pregnancies, 4(4.2%) cases were found to have simple or haemorrhagic ovarian cyst, 1(1.04%) case was found to have ovarian torsion, 2(2.08%) cases were found to have negative laparotomy.(Table 7)

In present study ampulla is the common site of ectopic (62.9%).(Table 8)

In present study ruptured tubal ectopic pregnancies were found in 79% of cases and unruptured tubal ectopic pregnancies in 21% of cases.(Table 9)

In present study, >750ml blood loss (class II, III, IV haemorrhagic shock) was seen in 50% cases of isthmic ectopic pregnancies, 46.7% cases of cornual ectopic pregnancies, 33.4% cases of fimbrial ectopic pregnancies, 26.7% cases of ampullary ectopic pregnancies, 25% cases of ovarian ectopic pregnancies.(Table 10)

P-value for the Table 10 comparision is 0.46 which is statistically non significant.

Most common procedure done was unilateral salpingectomy (63.5%) one case was managed medically and successfully with single dose methotrexate.(Table 11)

In present study incidence of blood transfusion, postop wound complications was noted in 65.9%, 3.1% cases respectively. Mortality was zero in this study.(Table 12)

Discussion

In the present study, majority of the women belonged to the age group of 20-30 years (87.5%) which is close to the studies done by Samiya Multi et al (75.4%),4 Panchal D et al (71.66%),5 Gaddagi et al (70.2),6 Sudha et al study (67.54%),7 Chate, et al study(70.96%).8

We observed maximum incidence of Ectopic pregnancy was in multigravida i.e, 77.4% followed by primigravida i.e.22.6%. This correlates with the studies done by Shraddha Shetty K et al. (83.9),9 Panchal D et al(81.66%)5 Poonam et al. (83.6%),10 Sudha, et al i.e.(82%).7

In present study, abdominal pain was present in 100% cases and amenorrhoea in 83.5% cases and bleeding pervaginum in 69% cases.Shetty S et al9 observed the commonest symptoms were abdominal pain (80.6%), amenorrhoea (77.4%) and vaginal bleeding (61.3%) Gaddagi et al6 observed that a majority of the cases presented with pain abdomen (89.2%), amenorrhoea (75.7%), spotting pv in 43.2%. Chate et al8 study observed pain abdomen in 92.47% cases and amenorrhoea in 77.4% cases and bleeding pv in 58% cases. Sudha et al7 observed amenorrhoea in 82.4% cases, pain abdomen in 78.5% cases bleeding pv in 63.3% cases.

Urine pregnancy test was positive in 92.7% of the cases which correlated with the study done by Sudha et al,7 Rashmi A Gaddagi, et al(97.3%)6 and WM Fgeeh(96%).11

In present study, 12.3% of women with ectopic pregnancy were infertile which is correlating with the studies done by Panchal D, et al (11.66%),5 Samiya Mufti, et al (8.77%),4 Sudha et al(7.01%),7 Chate et al(20.43%).8

In present study group, 7.2% of the women with ectopic pregnancy had tubal sterilization which correlates with the studies done by Uzmashabab, et al (5%),12 Shrestha et al. (5%),13 Sudha et al(6.57%),7 Chate et al (23.65%).8

In 95.5% cases ectopic pregnancy was tubal. Commonest site for ectopic pregnancy was ampulla in present study accounting for 62.9% cases followed by cornua and fimbria in 14.6% and 13.4% cases respectively. Similarly, reported in Chate et al8 study i.e. ampulla in 51.61%, fimbria in 19.3%.

Sudha et al7 reported ampullary pregnancies in 63.15% cases, cornual in 13.15% cases fimbrial in 16% cases.

In the present study, the incidence of rupture ectopic was 79% cases, followed by unruptured ectopic pregnancies in 21% cases. Similarly, reported in Chate et al8 study i.e. ruptured ectopic 76.35%. Gaddadi R et al6 reported that 78.3% cases showed a ruptured ectopic pregnancy on laparotomy. Sudha et al7 reported that ruptured ectopic was present in 66.66% cases on laparotomy.

In present study right sided ectopic pregnancies (58.1%) were more than left sided ectopic pregnancies (41.9%). In Sudha et al7 study right sided tubal pregnancy was present in 64% cases and left tubal involvement in 36% cases.

In present study, more than 750ml blood loss was observed in 30.3% cases of ectopic pregnancies.

In the present study, unilateral salpingectomy was done in 63.5% cases. In Sudha et al7 study it was 90%, in Chate et al8 study it was 75.2%. Shetty et al9 observed the most common surgery done was unilateral salpingectomy in 90.3% cases.

In present study, ruptured haemorrhagic ovarian cysts were found in 2 cases, simple ovarian cyst was found in 2 cases, 1 case was found to have ovarian torsion and 2 cases had negative laparotomy.

Medical management was done in 1 case successfully with single dose Methotrexate.

Morbidity included anaemia, blood transfusion and wound infection.

In the present study Maternal mortality rate is zero consistent with Sudha et al7 study and A, Abbas and H. Akram study.14

Conclusion

Clinicians should be aware of the fact that any women in reproductive age group presenting with pain in lower abdomen or vaginal bleeding, ectopic pregnancy should be suspected irrespective of presence or absence of amenorrhoea, whether or not she has undergone sterilization, because early diagnosis is critical in reducing maternal morbidity and mortality and improving treatment success rates.

Source of Funding

None.

Conflict of Interest

None.