Biomedical Research

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Research Article - Biomedical Research (2019) Volume 30, Issue 5

Clinical analysis of ectopic pregnancies in Majmaah, Saudi Arabia

Hussam Zain1, Rayan G Albarakati1, Yousif M.Y. Abdallah2*, Almuteri,tayseer dhayfallah1, Sami Elgak2, Elsadig Yousif Mohamed3, Elabbas A. Ebaid4

1Department of Obstetrics and Gynecology, College of Medicine, Majmaah University, Majmaah, 11952, Saudi Arabia
2Department of Radiological Science and Medical Imaging, College of Applied Medical Science, 11952, Majmaah University, Saudi Arabia
3Department of Society Medicine and Health, College of Medicine, Majmaah University, Majmaah, 11952, Saudi Arabia
4Department of Radiology, College of Medicine, Majmaah University, Majmaah, 11952, Saudi Arabia

*Corresponding Author:
Yousif Abdallah
Department of Radiological Science and Medical Imaging
College of Applied Medical Science
Majmaah University
Saudi Arabia

Accepted Date: April 23, 2019

DOI: 10.35841/biomedicalresearch.30-19-200

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Abstract

Ectopic Pregnancy (EP) is a serious emergency faced by physicians in obstetrics and gynaecology, and the identification of EP can be frequently missed. The common signs of ectopic pregnancy in fertile women are lower abdominal discomfort and vaginal hemorrhage. The aim of this paper was to study EP patients to determine the etiology and management of EP. This study aims to study the hazardous factors, types, and clinical complications associated with EP patients, as well as diagnostic methods and prognosis. This was a retrospective cohort study performed at King Khalid Hospital, Majmaah, Saudi Arabia. Patient demographic data were documented. These data included parity, hazardous factors, signs and symptoms, habits, occupation, past history of PID, ectopic pregnancy, pelvic surgery and management. The data were analyzed using statistical software in MS Windows. The data are presented as the mean plus standard deviation. In our study, most cases (83.3%) were managed surgically, which means that too few cases were given medical or conservative options; thus, medical staff training in how to apply medical or conservative management techniques according to guideline criteria can improve future outcomes.

Keywords

Clinical, Ectopic, Pregnancies, Saudi Arabia.

Introduction

Ectopic pregnancy is a gynaecological emergency that increases maternal mortality and morbidity, and a great deal of effort should be made for early diagnosis and treatment to reduce the mortality caused by ectopic pregnancy [1-3]. The most common presentation is classic symptoms of vaginal bleeding and abdominal pain, which can be described as sharp, dull or cramping. Bleeding into the peritoneum causes irritation, which results in shoulder tip pain [4-6]. Risk factors for ectopic pregnancy include pelvic inflammatory disease, smoking, pelvic surgery, past history of infertility and recent use of assisted reproductive techniques [7-9]. Most cases of ectopic pregnancy occur in a Fallopian tube; tubal pregnancy occurs in more than 90% of ectopic pregnancies, and less frequent sites include the cervix, ovary, and abdominal cavity [10-13]. The incidence of an ectopic pregnancy is approximately 1% to 2%, and it can reach 4% when assisted reproductive techniques are used. The medical signs of ectopic pregnancy usually occur between 4 weeks and 8 weeks, depending on the site of implantation. Many hazardous factors are associated with ectopic pregnancy. Reducing these factors can result in a decrease in incidence, but more than 30% of cases occur without risk factors. In normal pregnancy after fertilization, the embryo is advanced toward the uterus by the action of the cilia that are located in the tube; any factor, such as smoking, can lead to damage of the cilia, preventing the passage of the embryo from the tube to the uterus [14-16]. Women with PID have a higher risk for ectopic pregnancy because organisms, such as chlamydia and gonorrhea, can cause damage to the cilia and scar formation, which leads to a blockage of the tube [17-19]. Other factors, such as Asherman syndrome, the reversal of tubal ligation and a history of ectopic pregnancy, are also risk factors for EP. The diagnosis of ectopic pregnancy requires high clinical suspicion for any woman who presents with lower abdominal pain and vaginal bleeding; symptoms and signs should be followed by blood tests for BHCG and ultrasonography examination. Ultrasound has 90% accuracy in the detection of ectopic conditions [20]. Ectopic pregnancy is usually diagnosed as an adnexal bulky mass of the ovary [21]. The idea is to find an empty uterus in a patient with an adnexal mass and a positive pregnancy test. Both pregnancy checks and heterotopic pregnancy "pseudosacs" are detected in 20% of women [22]. Other diagnostic methods include laparoscopy and laparotomy, which are reserved for acute cases that are complicated by hypotension and have visual confirmation of the diagnosis. Some anomalies, such as miscarriage, ovarian torsion, ovarian cysts, acute appendicitis, kidney stones and pelvic inflammatory disease, have the same signs as an ectopic pregnancy. The management of ectopic pregnancy depends on the presentation of the patient. There are many choices for the management of EP, such as expectant management, in which the provider needs to follow the TVS and BHCG levels of the patient until the patent recovers completely; however, in this type of management, the patent must fulfill certain criteria, such as hemodynamic stability, a low concentration of BHCG, a small mass and no cardiac activity [23]. Early treatment for ectopic pregnancy with methotrexate is a viable alternative. If administered early during pregnancy, methotrexate ends the development of the emerging embryo. This approach causes an abortion, and an emerging embryo may later be removed by the body or menstruation. This approach should not be used in women who have liver, kidney, or blood illnesses or in women with an ectopic embryonic mass >3.5 cm. When the patient experiences bleeding, an emergency surgery should be performed. Nevertheless, it is a difficult decision in steady patients with no evidence of a blood clot on an ultrasound. Laparotomy is used to cut pretentious Fallopian tubes and to remove ectopic pregnancies [24]. Complications of ectopic pregnancy usually result from the rupture of the tube and hemoperitoneum with hypovolemic shock that leads to death [25].

Material and Methods

Patient characteristics, such as age, parity, presentation signs and symptoms, past history of PID, ectopic pregnancy and pelvic surgery, were documented. For statistical analysis, a computer-supported program was used.

Results

The results are mentioned in the table (Table 1-7).

Characteristics %
Age (Mean=29.67 ± 6.06; 18-42years)
21-30 years 62.8
31-40 years 34.9
>40 years 2.3
Occupations
House wife 2.7
Student 51.4
Employer 40.3
Labor 5.6
Parity
1 67.4
43500 25.6
>4 7
Risk factors
History of abortions ( = 1) 0
History of previous ectopic pregnancy 4.7
History of pelvic surgery 2.3
History of infertility 7
History of PID 9.3
History of intrauterine contraceptive device 23.3
Smoking
Active 2.4
Non-smokers 97.6
Signs
Haemodynamic shock 26.4
Abdominal tenderness 75
Cervical motion tenderness 58.3
Complications
Infections 4.7
Transfusion 41.9
Re-admission 18.6
Other 34.9
Counselling about ectopic pregnancy
Received 36.6
Not received 64.4

Table 1: Patient characteristics.

Factors

OR (95% CI)

Present Study

Mehta et al. [11]

Mol et al. [11]

Dart et al. [13]

Maka et al. [23]

Samiya et al. [9]

Shetty et al. [9]

Kendrick et al. [17]

Previous tubal surgery

2.3

21

-

-

4

-

3.2

-

Previous ectopic pregnancy

4.7

8.3

-

-

-

5.2

3.2

8.3

History of PID

9.3

2.5

-

-

2

10

3.2

15.8

History of infertility

7.0

2.5-21*

-

5.0

16

8.8

3.2

7.0

Tubal ligation

-

-

9.3

18

4

-

-

6.2

Current IUD use

23.3

-

4.2-45*

5.0

6

-

6.4

6.6

Table 2: Risk factors for ectopic pregnancy.

Authors Year Incidence
Shetty et al. [9] 2014 5:6 1000 delivers
Mehta et al. [11] 2016 30:2 1000 delivers
Present study 2017 12:1 1000 delivers

Table 3: Risk factors for ectopic pregnancy.

Procedure Present study Mehta et al. [11] Maka et al. [23]
Conservative 2.4 - -
Medical 14.3 - 6
Surgical 83.3 100 94

Table 4: Management of ectopic pregnancy compared with other authors.

Surgical procedure Present study Mehta et al. [11] Maka et al. [23]
Open Salpingectomy 58.5 51.25 64 Lap. Salpingectomy - 1.25 8 Open Salpingectomy with contralateral tubectomy - 35 14 Salpingostomy 7.3 3.75 - Salpingo-ophorectomy 2.5 2.5 4 Partial oophorectomy - 1.25 - Medical treatment 14.3 2.5 6 Partial salpingectomy - 1.25 - Milking - 1.25 -

Table 5: Surgical management of ectopic pregnancy compared with other authors.

Variables Present study Maka et al. [23] Porwal et al. [5] Samiya et al. [9] Maka et al. [23]
G1 67.4 28 40 53 18.4
G2 8.5 26 20 29 32.5
G3 8.5 26 31.5 10 43.0
G4 8.5 18 7.5 3.5 6.1
G6 7.0 2 - 2.63 -

Table 6: Gravida of ectopic pregnancy compared with other authors.

Clinical presentation Present study (%) Leveno et al. [4] Shetty A et al. [9]
Vaginal bleeding 58.2 43.2 61.3
Abdominal pain 86.1 89.2 80.6
Abdominal tenderness 75 70.3 48.4
Cervical tenderness 58.3 75.7 51.6

Table 7: Patients clinical presentation.

Discussion

The incidence of ectopic pregnancy in our study was 12 for every 1000 deliveries, which is considered less than international figures, as in the Mehta et al. study [11] performed in 2016, which found that the incidence was 30.2 for every 1000 deliveries. Most of the patients (62.8%) in our study group fell in to the age group of 21-30 years, which is close to the studies performed by Samiya [9] (75.4%), Panchal et al. [25]. The minority of patients (2.3%) was in the 40 years or older age group, which is similar to most studies because of the general fertility decline with age. In our study, most of the patients were primigravida (67.4%), followed by 8.5% for gravida 2, 3, and 4 as well as 7% for gravida 6. This result is similar to the studies performed by Samiya et al. [9] (53%) and Porwal et al. [5] (40%). In another study performed by Sudha et al. [24], the majority of patients (81.58%) were multigravidas, most likely due to previous infection resulting in tubal adhesion and damage. In the present study, 23.3% of the women had an IUCD in place, which can be considered a strong risk factor for ectopic pregnancy. This result is different from the studies performed by Maka et al. [23] and by Shetty et al. [9], in which 12% and 6.4% of the cases with ectopic pregnancy had an IUCD, respectively. In this area of study, IUCDs are the most popular means of contraception. In this study, 9.3% of the women had a history of pelvic inflammatory disease, which is quite similar to the study performed by Samiya et al. [9] (10%) and slightly different from the study performed by Maka et al. [23] (2%). Pelvic infection usually causes damage to the cilia in the tube, which interferes with transport and traps the fertilized ovum, resulting in an ectopic pregnancy. In our study group, 7% of the women with ectopic pregnancy were infertile, which is similar to the studies performed by Sudha et al. [24] (7.01%) and Mufti et al. [9] (8.77%). The association between infertility and ectopic pregnancy requires further study to find a logical explanation. A history of previous ectopic pregnancy was noted in 4.7% of women in our study, which correlates with a similar study performed by Samiya et al. [9] (5.2%) and Shetty et al. [9] (3.2%). This is most likely due to tubal factors that are usually bilateral; in some cases, having a history of ectopic pregnancy increases the chance to have another ectopic pregnancy by 17%. The common presenting complaints were abdominal pain and slight vaginal bleeding with clinical signs of abdominal tenderness in addition to cervical motion tenderness. In our study, 58.2% of patients presented with vaginal bleeding, and 86.1% of patients presented with abdominal pain, which were similar to the results of a study performed by Shetty et al. [9] (vaginal bleeding (61.3%) and abdominal pain (80.6%)). Clinical signs included abdominal and cervical tenderness. In the present study, the majority of patients (83.3%) were managed surgically, which was similar to the study performed by Mehta et al. [11] (100%) and Maka et al. [23] (94%). Regarding the details of surgery in our study, most surgically managed patients (58.5%) had unilateral salpingectomy by laparotomy, which is similar to findings by Mehta et al. [11] (51.25%) and Maka et al. [23] (64%). In the present study, 7.3% of patients underwent salpingostomy compared to 3.75% of patients in the Mehta et al. study [11]. Systemic methotrexate was given to 14.3% of women in our study compared to 6% of patients in the study performed by Maka et al. [23].

Conclusion

The incidence of ectopic pregnancy in Saudi Arabia is similar to the rate in developing countries (1% to 2%). This incidence can be reduced by working on preventable risk factors, such as patient education about how to prevent pelvic infections and the use of alternative contraception other than IUCDs; as evident in our study, 23.3% of patients were using an IUCD. In our study, most patients (83.3%) were managed surgically, which means that too few cases are given medical or conservative options; therefore, medical staff training in how to apply medical or conservative management techniques according to guideline criteria can improve future outcomes.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Ethical Approval

The Institutional Ethics Committee approved the study. [IRB registration KACST, KSA (1439-1073225)].

References