EPIDEMIOLOGY, DIAGNOSIS AND MANAGEMENT OF ECTOPIC PREGNANCY -
An Analysis of 196 Cases
Priti S Vyas*, Pratibha Vaidya**
*Ex-Resident; **Ex-HOD, Department of Obst. and Gynaec., LTMG Hospital, Sion, Mumbai 400 022.
An analysis of 196 cases of ectopic pregnancy presenting over a period of 5 1/2 years was done at our institution. The incidence of ectopic in our study was 7.06 per 1000 deliveries. We had maximum patients i.e. 74.8% who came to us with a ruptured ectopic. 75% belonged to age group of 21-30 years 25% had past history or intra-operative findings suggestive of PID, and 14.3% had infertility. The diagnosis of ectopic pregnancy was made by clinical examination, urine pregnancy test (UPT), colpopuncture, abdominal tap, USG etc., as per the clinical findings. Out of the 196 patients only one was subjected to medical management and rest all were managed surgically, of these 43.8% underwent conservative surgery. The mortality rate in out study was 4.08%.
Ectopic gestations are pregnancies resulting from misimplantation of the blastocyst, in an aberrant area that is not conductive to further development and growth (anywhere else apart from the endometrial lining of uterine cavity). It not only leads to foetal wastage, but also increases the incidence of maternal morbidity, mortality and problems of future fertility. To preserve the maternal life and future fertility of the patient, high index of suspicion, early and accurate diagnosis, immediate and skillful surgery and moral responsibility remains the cornerstone of management of ectopic pregnancy.
MATERIAL AND METHODS
This study includes an analysis of 196 cases admitted in our hospital over a period of 5 1/2 yrs from January 1993 to May 1998.
The history and examination details included, age, parity and marital status, socioeconomic conditions and presenting symptoms.
Any significant past history was noted down, such as;
H/O Infertility, H/O symptoms suggestive of PID, H/O previous ectopic pregnancy, H/O tubal surgery, H/O prior surgery or procedure done, contraceptive history and H/O any medical disease.
Examination findings including that of vital parameters, thorough abdominal and bimanual examinations were noted.
Diagnosis was made with the help of urine pregnancy test, colpopuncture, abdominal tap, ultrasonography and/or laparoscopy and laboratory investigations. The findings on exploration were noted.
Treatment given was divided as,
• Medical - methotrexate
• Surgical - Conservative
The blood loss and the number of blood transfusions given were noted.
The morbidity and the number of deaths and their details were studied too.
OBSERVATIONS AND RESULTS
In the present study conducted over a period of 5 1/2 yr. the total number of deliveries was 27754 and the total number of ectopic pregnancies were 196; giving an incidence of 7.06 per 1000 deliveries or 1 per 141 deliveries.
Age, Parity, Marital and Socioeconomic Status
In our study 75% of the patients belonged to the age group of 21 to 30 yr. The incidence of ectopic pregnancy decreased with increasing parity and only 3 patients were unmarried i.e. 98.5 percent of total were married. Also 52.04% were from lower socioeconomic class. Tables 1-3.
Table 1 Age Group No. of Cases(%) 16-20 14(7.14%) 21-25 77(39.28%) 26-30 70(35.71%) 31-35 22(11.2%) 36-40 11(5.61%) >40 2(1.02%) Total 196
Table 2 Parity No of Cases(%) 0 72(36.73%) 1 58(29.59%) 2 34(17.35%) 3 19(9.69%) 4 9(4.59%) 5 2(1.02%) 6 1(0.51%) 9 1(0.51%) Total 196
Of the various risk factors studied, it was found that past or present history of PID was most common i.e. 49 (25%) of patients. Also a significant number of patients had history of previous induced abortion or D and C done, i.e. 42 (21.43%) Table 4.
The classic tetrad of symptoms was seen in only 60 (30.6%) of the patients. From our present study, it was found that 178 patients (90.82%) had history of abdominal pain, which varied from mild to severe in intensity. The classic history of amenorrhoea ranging, from 6 wks to 12 wks was seen in 154 (78.57%) patients, suggesting that although an important symptom absence of amenorrhoea does not rule out the possibility of ectopic pregnancy.
Table3 Socioeconomic status No.of Cases(%) Low 102(52.04%) Middle 91(46.43%) High 3(1.53%) Total 196
Table 4 Predisposing Factors No of Patients Percentage(%) Primary 19 9.69 H/O Infertility Secondary 9 4.59 H/O PID 49 25 Lap TL 4 2.04 H/O Tubal Ligation Puerperal TL 13 6.63 H/O Tubal Recanalisation 7 3.57 H/O Prev induced abortion/D and C 42 21.43 H/O Prev ectopic 12 6.12 H/O IUCD use 8 4.08 H/O Pelvic surgery 1 0.51 H/O Koch's or Koch's contact 14 7.14 H/O LSCS 11 5.61 No risk factors 74 37.76
Tachycardia and hypotension, was seen in 103 patients (52.55%). On per abdominal examination 13.7% of patients had no abdominal signs, while 59.69% had abdominal tenderness and 31.12% had abdominal distension. On bimanual examination maximum number of patients had forniceal tenderness 140 (71.43%) or tender cervical movements in 137 (69.89%) and 54% also had forniceal bogginess.
Investigations and diagnosis
Majority of patients presented with significant degree of anaemia, corresponding to the blood loss. The haemoglobin was < 7 gm% in 101 patients (51.53%) Table 5.
Table 5 Haemoglobin(gm%) No. Of Patients(%) >10 14(7.14) 8-10 81(41.33) 4-7 92(46.94) <3 9(4.59)
Urine pregnancy test (UPT)
152 women out of the 196, presenting to our emergency ward were subjected to a rapid single-step urine test for HCG with a detection limit of 50 Iu/lit. Table 6.
Table 6 UPT No. of Cases(%) Positive 144(94.75%) Delayed Positive 1(00.66%) Negative 4(02.63%) Equivocal 3(01.97%) Total 152
Colpopuncture and Abdominal Paracentesis
Colpopuncture was done in 101 (51.53%) cases and was positive in 83 (82.18%) cases. In 5 patients it was found to be false negative. Abdominal tap was performed in 50 (25.5%) patients and was positive in 44 (88%).
This was used as an additional diagnostic aid where diagnosis was in doubt viz 82 (41.8%). It was conclusive in 57 (69.5%) patients and the diagnosis of ectopic was missed in 6 cases.
It was done in 7 patients to confirm diagnosis; and all were explored surgically.
181 patients had haemoperitoneum on exploration and it was found that degree of pallor detected clinically and by haemoglobin estimation correlated well with the amount of haemoperitoneum (Table 7).
Table 7 Haemoperitoneum (cc) No. Of Patients(%) Nil 15(07.65%) < 500 56(28.57%) > 500 < 1000 60(30.60%) > 1000 < 1500 36(18.37%) > 1500 29(14.80%) Total 196
Site of Ectopic Pregnancy
Tubal pregnancy was the most common finding (91.33%). The site of ectopic pregnancy in the present study was as in Table 8. On detailed study of tubal pregnancies, it was seen that ampullary ectopic was most common (42.46%) Table 9 and the natural history was as in Table 10.
In the present series out of 196 cases 195 were managed surgically while one with unruptured ectopic was managed medically with injection methotrexate.
Table 8 Site No. of Cases Tubal 179(91.33%) Tubal -> intra ligamentary 3(01.53%) 2x abdominal 2(01.02%) Rudimentary horn 5(02.55%) Ovarian 2(01.53%) Cervical 1(00.51%) Heterotopic 2(01.02%) Corpus luteum haematoma 1(00.51%)
Table 9 Site of Tubal Ectopic pregnancy No. of Patients(%) Ampullary 76(42.46%) Isthmic 40(22.35%) Fimbrial 28(15.64%) Isthmico ampullary 11(06.15%) Interstitial 16(08.94%) Infundibular 5(02.79%) Tubal stump 2(01.12%) Whole tube 1(00.51%)
Table 10 Event No. of Cases(%) Ruptured 134(74.86%) Unruptured 8(04.47%) Tubal abortion 23(12.85%) Chronic ectopic 12(06.70%) Haematosalpinx 2(01.12%) Total 179
Of the patients explored, 109 (55.61%) underwent radical surgery and 43.88% conservative surgery depending on the in situ findings. In spite of the efforts conservative surgery was not always possible and radical surgery was performed as in Table 11 while the conservative surgeries are in Table 12. Along with the main operation, many a time additional surgical procedures were performed either as a part of the surgery, like a Coffey’s stitch, round ligament plication or in the event of an incidental finding like dermoid, tuboovarian mass which were resected.
Table 11 Surgery No. of patients(%) Salpingectomy - Unilateral 65(59.63%) - Bilateral 7(06.42%) Salpingo - oophorectomy 17(15.59%) Excision of horn 4(03.67%) Cornual resection 13(11.92%) Oophorectomy 2(01.83%) Hysterectomy 1(00.91%) Total 109
Table 12 Surgery No. of Patients(%) -Unilateral 63(73.25%) Partial salpingectomy -Bilateral 1(01.16%) Salpingostomy 4(04.65%) Surturing of ruptured tube 4(04.65%) Frimbioplasty 2(02.33%) Milking of Tube 2(02.33%) Fimbriectomy 7(08.14%) Surturing of ovary 2(02.35%) Total 86
Out of 181 (92.04%) of the patients who came with haemoperitoneum and anaemia 172 patients (87.76%) were given blood transfusion.
Morbidity and Mortality
In our series 3 patients (1.53%) had post-operative fever, 5 cases (2.55%) had wound gap and 8 (4.08%) required ventilator support of which only 3 survived. The mortality we had was of 8 patients’ i.e. 4.08%.
We had two cases of heterotopic pregnancy; one had a missed abortion with left ruptured ectopic for which partial salpingectomy was done. The other was ovarian pregnancy who also had IU gestational sac as seen on post-operative USG for which MTP was done after 5 days. One patient 21 years old primigravida had ruptured cornual ectopic, the histopathology report of which came as vesicular mole. We had one case of cervical ectopic for which evacuation of the cervical ectopic with bilateral internal iliac artery ligation was done.
Out of the 8 patients who died; one was a known case of ITP. Out of the other 7 mortalities, four had cardiac arrest either preoperative or intraoperative, one patient who came to the emergency ward in a disoriented condition - post operative CT scan showed left ACA and MCA infarct affecting parietal, frontal, temporal lobes and died after 3 days; and 2 of the patients died of acute renal failure.
The incidence of ectopic pregnancy has been increasing worldwide. Makinen J et al have reported a three fold increase in Finland from 1966 to 1985 while Centers for Disease Control (CDC) USA reported a four fold increase in its incidence from 1970 to 1983[2,3] from 4.5 to 16.18 per 1,000 pregnancies. However, at the same time, the fatality rate decreased from 35.5 to 3.8 per 10,000 ectopic pregnancies - a decrease of 90%. Presently in the UK, ectopic pregnancy accounts for 11.5% of all maternal deaths. In a review of ectopic pregnancies in the USA Stock reported a 3.7 fold increase in the incidence from 1965 to 1985 to a rate of 14 per 1000. In a multicentric case control study in India, (ICMR Task Force Project, 1990) the incidence of ectopic pregnancy was 3.12 per 1000 pregnancies or 3.86 per 1000 live births. In our series the ectopic pregnancy rate is 7.06 per 1000 deliveries or in other terms 1 in every 141 deliveries.
In our study 75% ectopic pregnancy occurred in the age group of 21-30 yrs. Westrom in 1981 in Sweden and Rubin et al in USA reported the incidence of ectopic pregnancy increasing with age.7,8 This difference may be because in India most women marry at an early age finish child bearing at an early age and fewer pregnancies are seen in the 3rd decade of life. Kohl et al has reported an increasing incidence with increasing parity beyond 5 or 6. He also noted that more ectopics are seen in the lower socioeconomic classes than in higher society, which is also seen in our study (52.04%). However the class of patients who come to our institution may bias this observation.
In our study group 62.24% patients had one or the other risk factor associated with ectopic pregnancy. Garrett and Vukov studied the risk factors in patients with ectopic pregnancy in rural based population, which were different from those in urban populations. They found a predominant - risk factor being history of infertility in 35%, prior tubal operation in 38%, PID in 17% prior ectopic in 16% etc. Frequently no risk factor was found.4
Pelvic Inflammatory Disease (PID)
The commonest risk factor in our series was PID i.e. 25%. Westrom in a study showed that 45.3% of patients of ectopic pregnancy had PID clinically or pathologically proven. Skjeldestad et al (1998) and Hadgu et al (1997) from lund (Sweden) ectopic data; also confirm these findings that PID was strongest predictor of subsequent development of ectopic pregnancy and that severity of PID was directly related to the ectopic pregnancy. Also presence of mycoplasma in lower and upper genital tract was a strong predictor of ectopic pregnancy.
Prior Induced Abortion or D and C
Prior D and C or MTP has been stressed as an important risk factor but there is no clear-cut association in literature. In our series 42 patients (21.43%) had prior induced abortions or D and C.
We had history of prior use of or conceiving with IUCD in situ in 8 (4.08%) of our cases. The first association between ectopic and IUCD as suggested by Lippes in 1965, but this too is controversial. Tretz et al in 1966 attributed that IUCD enhanced intrauterine contraceptive effect without a concurrent effect on extrauterine implantation. Consequently the unintended pregnancy that occurs in IUD users is more likely to be an ectopic. Tatum et al reported incidence of ectopic pregnancy to be 3.7% in IUCD user.
Recurrent Ectopic Pregnancy
Langer in 1990 reported that in a series of 118 women treated conservatively for ectopic pregnancy 65 had normal contralateral tube, and recurrent ectopic pregnancy rate was 5%. 18 women in this series had damaged contralateral tubes or absent tube and a 28.5% repeat ectopic was noted. Conservative management of ectopic pregnancy may actually increase the likelihood of subsequent ectopic pregnancies by allowing the damaged tube to remain, although a higher incidence of intrauterine pregnancies is also appreciated. Medical treatment on the other hand does not require surgical manipulation there by minimizing damage to the tube.
In our series 8.67% patients had an ectopic pregnancy after tubal ligation. Tatum and Schimidt reported 15.9% of ectopic pregnancies after tubal sterilisation but in them laparoscopic coagulation was also included which is not so in our cases.12
We had 7 cases of ectopic pregnancy who had tuboplasty done (3.57%). Solves (13) reported that after tubal surgery, incidence of ectopic pregnancy varied between 2-7%.
Not always the patient presents with classical symptoms. Williams (1) reported 85% patients presenting with abdominal pain. Breen in his series showed 85% patients presenting with history of amenorrhoea. Cartwright in his series had 50% of patients with abnormal bleeding pattern. Ratnam reported in his series 75.9% patients who presented with cervical movement tenderness.
In our series, ultrasound was positive in 69.5% of cases and false negative in 6 cases. Lawson showed 76% of cases positive on ultrasonography with false negative results in 33% patients. Colpopuncture was positive in 83 patients (82.18%). Cartwright et al emphasised the value of culdocentesis and Chez Moore reported an accuracy rate of 97%.
The treatment options are
1. Surgical treatment
2. Surgically administered medical (SAM) treatment i.e. administration of an abortificient into or around the ectopic pregnancy using endoscopic, radiological or sonographical techniques.
3. Medical treatment i.e. systemic administration of a cytotoxic agent.
4. Expectant management i.e. observation and monitoring until the ectopic pregnancy resolves spontaneously.
Newer techniques especially recent advances in laparoscopic surgery and technology have brought in, an era of conservative surgical management.
In our series 43.8% patients underwent conservative surgical treatment. Table 12. De Cherney in his series reports 35.5% of patients undergoing conservative surgery at Yale.
Sherman reported a higher subsequent pregnancy rate with salpingostomy than with salpingectomy; which has also been confirmed by Yao and Tulandi, Thornton et al (1991) and Kooi and Kock (1993).[18-20] However, Silva et al (1993) reported overall pregnancy rates not significantly different for salpingostomy or salpingectomy; but a prior history of tubal damage was associated with a significantly reduced intrauterine pregnancy rate. Ory et al (1993) also had a similar conclusion to their series.
Obviously none of these techniques guarantee tubal patency. Nevertheless in the state and poor general health in which the patients are brought to us and in cases of extensive adhesions, inspite of low parity radical surgery would have to be carried out.
Treatment for an ectopic pregnancy has most often been removal of a shattered, bleeding tube with or without ipsilateral oophorectomy. The goal of such a treatment was and will be saving the mothers life. The various radical surgeries done in our patients are given in Table 11.
In our series we had 1 patient who underwent hysterectomy for ruptured ectopic in broad ligament along with uterine perforation which could have been caused by MTP done 1 month back elsewhere.
Future Fertility and Prevention
As the incidence of ectopic pregnancy increases, ways and means have to be found to reduce the associated morbidity and mortality and to preserve future fertility. With emphasis shifting from radical to conservative therapy, prevention and early diagnosis become very important.
Pelvic inflammatory disease (PID) being the most common aetiological factor and by far the most preventable; efforts for early symptom recognition and prompt treatment must be developed. Educational efforts for behavioural and attitudinal changes must be considered including easy and discrete access to condoms especially for those at highest risk (sexually active teenagers, women and men with a history of STD) especially in the developing world to minimise infertility and ectopic pregnancy. Also current literature suggests that frequent douching increase the risk of PID, ectopic pregnancy, and possibly cervical cancer, this being a modifiable behaviour.
Also a high degree of clinical suspicion of ectopic with any of the risk factors, must be considered ectopic unless proved otherwise, and must be monitored with serial b-HCG estimation and ultrasonography until localization of pregnancy is confirmed. Although ectopic pregnancy can never be eliminated completely, early diagnosis and prompt conservative surgical or medical management will not only help in reducing maternal mortality and morbidity rates but also go a long way in preservation of future fertility. Early diagnosis is the key to less invasive treatment for ectopic pregnancy.
- Cunningham, Macdonald, Gant, Leveno, Gilstrap : Ectopic Pregnancy Williams Obstetrics 20th Ed. Prentice Hall International, Inc, Appleton and Lange. 1997; 607-635.
- Centers for Disease Control. Ectopic pregnancy - United States: 1988-1989. MMWR 1992; 41 : 591.
- Nederlof KP, Lawson HW, Saftlas AF, Atrash HK, Finch EL. Ectopic pregnancy surveillance, United States, 1970-1987. MMWR 1990; 39 : 9.
- Garrett AM, Vukov LF. Risk factors for ectopic pregnancy in a rural population. Family Medicine Feb. 1996; 28 (2) :111-3.
- Department of Health and Social Security. Report on confidential inquiries into the maternal deaths in the United Kingdom 1985-1987. London : HMSO. 1990.
- Stock RJ. The changing spectrum of Ectopic pregnancy. Obstet Gynaecol 1988; 71 : 885.
- Westrom L, Bengtsson LPH, Mardh PA. Incidence trends and risks of ectopic pregnancy in a population of women. Br Med J 1981; 282 : 15-18.
- Rubin GL, Peterson HB, Dorfman SF, et al. Ectopic pregnancy in USA 1970 through 1978. JAMA 1983; 249 : 1725.
- Westrom L, Mardh PA. Impact of sexually transmitted diseases on human reproduction. Swedish study on infection and ectopic pregnancy. Washington DC, National Institute of Health, NIAID, STD study group.
- Skjeldestad FE, Hadgu A, Eriksson N. Epidemiology of repeat ectopic pregnancy : a population based prospective cohort study. Obst and Gynaecol Jan. 1998; 91 (1) : 125-35.
- Tietze C. Extrauterine pregnancy and intrauterine devices. Br Med J 1966; 2 : 322.
- Tatum HJ, Schmidt FH. Contraception and sterilisation practices and extrauterine pregnancy. A realistic perspective. Fertil Steril 1977; 28 : 407.
- Solves MR. Inf surgery in De Cherney AH (ed) Reproductive failure, NY Churchill Livingstone. 1986; 117.
- Breen JL. A 21-year survey of 654 ectopic pregnancies. AMJ Obstet Gynaecol 1970; 106 : 1004.
- Ory SJ, Villaneuva AL, Sand PK, Tamura RK. Conservative management of ectopic pregnancy with methotrexate. AMJ Obstet Gynaecol 1986; 154 : 1299.
- Ratnam SS, et al. Ectopic pregnancy Obstet Gynaecol for PG, Orient Longman. 1994; 2 : 394.
- Chez RA, Moore JG. Diagnostic errors in the management of ectopic pregnancy. Surg Gynaecol Obst 1963; 117 : 589-96.
- Yao M, Tulandi T. Current status of surgical and nonsurgical management of ectopic pregnancy. Fertil Steril Mar. 1997; 67 (3) : 421-33.
- Kooi S, Kock H CLV. Surgical treatment for tubal pregnancies. Surg Gynecol Obstet 1993; 176 : 519-26.
- Thornton KL, Diamond MP, DeCherney AH, et al. Linear salpingostomy for ectopic pregnancy. Obstet Gynaecol C1 N AM 1991; 18 : 95-110.
- Silva PD, Schaper AM, Rooney B, et al. Reproductive outcome after 143 laparoscopic procedures for ectopic pregnancy. Obstet Gynaecol 1993; 81 : 710-15.