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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 13  |  Issue : 2  |  Page : 53-57

Ectopic pregnancy: A 5-year review of cases in a secondary health facility in Delta State, Nigeria


Department of Obstetrics and Gynaecology, College of Health Sciences, Delta State University, Abraka, Delta State, Nigeria

Date of Submission25-Mar-2019
Date of Acceptance21-Jul-2019
Date of Web Publication30-Oct-2019

Correspondence Address:
Williams Obukohwo Odunvbun
Department of Obstetrics and Gynaecology, College of Health Sciences, Delta State University, Abraka, Delta State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/phmj.phmj_5_19

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  Abstract 


Background: Ectopic pregnancy and the associated risk factors remain a public health concern, with attendant maternal morbidity and mortality. Due to the reported increase in prevalence in several studies across Nigeria in the last few decades, periodic review of management is of relevance for institutional comparison.
Aim: The aim of the study was to determine the prevalence, risk factors and management of ectopic pregnancy in Eku Baptist Government Hospital, a secondary health facility providing free maternity services, and compare these with an earlier study in the same facility and other parts of Nigeria.
Methods: A retrospective study of cases of ectopic pregnancy managed at Eku Baptist Government Hospital in a 5-year period: 1 January 2013–31 December 2017. Data analysis was done by SPSS version 22 (IBM).
Results: The institutional prevalence rate of ectopic pregnancy was 2.7%. Ectopic pregnancies constituted 12.2% (113/926) of gynaecological admissions. The mean age of participants was 29 ± 5.5 years, and 69.5% of them were married. The highest (59.1%) risk for ectopic pregnancy was previously induced abortion. The most frequent (94.3%) complaint at presentation was a lower abdominal pain. Ruptured ectopic accounted for 97.1% of cases. All the patients had laparotomy including three unruptured cases. There was no fatality in this study amongst participants.
Conclusion: This study established a lower prevalence of ectopic pregnancy and zero mortality, with the introduction of free maternity service, compared to an earlier study. This findings suggest earlier presentation of patients with ectopic pregnancy. Prevalence and outcome of ectopic pregnancy can be further improved by effective contraceptive enlightenment and use, provision of postabortion care, provision of facilities for early detection and management.

Keywords: Ectopic pregnancy, induced abortion, prevalence


How to cite this article:
Odunvbun WO. Ectopic pregnancy: A 5-year review of cases in a secondary health facility in Delta State, Nigeria. Port Harcourt Med J 2019;13:53-7

How to cite this URL:
Odunvbun WO. Ectopic pregnancy: A 5-year review of cases in a secondary health facility in Delta State, Nigeria. Port Harcourt Med J [serial online] 2019 [cited 2019 Nov 21];13:53-7. Available from: http://www.phmj.org/text.asp?2019/13/2/53/270062




  Introduction Top


Ectopic pregnancy is the implantation of the fertilised ovum at a site other than the normal endometrial cavity.[1],[2],[3] It remains a potentially fatal gynaecological emergency, especially in the tropics where most of the patients present with ruptured ectopic, and the resultant contribution to maternal mortality.[3],[4]

In Nigeria, the reported incidence of ectopic pregnancy is 0.9%–4.38%.[5],[6] In the United Kingdom (UK), the incidence is approximately 11/1000.[7] Amongst women attending early pregnancy units (EPUs), the incidence is 2%–3%.[8],[9] Case fatality in the UK has been reducing over recent years, probably due to early diagnosis and treatment.[7] Case fatalities of 27.9/1000 and 37/1000 had been reported in Accra, Ghana, and Lagos, Nigeria, respectively.[10],[11]

The leading role of pelvic inflammatory disease in the aetiopathogenesis of ectopic pregnancy has been well documented, and early treatment does not necessarily prevent tubal damage.[12] Other factors reported include previous ectopic pregnancy, previous tubal surgery, endometriosis, infertility and its treatment.[13] Also implicated, as a cause of ectopic pregnancy, are previous caesarean sections, tubal spasm, psychological and emotional factors as well as a congenital defect in the  Fallopian tube More Details.[13],[14] Management of ectopic pregnancy is influenced by factors such as availability of laparoscopic skills and equipment, the clinical state of the patient, availability of transvaginal ultrasound scan and quantitative β-human chorionic gonadotropin, for early presentation.[5],[15]

Eku Baptist Government Hospital was established in the early fifties by the American Baptist Mission. For a period, spanning five decades, it provided broad-based health services, comparable to any teaching hospital in Nigeria, to the people of the Niger Delta and the Mid-West, in addition to residency training in family medicine. In November 2007, with the takeover of the health facility by the state government, it introduced free maternity services. An 11-year review[16] of ectopic pregnancies in the health facility was conducted when it was run as a mission hospital. This study, which is about 13 years after the last, was to determine the incidence, risk factors and management of ectopic pregnancy in Eku Baptist Government Hospital as a secondary public health facility with free maternity service and compare these with earlier studies, both at Eku and other parts of the country.


  Methods Top


This was a retrospective study of cases of ectopic pregnancies managed at Eku Baptist Government Hospital, a secondary health facility in Delta State of Nigeria. Between 1 January 2013 and 31 December 2017, relevant information on cases of ectopic pregnancies managed in the hospital was obtained from the theatre operating records and gynaecological ward. Statistics of deliveries was obtained from the maternity ward and confirmed with the data from the medical records. A total of 113 ectopic pregnancies were recorded during the period, for which 105/113 (92.9%) case notes were available for analysis. Information on sociodemographic, parity, risk factors associated with ectopic pregnancy, clinical presentation, surgical findings and nature of blood transfused was transferred to a computer database.

Data analysis

Data collected were analysed by the Statistical Package for the Social Sciences software version 22 (IBM., Chicago, Illinois, USA). Analysis of variables was summarised using means and standard deviations. Frequencies and proportions were used for qualitative variables.


  Results Top


During the 5-year period of study, there were 113 ectopic pregnancies and 4200 deliveries, giving a prevalence rate of 2.7%. Ectopic pregnancies constituted 12.2% (113/926) of gynaecological admissions. The highest number of ectopic pregnancies recorded was in 2016 with 30 cases, whereas the lowest was 2013 with 17 cases.

[Table 1] shows the sociodemographic characteristics of the participants. The mean age of participants was 29 ± 5.5 years. About 3/4 (70/105) of participants were below 31 years. Only 3.8% (4/105) were in the age range of 40–45 years. The majority (69.5%) of the participants were married. Over 50% (57/105) of participants had a secondary level of education. About 50% (47/105) were traders and 4.8% unemployed. Equal proportion (45.7% each) of nulliparous and parous participants had ectopic pregnancy. Only 8.6% of participants were in the parity range of 4–6.
Table 1: Sociodemographic characteristics of subjects with ectopic pregnancy (n =105)

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[Table 2] shows the risk factors associated with ectopic pregnancy. The majority (59.1%) of the participants with ectopic pregnancy in this study had a history of induced abortion. This was closely followed by 47.7% of participants with the previous history of pelvic inflammatory disease.
Table 2: Risk factor associated with ectopic pregnancy

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Lower abdominal pain was found in most of the patients (94.3%) on presentation, followed by amenorrhoea (63.8%) and history of abnormal vaginal bleeding (51.4%) [Table 3].
Table 3: Clinical presentation of patients with ectopic pregnancy (n =105)

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Findings at surgery revealed that 97.1% (102/105) of participants had a tubal ectopic, whereas 2.9% had an ovarian ectopic. Ampullary ectopic accounted for 56.2% [Table 4].
Table 4: Surgical findings at laparotomy/site of ectopic (n =105)

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Unilateral salpingectomy constituted 93.3% (98/105) of the surgical procedure, 3.8% had a cornual resection, while 2.9% had unilateral salpingo-oophorectomy.

The majority (85.7%) of the participants received homologous blood transfusion only, whereas 11.4% (11/105) received a combination of autologous and homologous units of blood. The three cases of unruptured ectopic were not transfused. The mean units of blood transfused was 2 ± 0.7. Six of the participants received four units of blood each [Table 5].
Table 5: Blood transfusion (n =105)

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The three unruptured ectopics had partial salpingectomy. This decision was informed by the fact that the three of them were parous and objected to conservative management. The contralateral Fallopian tubes for all three were grossly normal.

There was no case fatality recorded amongst the participants.


  Discussion Top


The institutional prevalence rate of ectopic pregnancy in this study was 2.7%. Ectopic pregnancy also accounted for 12.2% of gynaecological admissions. An 11-year review[16] of ectopic pregnancies in the health facility was conducted when it was run as a mission hospital reported a higher prevalence rate of 3.3%. During the same period, ectopic pregnancy accounted for 9.5% of gynaecological admissions. The reasons for this reduction in the incidence of ectopic pregnancy might include presentation of cases to a number of other secondary health facilities practising free maternity service, which were established in the last decade by the state government.

The prevalence rate of ectopic pregnancy in Lagos was 2.3%.[14] The reported rates from Sokoto, Zaria, Benin and Nnewi were all, however, between 1% and 2%.[3],[13],[15],[16],[17],[18] Some of the reasons frequently reported and replicated in our study for the varied incidence rates include the prevalence of sexually transmitted infection, induced abortions, contraceptive practice, chronic pelvic inflammatory disease and population studied (urban or rural) amongst others.[8],[14],[16],[19]

The proportion of married women (69.9%) in this study was higher than the 62.6%,[16] in the earlier work. When this high level of ectopic pregnancy amongst married women is compared with the high (59.1%) number of induced abortion, as a leading risk factor amongst participants, it could be suggested that induced abortion as a method of child spacing in suboptimal environment, inadequate post-abortion care and tubal infection might be an explanation for this. Findings from patients who presented with abortion complications supported the fact that the procedure was carried out by unskilled personnel. Pelvic inflammatory disease was the second leading risk factor. It is possible that some of the infections predated marriage.

The mean age of participants was 29 ± 5.5 years, and three-quarter of the participants were below 31 years. Nulliparous women accounted for 45.7% of cases. It is a source of worry that the fertility potential of these patients was likely to be compromised by the underlying risk factor(s) that led to the ectopic pregnancy. These demographic characteristics have been reported by other studies.[13],[16],[17]

The risk factors frequently cited from different studies[13],[16],[17],[18] in Nigeria on ectopic pregnancy have not changed over the last few decades. These include induced abortions, pelvic infections and abdominal surgeries amongst others. While admitting the fact that most of the rates quoted in literature on the incidence of ectopic pregnancy in Nigeria are institutional rates, and thus probably exaggerated, the institution of post-abortion care, sex education in secondary schools, with emphasis on genital disease prevention, through the barrier method of contraception, will go a long way in incidence reduction.

Eku Baptist Government Hospital, situated in Ethiope East Local Government Area of Delta State, is the only standard health facility serving the community. There are, however, patent medicine dealers, hospital health assistants and other hospital workers who are frequently patronised for induced abortion by dilatation and curettage, often in an unhygienic environment. Many of these patients later present at the government hospital with complications such as pelvic sepsis which has a negative impact on their reproductive performance.[16],[20],[21],[22] The association of induced abortion with ectopic pregnancy in this study is likely an indirect one, resulting from inadequate antibiotic management of ascending pelvic infection and consequent tubal damage.

Almost (97.1%) all our patients presented with ruptured ectopic pregnancy. A similar study conducted over a decade earlier had 95.3%,[16] of the participants presenting with ruptured ectopic, the study in Nnewi revealed 80.6%,[18] ruptured ectopic, while 94.6% and 80.3% rates of ruptured ectopic were reported in Makurdi and Benin, respectively.[17] The reason for this high rate of rupture is often due to delays before presentation at the facility. Despite the introduction of free maternity service in Delta State, observation seems to suggest that most women do not present for antenatal care until the second trimester, thereby closing the window of early diagnosis of ectopic pregnancy and conservative management. EPU, where it is practised, provides an opportunity for diagnosis and management of early pregnancy complications, including ectopic pregnancy. The unit does not exist at Eku Baptist Government Hospital.

In the more endowed setting, most women with ectopic pregnancy in EPUs are diagnosed before tubal rupture,[23] and with patients presenting in haemodynamically stable conditions, laparoscopy is a preferred surgical modality of management of patients with ectopic pregnancy.[24] In contrast, all our patients had laparotomy including the three with unruptured ectopic, due to late presentation and absence of laparoscopy equipment.

Tubal ectopic accounted for 93.3% of the participants. There was only three ovarian ectopic (confirmed with histological reports). Unilateral salpingectomy, corneal resection and salpingo-oophorectomy were performed on tubal, interstitial and ovarian ectopics, respectively. This was consistent with other studies.[11],[16],[25] The mean units of blood transfused was 2 ± 0.7.

There was no maternal death in this study. An explanation might be the fact that removal of user fee could have influenced the earlier presentation, and also as a result of the relatively shorter duration of this study which was 5 years compared to the 11 years in the earlier study,[16] that reported fatality of 2.5% in the same facility. Other studies in Nigeria without maternal deaths included those in Makurdi and Nnewi.[11],[16],[25]

The study limitation includes the relatively small sample size, bias, incomplete case note retrieval and its retrospective design.


  Conclusion Top


This study established a lower prevalence of ectopic pregnancy and a zero case fatality, with the introduction of free maternity service compared to an earlier study. This findings suggest earlier presentation of patients with ectopic pregnancy. Prevalence and outcome of ectopic pregnancy can be further improved by effective contraceptive enlightenment and use, provision of postabortion care, provision of facilities for early detection and management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Coste J, Job-Spira N, Aublet-Cuvelier B, Germain E, Glowaczower E, Fernandez H, et al. Incidence of ectopic pregnancy. First results of a population-based register in France. Hum Reprod 1994;9:742-5.  Back to cited text no. 1
    
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Rajkhowa M, Glass MR, Rutherford AJ, Balen AH, Sharma V, Cuckle HS. Trends in the incidence of ectopic pregnancy in England and Wales from 1966 to 1996. BJOG 2000;107:369-74.  Back to cited text no. 2
    
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Airede LR, Ekele BA. Ectopic pregnancy in Sokoto, Northern Nigeria. Malawi Med J 2005;17:14-6.  Back to cited text no. 3
    
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Okunlola MA, Adesina OA, Adekunle AO. Repeat ipsilateral ectopic gestation: A series of 3 cases. Afr J Med Med Sci 2006;35:173-5.  Back to cited text no. 4
    
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Akabr N, Shami N, Anwar S, Asif S. Evaluation of predisposing factors in multigravidas. J Surg PIMS 2002;25:20-3.  Back to cited text no. 5
    
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O'Herlily C. Centre for maternal and child enquiries. Deaths in early pregnancy. Saving mothers' lives: Reviewing maternal deaths to make motherhood safer: 2006-2008. The eight report of the confidential enquiries into maternal deaths in the United Kingdom. BJOG 2011;118 Suppl 1:81-4.  Back to cited text no. 7
    
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Kirk E, Papageorghiou AT, Condous G, Tan L, Bora S, Bourne T. The diagnostic effectiveness of an initial transvaginal scan in detecting ectopic pregnancy. Hum Reprod 2007;22:2824-8.  Back to cited text no. 8
    
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Mavrelos D, Nicks H, Jamil A, Hoo W, Jauniaux E, Jurkovic D. Efficacy and safety of a clinical protocol for expectant management of selected women diagnosed with a tubal ectopic pregnancy. Ultrasound Obstet Gynecol 2013;42:102-7.  Back to cited text no. 9
    
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Abdul IF. Ectopic pregnancy in Ilorin, Nigeria. A review of 278 cases. Niger J Med 2000;19:92-6.  Back to cited text no. 10
    
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Udigwe GO, Umeononihu OS, Mbachu IL. A five-year review of cases at Nnamdi Azikiwe university teaching hospital Nnewi, Nigeria. Niger J Med 2010;51:160-5.  Back to cited text no. 11
    
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Cates W Jr., Rolfs RT Jr., Aral SO. Sexually transmitted diseases, pelvic inflammatory disease, and infertility: An epidemiologic update. Epidemiol Rev 1990;12:199-220.  Back to cited text no. 12
    
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Anorlu RI, Oluwole A, Abudu OO, Adebajo S. Risk factors for ectopic pregnancy in Lagos, Nigeria. Acta Obstet Gynecol Scand 2005;84:184-8.  Back to cited text no. 14
    
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Igwegbe AO, Eleje GU, Ugboaja JO, Ofiaeli RO. Improving maternal mortality at a university teaching hospital in Nnewi, Nigeria. Int J Gynaecol Obstet 2012;116:197-200.  Back to cited text no. 15
    
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Igberase GO, Ebeigbe PN, Igbekoyi OF, Ajufoh BI. Ectopic pregnancy: An 11-year review in a tertiary centre in the Niger Delta. Trop Doct 2005;35:175-7.  Back to cited text no. 16
    
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Igwegbe A, Eleje G, Okpala B. An appraisal of the management of ectopic pregnancy in a Nigerian tertiary hospital. Ann Med Health Sci Res 2013;3:166-70.  Back to cited text no. 18
[PUBMED]  [Full text]  
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Jurkovic D. Ectopic pregnancy. In: Edmonds DE, editor. Dewhurst's Textbook of Obstetrics and Gynaecology for Postgraduate. 7th ed. UK: Blackwell Science Limited; 2007. p. 106-16.  Back to cited text no. 19
    
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Orhue AA, Unuigbe JA, Ogbeide WE. The contribution of previous induced abortion to tubal ectopic pregnancy. West Afr J Med 1989;8:257-63.  Back to cited text no. 20
    
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Okonofua FE, Onwudiegwu U, Odunsi OA. Illegal induced abortion: Indepth study of 74 new cases in IleIfe, Nigeria. Trop Doct 1992;22:758.  Back to cited text no. 21
    
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Adinma JI. An overview of the global policy consensus in women's sexual and reproductive rights: The Nigeria perspective. Trop J Obstet Gynaecol 2002;19:509-12.  Back to cited text no. 22
    
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Elson J, Tailor A, Banerjee S, Salim R, Hillaby K, Jurkovic D. Expectant management of tubal ectopic pregnancy: Prediction of successful outcome using decision tree analysis. Ultrasound Obstet Gynecol 2004;23:552-6.  Back to cited text no. 23
    
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Uzelac PC, Garmel SH. Early pregnancy risk. In: Decherrney AH, Nathan L, Goodwin TM, Laufer N, editor. Current Diagnosis and Treatment, Obstetrics and Gynaecology. 10th ed. New York: McGraw Hill Medical Publishing Division; 2007. p. 259-72.  Back to cited text no. 24
    
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Yakasai IA, Abdullahi J, Abubakar IS. Management of ectopic pregnancy in Aminu Kanu teaching hospital, Kanu Nigeria. A 3year review. Glo Adv Res J Med Sci 2012;1:181-5.  Back to cited text no. 25
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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