International Journal of Research in Medical Sciences

Soren M et al. Int J Res Med Sci. 2017 Nov;5(11):4776-4782

www.msjonline.org pISSN 2320-6071 | eISSN 2320-6012

DOI: http://dx.doi.org/10.18203/2320-6012.ijrms20174671
Original Research Article

A clinical study on ectopic pregnancy

Mamata Soren1, Ranjita Patnaik1*, Bismoy Kumar Sarangi2

1
Department of Obstetrics and Gynecology VIMSAR, Burla, Odisha, India
2
Consultant, Kishori Nursing Home, Bargarh, Odisha, India

Received: 26 September 2017

Accepted: 02 October 2017

*Correspondence:
Dr. Ranjita Patnaik,
E-mail: drranjitapatnaik@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Ruptured ectopic pregnancy is a medical emergency; therefore, it is imperative to diagnose the
unruptured ectopic pregnancy such that timely intervention will prevent morbidity and mortality Today with
availability of monoclonal β-HCG, high resolution transvaginal scan and laparoscopy it is possible to make early
diagnosis even before rupture.
Methods: Prospective study of two years duration with sample of 72 cases of suspected ectopic pregnancy observed
and treated out of total 20193 pregnant women admitted were included in this study.
Results: The incidence was 0.36%, maximum between the age group of 26-30 years (33.3%). Risk factors were
tubectomy (30.56%), D and C (6.94%), PID (5.6%), previous ectopic (1.39%), IUCD (2.78%). The typical triad of
amenorrhoea, pain abdomen and bleeding was observed in 54.2% of cases. 19 patients were brought in shock
(26.4%). Ultrasonography done in 56 cases.
Conclusions: There is an increase in the incidence of ectopic pregnancy but a decrease in maternal mortality during
the past two decades. Although the early diagnostic tools were available, we had to manage most of our patients as
surgical emergencies, as they were brought late in the trial, with established diagnosis of ruptured ectopic pregnancy.
Physicians should be sensitive to the fact that in the reproductive age group any women presenting with pain in the
lower abdomen, diagnosis of ectopic pregnancy should be entertained irrespective of the presence or absence of
amenorrhoea, whether or not she has undergone sterilization.

Keywords: Ruptured ectopic pregnancy, Tubectomy, Transvaginal scan

INTRODUCTION uterine gestation in which the fertilized ovum implants at

an aberrant site inconducive to growth and development.
Ectopic pregnancy is a life-threatening condition that
every practicing obstetrician and gynecologist encounters An ectopic pregnancy occurs when the developing
in his or her practice. blastocyst implants either outside the uterus [Fallopian
tube: ampullary (79.6%); isthmic (12.3%); fimbrial
It greatly endangers the life of the woman and also her (6.2%), Ovary (0.15%) and abdominal cavity (1.4%)] or
future fertility by causing damage to the fallopian tubes in an abnormal position within the uterus cornual (1.9%),
and/or ovary. The physician who is ectopic minded rarely cervical (0.15%).1 Highest percentage (98.3%) of ectopic
fails to make the diagnosis. pregnancies occur in the fallopian tubes.

The word ectopic is from Greek; ‘EX’ and ‘TOPOS’ Objective of present study was to study the incidence of
meaning “out of place”. It is defined as any intra or extra ectopic pregnancy, to study the clinical presentation of

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ectopic pregnancy, to study the risk factors associated In cases with atypical findings (history and examination)
with ectopic pregnancy and to study the immediate simulating other condition like pelvic infection, twisted
morbidity and mortality associated with ectopic ovarian cyst or acute appendicitis were hospitalized for
pregnancy. observation and taken for laparotomy subsequently.

METHODS Laparotomy were performed under either spinal or

general anaesthesia. Abdomen was opened with suitable
All diagnosed cases of ectopic pregnancy during two incision. The site of ectopic gestation, status of the
years of study period in our institute were enrolled in the fallopian tube, contralateral tube, ovaries and uterus was
study. noted. As majority of the patients had ruptured tubal
gestation, a decision for removal of the tube i.e.,
On admission detailed history and clinical evaluation was unilateral salpingectomy was made. Salpingectomy was
done. combined with contralateral tubectomy in patients who
did not wish to conceive. In cases with obvious
Detail history of the patient included: Patient identity; pathological findings on the opposite side, the diseased
Complains like history of amenorrhoea, acute pain adnexa were removed.
abdomen, vaginal bleeding (if present its duration and
nature), any attacks of syncope or vomiting, urinary or Prophylactic antibiotics were given to all patients at the
rectal symptoms, fever or other symptoms like backache time of induction of anaesthesia. Patients were followed
or shoulder pain; Detail Menstrual and Obstetric history up in the post-operative period with special attention to
including history of infertility or previous ectopic the development of fever, abdominal pain, distension of
pregnancy, if present; History of previous surgery - the abdomen and wound sepsis. Patients were discharged
dilatation and curettage, tubal surgeries – tuboplasty, with an advice to come for follow up after a week.
appendicectomy or any other abdominal surgery; History
of pelvic inflammatory disease or tuberculosis and RESULTS
treatment received for it; Family history of tuberculosis;
Method of contraception - IUCD, oral contraceptive pill 72 cases of suspected ectopic gestation were observed
or permanent method and treated during the study period of two years at our
institution. Total no. of pregnant women admitted during
Clinical evaluation included general examination of the same period were 20193. The incidence of ectopic
patient- including presence of anaemia, shock, pregnancy was 0.36%.
restlessness, cold and clammy extremities, pulse,
respiration, blood pressure, temperature and Table 1: Incidence of ectopic pregnancy.
cardiovascular and respiratory systems; abdominal
examination- for presence of mass, signs of free fluid in Total no. of ectopic Incidence
peritoneal cavity, guarding, rigidity, tenderness and 72 0.36%
Presence of rare signs like Cullen's sign; Vaginal
examination –for presence of bleeding, its nature, colour The study group includes maternal age ranged from 18
of the vaginal mucosa, position of the cervix, tenderness years to 36 years, the youngest being 18 years and oldest
on movement of the cervix, size of the uterus, mobility was 36 years. 8 patients were teenagers [6 (19 years) and
and consistency, presence of mass and/or tenderness in 2 (18 years)]. The maximum number of ectopic gestation
any of the fornices; Per-rectal examination whenever in the present study occurred between the age group 26 to
necessary for confirmation of findings. 30 years.

On admission after a detailed examination, a sample of Table 2: Ectopic pregnancy in relation to age.
blood was drawn for Blood grouping, Rh typing and
cross-matching to arrange blood for transfusion. Age group (years) No. of cases Percentage
Investigations like Hb%, HCT, routine blood tests as 15-20 12 16.7
advised by anaesthesiologists; TLC, DC, ESR if 21-25 16 22.3
necessary; urine pregnancy test and ultrasonography were 26-30 24 33.3
carried out. 31-35 14 19.4
36-40 6 8.3
In acute cases with the typical symptoms i.e. Total 72 100
amenorrhoea, pain and bleeding which was confirmed by
USG (wherever possible) followed by laparotomy. When previous reproductive performance was reviewed,
the maximum incidence of ectopic gestation (33.3%)
Patients in shock were managed and taken for surgery. occurred among the second para. In 23 out of 72 patients
(31.9%), ectopic pregnancy was the first conception.
Blood transfusion was given intra-operative or
postoperative as per the requirement of individual cases.

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Table 3: Distribution of cases based on parity. Maximum number of cases in present study group
belonged to the age group of 26-30 with parity 2,
Parity No. of cases Percentage accounting for 11 cases where as 10 cases in the age
Nulliparous 23 31.9 group 21-25 were nullipara.
1 13 18.1
2 24 33.3 There were only 5 cases between the age group 36-40
3 12 16.7 years.
Total 72 100

Table 4: Correlation of the sample by age and parity.

Parity
Age Total
Nullipara 1 2 3
15-20 9 (90%) 0 (0%) 1 (10%) 0 (0%) 10 (100%)
21-25 10 (66.67%) 2 (13.33%) 3 (20%) 0 (0%) 15 (100%)
26-30 2 (7.7%) 5 (19.2%) 11 (42.3%) 8 (30.8%) 26 (100%)
31-35 2 (12.5%) 6 (37.5%) 7 (43.7%) 1 (6.3%) 16 (100%)
36-40 0 (0%) 0 (0%) 2 (40%) 3 (60%) 5 (100%)
Total 23 (31.9%) 13 (18.1%) 24 (33.3%) 12 (16.7%) 72 (100%)

According to Kuppuswamy’s classification 41 patients Table 7: The risk factors in ectopic pregnancy.
(57%) belonged to low socio-economic status and 31
patients (43%) belonged to medium socio-economic Risk factors No. of cases Percentage
status and none belonged to high socio-economic status. None 38 52.77
Tubectomy 22 30.56
Table 5: Distribution of the cases by socio-economic PID 4 5.56
status. IUCD 2 2.78
D and C 5 6.94
Socio-economic status No. of cases Percentage Previous ectopic 1 1.39
Low 41 57
Medium 31 43 The typical triad of amenorrhoea, pain abdomen and
High 0 0 bleeding was observed in 39 (54.2%) cases. Abdominal
Total 72 100 pain was the most significant symptom in 70 (97.2%)
patients. Other symptoms were giddiness, nausea and
The study showed that as the interval between vomiting, syncopal attacks in 22 (30.6%) cases.
pregnancies increases, the incidence of ectopic pregnancy
also increases. In this study, when the interval between Table 8: Mode of presentation.
pregnancies was >5 years, the incidence of ectopic
pregnancy was 27.8 %. While in 23 cases (31.9%) it was Symptoms No. of cases Percentage
the first pregnancy. Amenorrhea 61 84.7
Pain abdomen 70 97.2
Table 6: The interval between last pregnancy and Bleeding 45 62.5
ectopic pregnancy. Others 22 30.6

Interval No. of cases Percentage Out of 72 patients, 19 (26.4%) cases were admitted in a
Nullipara 23 31.9 state of shock. Among these, pallor alone was found to be
1-2 years 9 12.5 present in 60 (86.1%) cases.
3-5 years 20 27.8
5+ years 20 27.8 Table 9: General physical examination.
Total 72 100
Symptoms No. of cases Percentage
Of the total 72 cases of ectopic pregnancies, there was no Pallor 60 86.1
specific risk factor in 38 cases (52.77%), tubectomy in 22 Shock 19 26.4
cases (30.56%), PID in 4 cases (5.56%), IUCD in 2 cases None 9 12.5
(2.78%), D and C in 5 cases (6.94%) and previous
ectopic in one case (1.39%).

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Abdominal tenderness was found to be a significant Urine pregnancy test was a simple test which aided in
finding in 60 (83.33%) cases. Other symptoms like rightly diagnosing cases of ectopic pregnancy. It was
distension and guarding was seen 13 (18.1%) and 7 negative in 2 (2.8%) cases while positive in 70 (97.2%)
(9.7%) of the cases respectively. No abdominal case.
abnormality detected in 2 (2.8%) cases.
Table 15: Urine pregnancy test.
Table 10: Abdominal findings.
Urine pregnancy test No. of cases Percentage
Abdominal findings No. of cases Percentage Positive 70 97.2
Tenderness 60 83.33 Negative 2 2.8
Distension 13 18.1
Guarding 7 9.72 Ultrasonography was done in 56 patients and it was not
Rigidity 1 1.39 possible to be done in 16 cases. 28 cases (38.9%) were
Mass 2 2.78 ruptured and 28 (38.9%) were unruptured in
No abnormality 2 2.78 ultrasonography, fluid in POD detected in 38 cases
(52.7%).
On speculum examination 45 (62.5%) patients had
bleeding per vaginum while 27 (37.5%) did not have Table 16: Distribution by ultrasonography.
bleeding.
Ultrasound findings No. of cases Percentage
Table 11: Per speculum examination. Ruptured 28 38.9
Unruptured 28 38.9
Bleeding No. of cases Percentage Fluid in POD 38 52.7
Absent 27 37.5 USG not done 16 22.2
Present 45 62.5
Total 72 100 On surgery, 66 cases were found to be tubal, of which 51
(70.83%) were ampullary and 15 (20.83%) were isthmic.
Majority of the cases had normal uterine size 62 (86%). It There was one case each of ovarian and secondary
was found increased in 10 (14%) cases only. abdominal pregnancy and two cases were cornual. On
two occasions the site of pathology could not be
Table 12: Uterine size. delineated on surgery. 48 cases had pathology in right
side and in 24 cases the pathology was in left side. Thus,
Uterine size No. of cases Percentage ectopic pregnancy occurred more commonly in the right
Normal 62 86 side.
Increased 10 14
Table 17: Site of ectopic pregnancy.
Painful cervical movement was seen in 47 patients
(65.3%). In the rest 25 patients (34.7%) there was no Site No. of cases Percentage
cervical motion tenderness. Tubal 66 91.66
Ovary 1 1.39
Table 13: Cervical motion tenderness. Cornual 2 2.78
Secondary abdominal
1 1.39
Cervical tenderness No. of cases Percentage pregnancy
Absent 25 34.7 Not delineated on surgery 2 2.78
Present 47 65.3
Total 72 100 There were 34 cases (47.2%) of ruptured ectopic on
surgery. Out of which 31 were tubal rupture, 2 were
Majority 38 cases (52.8%) had forniceal tenderness cornual rupture and 1 ovarian ectopic pregnancy rupture.
alone. However, 11 (15.3%) cases had tenderness with 20 cases (27.8%) were unruptured and 17 cases (23.6%)
mass in the fornix. presented as tubal abortion. There was one case of
secondary abdominal pregnancy.
Table 14: Forniceal tenderness.
Table 18: Condition on laparotomy.
Forniceal tenderness No. of cases Percentage
Absent 23 31.9 Condition No. of cases %
Tenderness alone 38 52.8 Ruptured 34 47.2
Tenderness with mass 11 15.3 Unruptured 20 27.8
Total 72 100 Tubal abortion 17 23.6
Secondary abdominal pregnancy 1 1.4

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Out of the 63 cases who went laparotomy 20 cases Table 21: Histopathology study.
underwent right salpingectomy. 12 cases underwent right
salpingo-oophorectomy and 11 cases underwent left HPS study No. of cases Percentage
salpingo-oophorectomy. Sent and positive
14 19.44
for ectopic tissue
Other procedures performed were left salpingectomy (7 Not done 58 80.56
cases), right partial salpingectomy (5 cases), right Total 72 100
salpingo-oophorectomy with left salpingectomy (4 cases),
bilateral salpingectomy (3 cases) and one case underwent Blood transfusion was given in 49 (68%) cases. While 23
laparotomy for secondary abdominal pregnancy. (32%) cases need no transfusion. Patients who were
brought in shock were managed with both blood
Table 19: Laparotomy procedure done. transfusion as well as plasma expanders.

Laparotomy procedure No. of cases % Table 22: Blood transfusion.

RSE (Right salpingectomy) 20 27.8
RSO (Right salpingo- Blood transfusion No. of cases Percentage
12 16.7
oophorectomy) Done 49 68
LSO (Left salpingo Not done 23 32
11 15.3
oophorectomy) Total 72 100
LSE (Left salpingectomy) 7 9.7
RPSE (Right partial DISCUSSION
5 6.9
salpingectomy)
RSO+LSE (right salpingo- Ectopic pregnancy may occur at any age from menarche
oophorectomy +left 4 5.6 to menopause. A study by Rose et al found maximum
salpingectomy) cases in age group of 21-30 years (43%) which
BSE (Bilateral salpingectomy) 3 4.2 corroborated with the present study (55.6%).2
Laparotomy for secondary
1 1.4
abdominal pregnancy In the present study, the maximum incidence of ectopic
Total 63 87.6 occurred between, parity 0 and 3. In the study by Rose et
al, as parity increases there is a decrease in the incidence
9 cases were managed by laparoscopy. The most of ectopic pregnancy.2 Munro Kerr and Eastman are of
common laparoscopic procedure performed was the opinion that there is no specific relation between
laparoscopic left partial salpingectomy in 3 cases, parity and ectopic According to ICMR Multicentric Case
followed by laparoscopic right salpingo-oophorectomy (2 Control Study (1990) of ectopic pregnancy, majority of
cases), laparoscopic left salpingostomy (2 cases), women were young and had low parity.3
laparoscopic left salpingectomy (one case) and
laparoscopic right salpingectomy in one case. PID is an important factor predisposing to the
development of ectopic pregnancy. PID following
Table 20: Laparoscopic procedure done. gonococcal, chlamydial and other bacterial infection
cause 3.3-6 fold increased risk of ectopic pregnancy.
No. of Levin et al demonstrate the risk of ectopic pregnancy is
Laparoscopic procedure %
cases increased in women with history of PID.4 In the present
Lap LPSE (Laparoscopic Left study, only 4 patients had a history of PID which
3 4.2
partial Salpingectomy) contributes to 5.6%. Relative risk based upon ICMR
Lap RSO (Laparoscopic Right Multicentric Case Control Study was 6.4. Other studies
2 2.7 by Marchbanks et al, Savitha Devi et al and Rose et al the
Salpingo-oophorectomy)
Lap LSOS (Laparoscopic Left incidence of PID as a risk factor is 4, 25 and 34.4%
2 2.7 respectively.2,3,5,6
Salpingostomy)
Lap LSE (Laparoscopic Left
1 1.4 Many cases of chlamydia salpingitis are indolent may go
Salpingectomy)
Lap RSE (Laparoscopic Right unrecognized causing tubal damage and subsequent tubal
1 1.4 pregnancy. A strong association between Chlamydia
Salpingectomy)
Total 9 12.4 infection and tubal pregnancy was found by Brunham et
al.7 So a recent change in sex life can cause pelvic
Only 14 cases brought histo-pathology reports and all 14 inflammation and tubal damage in younger age groups
(19.44%) showed evidence of ectopic tissue. It was not causing more incidence of ectopic pregnancy in young,
done in 58 (80.56%) cases. nulliparous or low parity women. In present study
nullipara constitute 31.9% ectopic pregnancy.

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In present study Patients who had abortion and underwent On general examination, pallor was seen in 86.1% of
D and C within the past two years was constituted 6.94%. cases similar to other studies by Rose et al and Pendse et
Rose et al reported previous abortion as a risk factor in al having incidence 0f 70.9% and 84.5% respectively.2,10
25.8%.2 Tubal dysfunction or damage following abortion
induced or otherwise appears to be a chief factor in these Abdominal tenderness was present in 83.3% cases in the
cases. present study and Rose et al also reported similar
percentage (83.9%).2 Pendse et al reported guarding in
In the present series 1 (1.39%) case had been operated for 5.4% cases and in the present study it was 9.7%.10
previous ectopic gestation, which is in concurrence with
the study of Rose et al who reported 3.2% of repeat The classical sign of cervical motion tenderness was
ectopic pregnancy.2 Since tubal disease is nearly always present in 65.3% patients. Rose et al reported it to be
bilateral there is a strong tendency for ectopic pregnancy 55.9%.2
to occur first on one side and then at a later date on the
other. Ultrsonography reported 38.9% of them as ruptured,
38.9%unruptured and in 16 cases (22.2%)
In this study, 30.55% (22 cases) had previous tubectomy. ultrasonography was not done and taken up for surgery
According to McCousland et al electrocoagulation for based on clinical findings.
female sterilisation causes more tubal pregnancies.8
Most of our patients were referred from outside with
In the present series IUCD was used by only two patients diagnosis of ruptured ectopic pregnancy. So, our
(2.8%). Marchbanks et al quotes 1.6% incidence of treatment modality was surgical.
ectopic pregnancy in patients who were on progestin-only
contraceptive.9 An incidence of 11.9%, 7.69% and 33% 43.05% cases of fallopian tubes were ruptured. Total 34
ectopc pregnancy were quoted in relation to the use of cases (47.2%) were ruptured (including 2 cornual and one
intrauterine devices by Marchbanks et al, Savitha Devi et ovarian pregnancy). Wills and Mohanambal reported
al and Wills and Mohanambal respectively.6,9 ruptured cases to be 66%. Unruptured cases accounted
for 27.8% in our present study and according to Wills and
No specific sign or symptom can be said to be Mohanambal was 34%. Tubal abortion was entered as a
pathognomonic of ectopic gestation. The classical history different entity in the present study accounting for 17
of amenorrhoea, pain abdomen and vaginal bleeding was (23.6%) cases.
present only in 54.2% cases in the present study.
Presence of shock was seen only in 19 cases (13.9%). Ampullary pregnancy on surgery was found in 70.8%
The clinical picture is dependent on several factors cases. Khera et al and Devi S et al reported it to be 71.7%
mostly the extent of time taken for disturbance to occur in and 61.53% respectively.6,12 Pregnancy in Isthmus region
ectopic gestation. The more extensive and rapid the was found in 20.8% cases and Khera et al reported it to
disturbance, the clearer is the clinical picture. Hence, be 20.75%.12 Interstitial/cornual and ovarian pregnancy
undisturbed ectopic gestation is likely to be missed in accounted for 2.78% and 1.39% respectively in the
majority of the cases as the clinical features are vague. present study while it was 3% and 1% by the study by
Wills and Mohanambal.
Acute lower abdominal pain was the most common
presenting feature in 97.2% of the cases. It was present in Out of the 72 patients 63 patients underwent open
51.5% of cases of tubal rupture in the present series. No laparotomy out of which majority (27.8%) underwent
history of pain abdomen was seen in 2 cases (2.8%), may right salpingectomy and 16.7% and 15.3% right and left
be due to undisturbed nature of tubal pregnancy or due to salpingo-oophorectomy respectively. 9 patients
individual differences in the pain threshold. Pendse et al underwent laporoscopic procedure of which 2.7% had
in 3.6% of his cases noted absence of pain.10 laparoscopic salpingostomy and 2.7% underwent
laparoscopic right salpingo-oophorectomy and 4.2%
Amenorrhoea was present in 84.7% cases, incidence is underwent laparoscopic left partial salpingectomy. On
comparable to Rose et al2 and Pendse et al.10 Oumachigui surgery 48 cases had pathology in right side and in 24
et al reported absence of amenorrhoea in 23% cases as cases the pathology was in left side. Thus, ectopic
against 15.3% in the present series.11 pregnancy occurred more commonly in the right side.
There was mortality in 3 patients. Blood transfusion was
Vaginal bleeding was present in 62.5% comparable to given for 49 patients either intra operatively and/or post
65.4% and 66.6% in study by Rose et al and Pendse et al operatively taken into account.
respectively.2,10 Other symptoms were giddiness, nausea,
vomiting and syncopal attacks. Oumachigui et al reported Funding: No funding sources
shoulder pain in 8%, fainting attacks in 18%, vomiting in Conflict of interest: None declared
31% and urinary symptoms in 12.5%.11 Ethical approval: The study was approved by the
Institutional Ethics Committee

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