Journal of Pregnancy and Child Health
Open Access

EP: Ectopic Pregnancy; ANC: Antenatal Care; IESO: Integrated Emergency Surgical Officer; OPD: Out Patient Department; NRH: Nekemte Referral Hospital; PID: Pelvic Inflammatory Disease

Ectopic pregnancy is derived from the Greek word “ektopos” means out of place and it refers to implantation of a fertilized egg in a location outside of the uterine cavity [1,2]. It occurs in approximately 1% of pregnancies and it is the most important cause of maternal morbidity and mortality in the first trimester [3,4]. The etiology of ectopic pregnancy is not well understood. However, multiple risk factors have been associated with ectopic pregnancy, although some patients may not have any risk factor yet developed ectopic pregnancy.

Theoretically, any condition that prevents or retards the normal transport of the fertilized ovum to the uterus could predispose women to ectopic gestation [5-7]. Several risk factors for ectopic pregnancy have been identified, including a history of Pelvic Inflammatory Disease (PID), smoking at the time of conception, previous ectopic pregnancy, previous pelvic surgery, induction of ovulation and intrauterine device usage. An understanding of the risk factors for ectopic pregnancy assists more rapid diagnosis and could result in a reduction in the need for surgery and an improvement in preventive strategies against ectopic pregnancy [8].

A “classic” presentation of ectopic pregnancy is characterized by the triad of delayed menstruation, pain and vaginal bleeding or spotting [9]. Classically, the diagnosis is based on a history of pelvic pain associated with amenorrhea, a positive pregnancy test with or without slight vaginal bleeding [10].

The treatment of ectopic pregnancy is influenced by the clinical state of the patient, site of the ectopic gestation, the reproductive wish of the patient as well as availability of facilities and technological expertise. However, surgical treatment still remains the norm [11].

Statement of the problem

Ectopic pregnancy is the leading cause of maternal morbidity and mortality World Wide [12]. In the western world, the incidence of EP is approximately 2% in the general population but as high as 20%, in patients who have undergone tubal surgery. Risk factors for EP after natural conception (e.g. tubal surgery, previous EP, pelvic inflammatory disease and infertility) have been well described. Ectopic pregnancy remains a leading cause of maternal mortality and morbidity in the first trimester of pregnancy in developing countries [13].

Ethiopia is one of the six countries which have contributed to more than 50% of all maternal deaths across the world [14,15]. Among the causes of maternal mortality, ectopic pregnancy is the leading in the first trimester of pregnancy. Approximately 1-2% of all naturally conceived pregnancies end up with ectopic pregnancy [16,17]. In the past decades, the occurrence of ectopic pregnancy has been rised in many countries though the condition varies from country to country depending on the risk factors predominant in the geographical region [5].

There is extensive literature regarding the potential risk factors for EP. The identified risk factors for ectopic pregnancy include prior history of ectopic pregnancy, history of appendectomy, previous pelvic surgery, history of pelvic infection, early age, prior spontaneous and medical abortion, history of contraceptive use including emergency pills, cigarette smoking in dose dependent manner, history of having multiple sexual practices, history of infertility, usage of artificial reproductive technology, presence of a hydrosalpinx or fibroid [18]. While usage of condom and treatment for urinary tract infection showed to decrease the occurrence of ectopic pregnancy [19].

Although several studies have been published examining risk factors for ectopic pregnancy worldwide, women in Ethiopia, Nekemete have different characteristics (cultural, religious, socio-demographic characteristics, sexual behavior and beliefs, contraception usage and preference). Therefore, risk factors for ectopic pregnancy may differ from place to place. Therefore, this case-control study will identify the risk factors in the study area [20].

Study area and period

The study was conducted on October 1-30, 2015 in NRH, which is found in Nekemte Town, at a distance of 331 km from the capital Addis Ababa to the west. The hospital is serving for a total population of about 2.1 million peoples of Nekemte Town, East Wollega Zone, part of West Wollega, Horogudru zone and West Showa Zone. The number of beds in the hospital is 178, which is on medical, pediatrics, surgical, gynecology and obstetrics ward. Out of this 27 are found in gynecological ward. Some of the services which are given by this department are in patient service, emergency and elective minor and major gynecological operations and blood transfusion. The hospital also provide medical treatment, ophthalmic treatment, MCH, compressive HIV care, X-ray, laboratory, psychiatric treatment, ultrasound, pharmacy, training services and physiotherapy. The total number of staff in the hospital is 302. Out of these 192 of them are health professionals including two surgeons, one gynecology and obstetrician, two internists, two pediatrician, two emergency surgical officers, 14 General practitioners, Nurses, Lab technician and others. The number of health professionals in gynecology ward is one gynecologist and obstetrician, one IESO and 18 midwives.

Study design

A hospital based unmatched case control study was employed.

Source population: Record of all pregnant women who had visited NRH in Gynecological OPD, ANC and maternity ward from 1/07/2014 to 1/07/2015.

Study population: Record of pregnant women who were diagnosed by ultrasound to have Intra-uterine pregnancy or ectopic pregnancy in Gynecological OPD, ANC clinic, maternity ward and operation room.

Eligibility criteria

Inclusion criteria: Record of pregnant women who were diagnosed to have term Intra-uterine pregnancy or ectopic pregnancy in Gynecological OPD, ANC clinic, maternity ward and operation room.

Exclusion criteria: Record of pregnant women with incomplete data.

Sample size and sampling technique

Sample size was calculated using Epi Info version 7 for unmatched case control study design based on the assumption that PID is significant risk factor for ectopic pregnancy. From previous case control study with 3.0% of controls and 13.4% of cases were having prior history of PID and the level of significance α=0.05, the power of the test(1-β)=80%, the control to case ratio(r)=2, the proportion of exposure among controls (p1)=3% with the proportion of exposure among cases (p2)=13.4% and AOR=5. The final sample size calculated by using the above assumption gives 88 cases and 176 controls with a total of 264 study subjects. However, since there are 99 actual cases in the study period, it was found preferable to take all the total cases in 1:2 ratio to have a total of 299 study subjects (Table 1).

Table 1: Epi Info sample size calculation.

Sampling procedure

Simple random sampling technique was used to select study participants with Intra uterine pregnancy (controls) while for cases all subjects were included as their number is too few (only 99).

Variables of the study

Dependent variable:

• State of pregnancy

• Ectopic pregnancy

• Normal pregnancy

Independent variables:

• Socio-demographic variables

• Age

• Marital statusReligion

• Ethnicity

• Address

• Habits (Alcohol drinking, cigarette smoking)

• Obstetric and gynecological variables

• Gravidity

• Abortion history

• Ectopic history

• History of STI

• History of contraceptive use

• Obstetric and gynecologic surgery

• Co-morbid diseases

Data collection procedure

The available information on the patient records had been first observed and appropriate data extraction format was prepared in English. Then the data were collected by year one 4 IESO students using the prepared data collection format on the already existing records after half a day theoretical and half a day practical training was given. One data clerk also supported them by identifying the charts. One supervisor and principal investigator were controlling every activity during data collection. Charts were retrieved using the patient registration number which was found in the registration of Operation Theater, ANC and GYN OPD and maternity sections of the hospital.

Data quality control

Quality of data were maintained by recruiting data collectors who are IEOS year one and supervisor IESO year three. The data collectors and supervisor were given intensive training for one day before the data collection on the objective of the study and how to retrieve data for this study purpose using the data extraction format. They briefed on the definition of variables on the questionnaires and registration charts. The data extraction tool was pre-tested for consistency of understanding the review tools and completeness of data items on 10 charts at the same facility as it was a secondary data and the necessary amendment were made on the final data extraction format. The retrieval process was closely monitored by the principal investigator throughout the data collection period. Completed questionnaires were checked regularly for completeness of information and any gaps identified were immediately communicated to the data collectors.

Data processing and analysis

Data have been first checked manually for completeness and consistency by supervisor and principal investigator during data collection and rechecked again before data entry. Data was entered and cleaned using Epi Info version 7 then exported to SPSS version 20 for analysis and interpretation. Descriptive analysis was conducted to summarize the data. Bi-variable analysis has been executed to see the association between independent and outcome variables. All explanatory variables associated with outcome variables with p<0.25 was entered into Multivariable logistic regression analysis. Back ward step wise likely hood was used and Variables with a p-value <0.05 in multi-variable analysis were considered as significant risk factor for ectopic pregnancy.

Ethical consideration

Ethical clearance was obtained from the Institutional review board of Jimma University college of health sciences. Permission letter was obtained from Nekemte Referral Hospital’s management and oral permission also obtained from focal person in the respected wards to use the secondary data for the purpose of this study. The name or any other identifying information was not recorded on the questionnaire and all information taken from the chart was kept strictly for confidential and in a safe place. The information retrieved was used only for the study purpose.

Limitations of study

Since the study is based on secondary data, this study faced with incomplete information, unreadable patient card, registration book and operation room records. Details of socio demographic variables not addressed due to lack of documentation. Since the study is institutional based, findings couldn’t generalize the general population unlike prospective population based study.

Socio-demographic, clinical characteristic of participants

From October 1-30, 2015, there were 99 cases of ectopic pregnancy in Nekemet hospital. The average age was 27 ± 5 years. Majority of participants were married 91.31% (273 of 299) and almost half of them 50.5% (151 of 299) came from Nekemte town.

Only 5.0% (15 of 299) and 18.39% (55 of 299) of study participant had previous history of ectopic pregnancy and abortion, respectively while 23.41% (70 of 299)had previous history of surgery with 48.5% (34 of 70) cases of C/s. one third 29.10% (87 of 299) of participants had history of STI with 57.4% (50 of 87) of PID and 42.5% (37 of 87) of vaginal discharge.

Among Contraceptive users 207 of 299 (69%), depo-provera was highest one 62.3% (129 of 207). One in three (32.78%), had four or more history of gravida and about 21.4% (64 of 299) had co-morbid disease including hypertension 64% (41 of 64), Dm 17.2% (11 of 64), HIV 12.5% (8 of 64) and asthma 6.3% (4 of 64) (Table 2).

Table 2: Distribution of ectopic pregnancy with socio demographic and clinical characteristics, Nekemte Referral Hospital, 2015.

Risk factor for ectopic pregnancy

Findings from bi-variable logistic regression analysis showed that age, marital status, history of contraceptive user, type of contraceptive used and prior history of STI syndrome had association with ectopic pregnancy with p-value of less than 0.25. However, in multi-variable regression analysis, only marital status and history of contraceptive use remained statistically significant risk factor for ectopic pregnancy.

Accordingly, women with single marital status were 10.81 (95% CI A0R (3.601, 32.465), p-value 0.001) times higher risk to developed ectopic pregnancy than married once and history of contraceptive use was 2.27 AOR (0.214, 24.02) times more likely to develop ectopic pregnancy than those who had no history of contraceptive use (Table 3).

Table 3: Sociodemographic and clinical characteristics of women with state of pregnancy (ectopic vs. intrauterine pregnancy).

This case control study tried to identify the determinants of EP in Nekemte Referral Hospital. In this study the average age was 27 ± 5years, similar studies done in Lagos, Nigeria and Niger Delta showed the mean age was 27.8 ± 6.21 years and 26.8 years, respectively [12,17].

Majority of clients in this study were married 91.3% (273 of 299) which is the same as that of the study done in Aminu Kano Hospital Nigeria [21-23].

In this case control study many variables that have been well studied and identified as a risk factor do not appeared to show association with ectopic pregnancy and the variable that were identified as risk factor for ectopic pregnancy were marital status and history of contraception use.

Thus, women with single marital status were 10.81 times (95% CI A0R (3.601, 32.465)) times higher risk to developed ectopic pregnancy than married once. This may be because single women are at higher risk of encountering multiple sexes, PID, STI and more tendencies to use contraceptive like emergency pills that are incriminated to increase the risk of ectopic pregnancy than those married women.

To my knowledge this is the first study that tries to identify risk factor to ectopic pregnancy in the study area. Like other case control studies it has certain limitation [24]. The first was ascertained based on the written records in clients chart. The other was difficulty of findings similar research to compare the main findings of this thesis. The last but not the least was as it is based on chart review it was impossible to fully incorporate other variables like educational status, alcohol use, cigarette smoking and so on which could have impact on the occurrence of ectopic pregnancy.

Although several risk factors for ectopic pregnancy are known, the only factors associated were marital status and history of contraception use. Accordingly, women with single marital status were 10.81 times (95% CI AOR (3.601, 32.465)) more likely to develop ectopic pregnancy than married once. Those who used contraceptive were 2.27 times (95% CI, AOR (0.214, 24.02)) more likely to develop ectopic pregnancy.

Though it is not identified in this study, there are known risk factors for ectopic pregnancy, thus large scale study shall be conducted to identify possible determinates of ectopic pregnancy. Tracing and integrated management of sexually transmitted infection is very important so as to reduce the incidence of pelvic infection and EP. The clinicians need to record all the findings on medical charts of the patients and Patient’s medical records should be kept appropriately.

It is a pleasure to me to forward my heartfelt gratitude to the advisors Demisew Amenu (Gynecologist and obstetrician) and Elias Ali (MD, MPH) for their unreserved and constructive comments and follow up right from selection of title to completion of thesis. We would also like to thank Jimma University for giving me this opportunity. We would like also to thank Nekemte referral hospital. Last but not least we would like to acknowledge UNFPA for financial support.