Management of Ectopic Pregnancy: A 5-year Review at a Tertiary Hospital in Benin City.

*Osazee K and Oyagha F E
Department of Obstetrics and Gynaecology, School of Medicine, College of Medical Sciences, University of Benin, Nigeria.

All correspondence to:
College of Medical Sciences, University of Benin, Nigeria. Email; kehindeosazee@gmail.com
Osazee K Department of Obstetrics and Gynaecology, School of Medicine,

ABSTRACT
Background: Ectopic pregnancyis a common life-threatening emergency in pregnancy and leading cause of maternal mortality in the first trimester.Also, the morbidity associated with ectopic pregnancy could pose a severe challenge to reproductive potential.

Objective: To determine the trend, incidence, pattern of presentation, diagnostic and treatment modalities of ectopic pregnancy in University Benin Teaching Hospital, Benin City. Method: A retrospective review of ectopic pregnancy cases managed in our hospital between 1st January 2010 and 31stDecember 2014.
Results: The incidence of ectopic pregnancy was 0.87%. The mean age of the patient was 28.3 ± 6.9years, the most frequent presenting symptom was abdominal pain in 108(90.7%) patients, and it was commonest among the primiparous group (26.9%). Tubal ectopic pregnancy was the most typical (96.6%), followed by ovarian ectopic pregnancy (1.6%), then cornual ectopic (0.8%). Right tubal ectopic pregnancy (65.5%) was commoner than left tubal ectopic pregnancy (34.5%). Ampullary implantation was the most common site of ectopic tubal pregnancy (57.1%), and the least was interstitial implantation (5.9%). Ruptured ectopic pregnancy occurred in 60.5% of the cases while 28.6% were slow leaking, 2.5% were tubal abortions, and 8.4% were unruptured. Conclusion: Ruptured ectopic pregnancy is the most frequent variant necessitating laparotomy with salpingectomy as the mainstay treatment modality. However, some of the women were hemodynamically stable at presentation, and operative laparoscopy could have been a viable option.
Keywords: Ectopic Pregnancy, Salpingectomy, Laparotomy, Laparoscopy

INTRODUCTION:

Ectopic pregnancy is the pregnancy in which thefertilised ovum implants in any location other than the endometrial lining of the uterus [1]. It is a common life-threatening emergency in pregnancy and a leading cause of maternal mortality in the first trimester [2,3] which results in significant morbidity for the mother and inevitable loss of pregnancy [4].It constitutes a significant cause of maternal morbidity and mortality especially in developing countries where the majority of the patients often present late with ruptured
variant and hemodynamic compromise [5]. Ectopic pregnancy was first recognised by Busiere in 1693
on examination of an executed prisoner in Paris [6]. The incidence varies from country to country and within the same geographical region depending on the risk factors in the population concerned [5]. In Nigeria, the incidence ranges between 1.2-2.7% of deliveries [4,7-11] and 1.68% in a previous study in our centre[12].
Pregnancies in the fallopian tube account for 97% of ectopic pregnancies; 55% in the ampulla; 25% in the isthmus; 17% in the fimbria and 3% in the abdominal cavity, ovary and cervix [13]. Damage to the fallopian tubes from pelvic inflammatory disease, previous tubal surgery or previous ectopic pregnancy poses strongly associated with an increased risk of ectopic pregnancy [11,13]. Other risk factors include a history of cigarette smoking [13], age over 35years [11,12]and multiple lifetime partners [13], the use of ART [12] and progesterone contraceptive pill [13,14]. However, half of all women who have ectopic pregnancy do not have any known risk factor [14]. Ectopic gestation may present with typical features of acute abdomen and cardiovascular collapse [14,15]. The typical symptoms associated with ectopic pregnancy are amenorrhea, lower abdominal pain, vaginal bleeding and syncope [15].While the signs can be diffused or localised abdominal tenderness, adnexal mass, vagina bleeding which is of uterine origin caused by endometrial involution and decidual sloughing [16]. The association of cardiovascular collapse is suggestive of ruptured ectopic pregnancy [14]it is the most prevalent variant in the developing countries [16] necessitating radical surgeries [15,16].The unruptured variant tends to predominate in the developed countries.With early diagnosed in the course of early pregnancy evaluation [17]. Thus, allows for conservative surgeries such as linear salpingotomy, salpingostomy and milking of the tube [15-17]. The diagnostic approach of ectopic gestation depends on the clinical presentation [18]. The diagnosis of the unruptured variant, as evidenced by the stability of the cardiovascular parameters, relied on the high index of suspicion as well as the -subunit of human chorionic gonadotropin (-hCG) assessment and transvaginal ultrasonography (TVS) [17,18]. Where the facility is available, the use of laparoscopy remains the gold standard [19]. Typically, the serum level of hCG  approximately doubles every 48 hours within the first forty days of conception [18,19]. The trend lowers in extra-uterine pregnancy [18]. However, it is subject to debate as about 17% of extrauterine pregnancy exhibit doubling of hCG within 48 hours,and 15% of a healthy pregnancy associated with lower hCG level [18-20].Furthermore, the concept of discriminating zone is another diagnostic tool that determines the level of serum hCG at which TVS can demonstrate the intra-uterine gestational sac [17,18]. Despite the benefits of these diagnostic tools, the scenario in the developing countries tends to be the ruptured variant due to the paucity of resources and diagnostic facilities [18- 20]. Treatment options include expectant, medical and surgical managements [20]. The surgical approach could be laparoscopy or laparotomy [19]. Also, depending on the state of the tube involved, it could be radical or conservative surgery [18,19].The choice of treatment modality is informed by the state of the fallopian tubes, size of the gestational sac, serum -hCG level and the cardiovascular parameters of the patient [16-21]. Expectant management is considered if the tube involved is unruptured, hCG 1500iu and the gestational sac less than 4cm in diameter without cardiac activity and background haemodynamic stability [19].With rising hCG level and the onset of cardiac activity, the medical option is indicated [20].The treatment involves the use of methotrexate and mifepristone [17]. Where the facilities are available, laparoscopy could be used [18, 19]. Especially in a situation with diagnostic dilemma [19-21]as well as its advantages of less morbidity and shorter hospital stay [18]. In developing countries, laparotomy remains the main surgical approach [20,21]due to the scarcity of operative laparoscopy. However, it remains the most expedient route in the event of ruptured ectopic pregnancy with massive hemoperitoneum and haemodynamic instability [16-20].The conservative approach is indicated by an munruptured tube with compromised contralateral tube and desire to sustain future fertility potential [20].

MATERIALS AND METHOD
A retrospective analysis of all the cases of ectopic pregnancy admitted and managed at the University of Benin Teaching Hospital Benin city(UBTH) a major referral for Edo, Delta, Ondo and Kogi States during a five years period from 1st Jan 2010 and 31st December 2014. The study population consisted of all the patients admitted with ectopic pregnancy. There was a total of 119 patients admitted with ectopic pregnancy over the period under review. Case records of patients were obtained from the records department, wards and theatre operation register. Sociodemographic data, the pattern of presentation, treatment options, a cadre of the surgeon and the type of transfusion were obtained from case note. Other information include previous ectopic pregnancy, previous abdominal surgery, previous treatment of PID and contraceptive use. Also, data on the total number of deliveries, gynaecological admissions and surgery extracted from the hospital database. The data were analysed with simple descriptive statistics and presented in frequency charts and tables

RESULTS
The total number of delivery in the period under review was 13655,and a total of 119 cases of ectopic pregnancy were recorded giving the incidence as 0.87% (table 1). The commonest presentations were abdominal pain, 108
(90.7%), amenorrhoea 97(81.5%) and bleeding per vaginam 55(46.2%) Table 2. The occurrence of ectopic pregnancy was highest in 25-29 years age group, 47(39.5%) and was more in the primigravida 32(26.9%) Table 3. Tubal gestation was the most frequent type in 116(96.6%) of patients. The right side accounted for 75(65.5%) and the left side in 41(34.5%) Table 4.Ampullary tubal ectopic pregnancy constituted 68(57.1%), followed by isthmic ectopic with 32 (26.9%), fimbrial12(10.1%).Theleast being interstitial ectopic pregnancy constituting 7 (5.9%)as shown in table 5. 72(60.5%) of the patients had ruptured at presentation, and 10(8.4%) were unruptured.34(28.6%) were slowly leaking, while 3(2.5 %) were tubal abortion. Table 6. 108(90.8%) had total salpingectomy,and 9(7.6%) had partial salpingectomy. 2(1.6%) of the patients had a unilateral oophorectomy. Table 7. 81(68.1%) had a homologous transfusion. While 12(10.1%) had autotransfusion and 26(21.8%) were not transfused. Table 8

DISCUSSION
Ectopic pregnancy constitutes asignificant cause of morbidity and mortality in early pregnancy and constitutes a significantgynaecological emergency. The incidence of 0.87% in this study shows a downward trend in the incidence of ectopic in our centre when compared with 1.68% in a previous study by Gharoro et al [12]; this could be attributed to the increase in total deliveries in the period reviewed. However, other series in the country reported a relatively higher incidence [ 7, 8, 13,14].

The peak age incidence was amongst women age group of 25-29 years which corroborate with findings of Udigwe et al [4]. and Etuknwa et al [10], the relatively high frequency of ectopic gestation in the age group 16-35years was not surprising since this corresponds to the age of reproductive and peak sexual activity [7-13]. It occurred mainly among the primiparous group and was similar to that of other workers [2,10,11]

Most of the patient in this review were treated mainly by laparotomy and salpingectomy. This constituted 15.2% of all gynaecological operations and 72.5% ofall gynaecological emergencies. These findings are similar to reports of other series in developing countries [7,12,20]. The explanation could be due to late presentation of most patient to the hospital as well as the paucity of diagnostic tools at the various levels of health facilities. Thus, depriving the patients the benefit of early diagnostic and possibility of unruptured variant [7,10,16].Often, the diagnosismade by clinical presentation, transabdominal ultrasonography and positive serum or urine pregnancy test, may not elicit early diagnosis before it ruptures necessitating laparotomy and salpingectomy [6,21].

The occurrence of the right-sided tubal ectopic was observed in this study to be commoner than the left-sidedectopic tubal pregnancy. This finding isconsistent with studies byGharoro et. Al[12] insame centre as our study and Musa et al [11] in Jos.This occurrence may be explained by the infective process especially caused by sub-acute appendicitis because of its close proximity [14,15,19,20]. Also, other infections such as PID post-abortion and puerperal sepsis could cause tubal damage. These are not peculiar to either of the tubes [15-21]. The ampulla (57.1%) was themost common site in the fallopian tube followed by this isthmic portion (26.9%), fimbrial (10.1%) and the least being the interstitial portion (5.9%), comparable to other studies in Nigeria [22]and some parts in the developed countries [7,20]. The ampulla-isthmic junction is where fertilisation of ovum takes place,and any delay in transporting the embryo to the uterus may lead to implantation in the segment of the tube. Thus, explains why ectopic pregnancy occurs most in these two segments of the tubes [15].

In this review, total salpingectomy was preferred over partial salpingectomy and this preference was similar to other studies done in Markurdi, Jos [11]where 88.5 % had total salpingectomy. Also corroborated by the reports of Nayama et. Al [23]. Thus, may be due to the risk of recurrence and the advent of in-vitro fertilisationmay have rendered the need for partial salpingectomyunnecessary [17-22].

12(10.1%) of the patients had autologous transfusion with blood drainedfrom the peritoneal cavity. Hence, provided a quick means of correcting the post haemorrhagic anaemia, volume replacement and augmentation of oxygen-carrying capacity [13,17,23]. Furthermore, save the stress and time consuming associated with grouping and cross-matching of blood [24].

CONCLUSION
Ectopic pregnancy still has remained a criticalgynaecologicalcondition in our Centre. Although several risk factors for ectopic are known, the cause of a significant proportion of ectopic pregnancy remains unknown. The compliments of high index of suspicion and use of modern diagnostic techniques such as TVS and laparoscopy will assist in early diagnosis obviating the mobility and need for radical treatment. Furthermore, creating awareness for early presentation as well as prevention of pelvic inflammatory disease (PID) and adoption of safe abortion programme may help to reduce the scourge of ectopic pregnancy in our environment.

RECOMMENDATION
There is the need to create and adopt a protocol for the diagnosis and management of ectopic pregnancy, develop laboratory capacity for rapid serum hCG assay and make diagnostic laparoscopy a routine tool in evaluating any acute pain in the hospital. There is also the need to research intothe acceptability of vaginal ultrasound with the view to utilising it in assessing early pregnancy complications.

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