European Journal of Cardiovascular Medicine

Ectopic pregnancy represents a significant challenge in obstetrics, given its potential to lead to severe maternal morbidity and mortality.  This condition, wherein a fertilized ovum implants outside the uterine cavity, most commonly occurs in the fallopian tubes. Globally, the incidence of ectopic pregnancies has seen a noticeable rise, attributed to factors like increased incidences of pelvic inflammatory diseases, use of assisted reproductive technologies, and changes in contraceptive practices.  Despite advancements in diagnostic modalities and therapeutic interventions, ectopic pregnancies remain a critical concern due to their unpredictable nature and the potential for life-threatening complications. In India, the incidence of ectopic pregnancies ranges from 1-2% of all pregnancies, with pelvic tuberculosis identified as an important etiological factor.  The prevalence and outcomes of ectopic pregnancies vary significantly across different regions, reflecting disparities in healthcare infrastructure and quality of care1.

Risk factors for ectopic pregnancy are multifaceted and can be categorized into reproductive, infectious, and procedural domains. Prior ectopic pregnancy, history of pelvic inflammatory disease, tubal surgery, and use of intrauterine devices (IUDs) are well-documented risk factors. Additionally, assisted reproductive technologies and certain contraceptive practices have been implicated in increasing the risk of ectopic pregnancies. In the context of Kashmir, exploring the prevalence and impact of these risk factors within the local population is crucial.  The interplay between genetic predispositions, environmental exposures, and lifestyle factors specific to the region could offer novel insights into the etiopathogenesis of ectopic pregnancies. The clinical presentation of ectopic pregnancies also varies widely, ranging from asymptomatic cases to acute abdomen with hemodynamic instability. Typical symptoms include abdominal pain, vaginal bleeding, and amenorrhea. However, atypical presentations are not uncommon and can complicate the diagnostic process.  The outcomes of ectopic pregnancies hinge on timely diagnosis and management. While medical management with methotrexate and surgical interventions are mainstays of treatment, the choice of modality depends on clinical presentation and resource availability.

The landscape of ectopic pregnancy in Kashmir, a region known for its unique sociocultural and environmental attributes, presents an intriguing area for focused research. The geographic and demographic specifics of Kashmir, including its mountainous terrain and the relative inaccessibility of healthcare services in rural areas, could play a pivotal role in influencing the risk factors and clinical presentations of ectopic pregnancies.  Additionally, the sociocultural norms and healthcare-seeking behaviors prevalent in the region may further modulate the clinical outcomes of this condition.

The present study aimed to study the risk factors, clinical presentations and outcomes of ectopic pregnancies among the patients attending the Department of Obstetrics and Gynaecology of GMC, Srinagar, Jammu & Kashmir.

Study type and design:  The present study was a records-based retrospective observational study which included a timeframe of 20 months (Jan 2022 to Aug 2023).

Study population: All patients diagnosed as ectopic pregnancy in the age groups of 18-44 years presenting to the study institution during this period were included in the study.

Incusion criteria: The inclusion criteria for the present study were:

·         Age >18 years

·         Diagnosed case of ectopic pregnancy

Exclusion criteria: The exclusion criteria for the present study were patients who were referred to other institution for management or were lost to follow-up during the course of their treatment.

Sample size and sampling technique:  A complete enumeration study sampling was utilized to include all patients with ectopic pregnancy who presented to and were managed at the study institution during the period of the study. A thorough records-review yielded a sample of 153 patients.

Data collection: A predesigned study proforma was utilized to collect and store data pertaining to each patient. A thorough records review yielded sociodemographic, clinical, and ectopic pregnancy related characteristics of the participants. Based on the records review, clinical outcomes of the patients in terms of mode of management and incidence of rupture were obtained and collected in the study proforma.

Ethical clearance: Appropriate permission and clearance was obtained for the present study from the institutional ethics committee of the study institution.

Data analysis: The data was stored in an MS Excel spreadsheet and analysed using SPSS v. 22. Chi-square and unpaired student’s t-test were utilized to assess risk factors associated with rupture of ectopic pregnancies, and a p-value of <0.05 was considered to be statistically significant.

The study included a total of 153 patients diagnosed with ectopic pregnancy at the Department of Obstetrics and Gynaecology, GMC Srinagar, Jammu & Kashmir, over a 20-month period. The sociodemographic characteristics revealed that the majority of patients (52.9%) were aged between 25-30 years, followed by 27.5% in the 31-35 years age group. A significant proportion of the participants (56.2%) were multiparous, while 43.8% were nulliparous.

In terms of clinical presentation, abdominal tenderness was the most common symptom, reported in 89.5% of cases, followed by bleeding per vaginum (57.5%) and adnexal mass (45.8%). Other signs included cervical motion tenderness (45.8%), abdominal distension (13.7%), and shock (2.0%). (Table 1)

The prevalence of previous abortions was 14.4%, and 9.2% of patients had a history of a prior ectopic pregnancy. Among the notable risk factors, previous lower segment cesarean section (LSCS) was present in 39.2% of the cases, pelvic inflammatory disease (PID) in 1.3%, and other surgical histories in 5.2%. (Table 2)

Management strategies varied among patients, with 39.9% undergoing laparotomy and 19.0% managed laparoscopically. A medical approach using methotrexate was employed in 11.8% of cases, while expectant management was applied in 26.8%. Blood transfusions were required in 16.3% of cases, and ICU admission was necessary in only 1.3% of patients. (Table 3)

Regarding clinical outcomes, rupture of the ectopic pregnancy was observed in 39.2% of cases, while 60.2% were unruptured. A single case (0.6%) was diagnosed as interstitial ectopic pregnancy. Cardiac activity was detected in 13.1% of ectopic pregnancies, whereas 86.9% exhibited absent cardiac activity. (Table 4)

The analysis of factors associated with rupture revealed that the mean age of ruptured cases (28.5 years) was not significantly different from unruptured cases (29.1 years, p = 0.432). Parity distribution also showed no significant difference between the two groups. A history of abortion did not significantly impact the likelihood of rupture (p = 0.787). The presence of known risk factors, such as LSCS, PID, or prior abdominal surgeries, did not show a statistically significant association with rupture.However, certain clinical symptoms were strongly associated with ruptured ectopic pregnancy. Abdominal distension was significantly more frequent in ruptured cases (25% vs. 6.5%, p < 0.001). Similarly, adnexal mass (71.7% vs. 29%, p < 0.001) and cervical motion tenderness (73.3% vs. 28%, p < 0.001) were significantly more common in the ruptured group. Bleeding per vaginum was also significantly associated with rupture (71.7% vs. 48.4%, p = 0.004).The mean β-HCG levels were significantly higher in ruptured ectopic pregnancies (14230.4mIU/ml) than in ruptured cases (3813.6mIU/ml), (p =<0.001). (Table 5)

Table 1. Clinical characteristics of the participants (n=153)

Table 2. Risk factor characteristic of participants (n=153)

Table 3. Management characteristics of the participants (n=153)

Table 4. Outcome of ectopic pregnancy in the participants (n=153)

Table 5. Factors associated with rupture in the participants (n=153)

 *Statistically significant

The present study analyzed the risk factors, clinical presentations, management approaches, and outcomes of ectopic pregnancy in a tertiary care setting in Kashmir. The age distribution in this study revealed that the highest proportion of cases (52.9%) occurred in women aged 25–30 years, followed by those aged 31–35 years (27.5%). Similar findings were reported by Noor et al. (2022), where the highest incidence of ectopic pregnancy was observed in the 25–29-year age group.  Additionally, Verma et al. (2023) noted that the majority of patients in their study were between 20 and 24 years.  These findings support the notion that ectopic pregnancy is more common in women of reproductive age, with a peak incidence in the late twenties and early thirties.Parity distribution in this study showed that 56.2% of participants were multiparous, while 43.8% were nulliparous. Sharma et al. (2020) similarly reported that ectopic pregnancy was more prevalent among multigravida women (77.3%).  However, Verma et al. (2023) found that 12.3% of patients were nulliparous, with a gradual increase in incidence with parity.2 These findings suggest that both nulliparous and multiparous women remain at risk for ectopic pregnancy, with prior obstetric history playing a role in susceptibility.

A significant proportion of patients in this study had a history of previous abortion (14.4%) and previous ectopic pregnancy (9.2%). Muzaffar et al. (2020) and Gandotra et al. (2020) identified prior abortions as a significant risk factor for ectopic pregnancy, with odds ratios (OR) of 2.42 and 3.85, respectively. ,   These studies emphasized the role of tubal damage and previous surgical interventions in increasing the likelihood of ectopic implantation. Furthermore, Muzaffar et al. (2020) found that previous ectopic pregnancy was a strong predictor (OR=8.129), reinforcing the finding that prior tubal pathology increases recurrence risk.4Previous lower segment cesarean section (LSCS) was found in 39.2% of cases, aligning with Noor et al. (2022), where 26.6% of patients had a history of LSCS.1 This association may be attributed to altered tubal anatomy or adhesion formation post-cesarean, increasing the risk of abnormal implantation. Rab et al. (2023) also identified previous cesarean delivery as a major risk factor (26.6%), highlighting the growing concern regarding cesarean-related complications. Pelvic inflammatory disease (PID) was noted in only 1.3% of cases in this study, in contrast to Muzaffar et al. (2020), where PID was a significant contributor to ectopic pregnancy (OR=2.856).4 Similarly, Gandotra et al. (2020) reported that a history of pelvic infections, particularly tuberculosis and Chlamydia, increased the likelihood of tubal pathology.5 The lower incidence of PID in this study may reflect differences in screening practices or underdiagnosis due to the retrospective nature of the study.

Regarding clinical presentation, abdominal tenderness was the most common symptom (89.5%), followed by vaginal bleeding (57.5%) and adnexal mass (45.8%). These findings are consistent with Verma et al. (2023), where abdominal pain (95.4%) and vaginal bleeding (49.2%) were the predominant symptoms.2 Sharma et al. (2020) also reported abdominal pain (95.7%) and amenorrhea (85.1%) as key presenting complaints.3 These similarities emphasize that abdominal pain remains the most reliable indicator of ectopic pregnancy, necessitating high clinical suspicion in symptomatic women.In terms of management, 42.5% of patients underwent laparotomy, while 19.0% were managed laparoscopically. Shah et al. (2019) highlighted the advantages of laparoscopic management, where 73.77% of chronic ectopic cases and 78.26% of acute cases were treated via laparoscopy.  The benefits of laparoscopic surgery include reduced morbidity, shorter hospital stay, and faster recovery. However, in settings where laparoscopic expertise is limited, laparotomy remains the preferred approach, particularly in cases of ruptured ectopic pregnancy. Medical management using methotrexate was used in 11.8% of cases in the present study, whereas Rab et al. (2023) reported that medical management was less commonly employed, with 90.3% of patients requiring surgical intervention.6 This difference likely reflects variations in case selection, as medical management is typically reserved for hemodynamically stable patients with lower β-HCG levels and unruptured ectopic pregnancies.

Rupture of the ectopic pregnancy was observed in 39.2% of cases in this study, a figure comparable to Noor et al. (2022), where 47.5% of patients presented with ruptured ectopic pregnancy.1 Similarly, Sharma et al. (2020) reported that 85.1% of cases were acute ruptured ectopic pregnancies, indicating a higher proportion of delayed diagnoses in their study population.3 The present study found that adnexal mass (71.7%), cervical motion tenderness (73.3%), and vaginal bleeding (71.7%) were significantly associated with rupture, consistent with the findings of Rab et al. (2023), where 71% of cases presented with rupture necessitating urgent surgical management.6Analysis of β-HCG levels revealed that mean values were higher in ruptured ectopic pregnancies (14230.4mIU/ml) compared to ruptured cases (3813.6mIU/ml), and the difference was statistically significant. Verma et al. (2023) and Noor et al. (2022) also found a wide difference of β-HCG levels between ruptured and unruptured ectopic pregnancies.1, 2 This highlights the importance of combining β-HCG with ultrasonographic findings for timely diagnosis.Blood transfusion was required in 16.3% of cases, which is lower than the 81% reported by Rab et al. (2023).6 The higher transfusion rates in their study may be attributed to a greater proportion of hemodynamically unstable patients requiring emergency intervention. ICU admissions were required in only 1.3% of patients in this study, contrasting with Rab et al. (2023), where ICU admission was necessary in 3% of cases.6 This suggests that prompt surgical intervention and early diagnosis may reduce the need for critical care support.

The limitations of the present study were twofold. Firstly, even though a persistent pelvic inflammatory disease (PID) is a known risk factor for the development of ectopic pregnancy, in the present study none of the participants underwent screening for PID in the setup. Secondly, in the study institution, emergency laparoscopy facilities are not available, so all of the patients were managed by laparotomy.

In conclusion, this study corroborates previous findings regarding the risk factors, clinical presentation, and management of ectopic pregnancy. The high incidence of previous cesarean section and abortions as risk factors highlights the need for patient education and careful monitoring of high-risk individuals. The predominance of abdominal pain as a presenting symptom underscores the importance of maintaining a high index of suspicion in reproductive-age women.

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