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Apprasial Ectopic Pregnancy

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Address of the article:

Predictors of ectopic pregnancy in nulliparous women: A case-control study.
Name of the Journal:
Middle East Fertility Society Journal.
Names of the authors:
Ahmed Ragab, Yasser Mesbah , Ibrahim El-Bahlol , Muhammed Fawzy , Mohamed Alkhatim
Alsammani.
Year of publication: 2015
Number of pages: 5 pages
Why I chose this paper?
I chose this paper because I am interested in understanding the underlying factors that predict
the possibility of having an ectopic pregnancy in nulliparous women. I also wanted to know the
best management plan for ectopic pregnancy in nulliparous woman.
What is this paper about?
This paper evaluates the correlation between several risk factors; age, gravidity, history of
previous abortion, previous pelvic abdominal surgery, infertility treatment IVF/ET, history of PID,
ectopic pregnancy in nulliparous women.
Research question:
The research question wasnt clearly stated but I believe it is as follows; what are the most
common risk factors of ectopic pregnancy in nulliparous women and what are the main lines of
treatment offered?
Objectives:
- The objectives of the study were specific and well defined and were appropriate for the
research design.
- This study aimed to determine risk factors in nulliparous women and treatment offered as
these women have never given birth, and their future fertility is at risk.
Study design:
A case control study.
Study population:
- Clearly stated.
- Criteria for inclusion:
The study included all nulliparous patients admitted as a case of ectopic pregnancy according to
American College of Obstetrics and Gynecology (ACOG) guidelines 2009 (10). A total of 36
patients were included in the study. They were matched in age, gravidity and parity to 72
apparently healthy patients. Each patient with ectopic pregnancy was matched to two
subsequently admitted patients.
- Criteria for exclusion:
All multiparous patients with clinical or investigatory criteria of EP were excluded from the
study.
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Data collection:

- The study was conducted from January 2013 to December 2014 at the emergency
department of Obstetrics and Gynecology, Mansoura University Hospitals, Egypt.
- Data were collected from all interviewed patients by the senior registrar on duty. It
contained patients demographic data including age, gravidity, parity, history of pelvi-
abdominal surgery (appendectomy, ovarian cystectomy), previous ectopic pregnancy and its
surgical treatment, history of previous abortion and method of its terminations, induction of
ovulation or use of IVF/ET in the index pregnancy
- All cases after sure diagnosis were subjected to treatment according to NICE guidelines 2012
where laparoscopy was the initial treatment in most cases as they presented early before
becoming hemodynamically unstable.
- Those who were hemodynamically unstable were subjected immediately for laparotomy.
- Medical treatment by Methotrexate was offered to women who fulfilled its inclusion
criteria, and successful treatment was defined as a decrease of beta hCG level more than
15% between days 4 and 7 of Methotrexate injection.
Ethical consideration:
The study was approved by the University Ethics Committee and the Institutional Research
Ethical Committee of the concerned Mansoura University Hospitals, Egypt. The study was
performed in accordance with the ethical standards laid down in the Helsinki Declaration 1975
as revised in 1983 and its later amendments.
Data analysis method:
- The Statistical Package for Social Sciences Computer Program, SPSS version was used for
statistical analysis.
- Means and proportions were calculated by using the frequency. Chi-square analysis was
performed to test for differences in the proportions of categorical variables between two or
more groups.
- Students t-test (two-tailed) was used to determine the significance of the difference
between means of continuous variables.
- In univariate analysis, all independent variables were entered separately. In multivariate
analysis, all independent variables were added to the model simultaneously. The results of
these analyses are expressed as odds ratios (OR) and their 95% confidence intervals (95%
CI). The level P < 0.05 was considered as a cutoff value for significance.
Results: clearly stated and demonstrated in tables as well.
- The control and study groups were similar in age and gravidity (p > 0.05). Compared to
controls, women with ectopic pregnancy had significantly higher frequencies of past PID,
previous abortions or its surgical treatment, history of pelvi-abdominal surgery, surgery for
previous ectopic pregnancy, and induction of ovulation in the index pregnancy (p values, <
0.05).
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- In 63.9% (n = 23) of studied women, there was a history of pelvic-abdominal surgery. In the
majority of these subjects, the primary treatment involved laparoscopic salpingectomy
86.1% (n = 31), 2 cases (5.6%) were treated by laparotomy, and only 8.3% (n = 3) were
offered Methotrexate therapy.
- Univariate analysis showed that history of previous abortion, history of abdominal surgery
(ovarian cystectomy or appendectomy), PID, history of previous D&C, and use of IVF in the
current pregnancy were significantly associated with the increased risk of ectopic pregnancy
(P values, 0.031, 0.027, < 0.001) respectively.
Discussion and interpretations:
- The main findings of this study were significant association of ectopic pregnancy and history
of PID, previous pelvi-abdominal surgery, and infertility treatment. Maternal age gravidity
was not associated with increased risk of ectopic pregnancy.
- The mean age of women in this study was 25.19 3.17 years. This is consistent with recent
evidence that ectopic pregnancy is increasing in young nulliparous women while other
researchers believed that ectopic pregnancy is a disease of multiparous as it tends to occur
at old age (3544 years).
- The results concluded that, the risk of EP among the studied population was 10 times higher
for women who had prior PID compared to controls (OR = 10.1, 95% CI = 3.430.4).
Literature is consistent on PID as an important risk factor for ectopic pregnancy ranging
from 2 to 10 times. This might be explained by tubal damage in young patients as a result of
ascending infections possibly due to sexually transmitted diseases.
- Consistent with the previous findings, the current study documented the risk of EP following
IVF increased 8.746 compared to controls (adjusted OR = 8.7, 95% CI = 1.455.3).
- Women with histories of laparotomy and appendectomy or cystectomy are 4 times likely to
develop EP compared with controls (OR = 4, 95% CI = 1.455.3).
- Like some previous studies this study failed to find an association between spontaneous
abortions and ectopic pregnancy. However, some others showed significant association
between abortion and EP which may be due to rates of post-abortive sepsis with more
postoperative pelvic infection that differ between countries.
- None of the patients used IUCD so the risk of IUCD couldnt be evaluated.
- In the majority of the patients, the primary treatment involved laparoscopic salpingectomy
86.1% (n = 31), 2 cases (5.6%) were treated by laparotomy, and only 8.3% (n = 3) were
offered methotrexate therapy. This high rate of salpingectomy may be because in most of
the developing world patients report late for medical services.
Conclusion:
This study concludes that the risk factors for ectopic pregnancy in nulliparous women are pelvic
inflammatory diseases followed by infertility treatment and pelvi-abdominal surgery. Since
these women have not given birth to babies, salpingectomy is not a good option for treatment.
Therefore, conduction of a good antenatal care detects cases earlier to preserve their future
fertility.
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How do the results of this study apply to my clinical practice?

Personal reflection:
This research
This research signifies the important risk factors associated with ectopic pregnancies which are
PID, infertility treatment and pelvic abdominal surgery. Now that I understood the risk factors of
ectopic pregnancy I will always consider investigating about them in ectopic pregnancy patients.
I also believe that the knowledge of the risk factors of a disease may aid in the prevention or
early proper treatment.