European Journal of Obstetrics & Gynecology and

Reproductive Biology 131 (2007) 85–88

www.elsevier.com/locate/ejogrb

Rupture of tubal pregnancy in the Vilnius population

Pasquale Berlingieri a,*, Grazina Bogdanskiene b, Jurgis G. Grudzinskas a,c
a
Department of Obstetrics and Gynaecology, St. Bartholomew’s and The Royal London School of
Medicine and Dentistry, London, United Kingdom
b
Gynaecology and Fertility Clinic, Vilnius, Lithuania
c
The London Bridge Fertility, Gynaecology and Genetics Centre, London, United Kingdom
Received 30 September 2005; received in revised form 19 January 2006; accepted 12 March 2006

Abstract

Objectives: To evaluate the determinants of tubal rupture in women who suffered from ectopic pregnancy in relation to their demographic
profile and medical history.
Study design: This retrospective observational clinical study was conducted in five general hospitals in Vilnius, Lithuania. The population
was composed of 879 women with surgically proven ectopic pregnancy. Tubal rupture was diagnosed at the time of surgery. Univariate and
multivariate logistic regression analyses were performed to identify the risk factors for tubal rupture.
Results: The occurrence of tubal rupture was 29.5% (259/879). It was encountered significantly more often in women with age of 35 years
(odds ratio 1.9 [1.3–2.8]). Patients whose EP was located in the isthmus were at higher risk of having tubal rupture (odds ratio 3.2 [2.2–4.5])
while known risk factors for EP were not associated with an elevated risk.
Conclusions: Our data suggest that age of 35 years and implantation in the straightest segment of the tube could be associated with
increased rate of tubal rupture. Of particular interest is the overall tubal rupture prevalence (29.5%) observed since these women were
managed in an environment where transvaginal ultrasound equipment and quantitative assessment of b-human chorionic gonadotrophin were
not routinely available.
# 2006 Elsevier Ireland Ltd. All rights reserved.

Keywords: Ectopic pregnancy; Tubal rupture; Lithuania; b-hCG; Ultrasound

1. Introduction Lithuania, using study design similar to Coste et al. [1]; we

Tubal rupture represents the major cause for deaths in
women with ectopic pregnancy (EP). It requires more
invasive treatment with the result that the Fallopian tube is
conserved only in few cases. Moreover, it is a potential risk
in women undergoing non-invasive management such as
medical treatment with systemic methotrexate.
We have previously reported aspects of EP in women
admitted in 1993 to all five hospitals with accident and
emergency departments of Vilnius, the capital city of
* Corresponding author at: UCL BioMedica, Anthony Nolan Research
Institute Building, Royal Free and University College Medical School
(Hampstead Campus), University College London, Rowland Hill Street,
London NW3 2PF, United Kingdom. Tel.: +44 20 7794 4066;
fax: +44 20 7794 3239.
E-mail address: p.berlingieri@medsch.ucl.ac.uk (P. Berlingieri).
described the incidence of EP to be 18.9 per 1000 live births,
11.2 per 1000 reported pregnancies and 10.1 per 10,000
women of reproductive age (15–44 years) in that year [2].
This survey was expanded to include information on EP
in all the 885 women at the time of presentation and surgery
from all five Vilnius hospitals with accident and emergency
departments for a 5-year period (1993–1997 inclusive).
During this time, patient’s management was routinely based
on clinical and surgical findings as vaginal ultrasound
equipment and quantitative serum b-hCG measurements
were not available.
In order to identify patients at greatest risk for tubal
rupture, we analysed this large population based record by
assessing the determinants of tubal rupture in relation to the
demographic profile and medical history of women who had
EP diagnosed at the time of surgical treatment.

0301-2115/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejogrb.2006.03.004

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86 P. Berlingieri et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 131 (2007) 85–88
2. Materials and methods
A register of women resident in Vilnius City, Lithuania
(population 592,000; 1993), who had suffered from
surgically proven EP, was derived using the method of
case record retrieval described in detail previously [2]. At
the five general hospitals, which provide Accident and
Emergency facilities, operating theatre records were
examined for the identification of women who had
undergone surgery for EP in the 5-year period 1 January
1993 to 31 December 1997.
An additional search in each hospital medical records
department was conducted to obtain each woman’s case
record to confirm the surgical diagnosis and, in particular, to
extract detailed information on demographic factors as well
as gynaecological, obstetric and surgical history. All cases of
surgically proven EP were identified and validated by
reviewing pathology department records of all EP tissues
submitted for microscopic examination in addition to
discharge summaries, except in 11 women who were treated
with methotrexate after surgical diagnosis. Tubal rupture
was defined as any loss of integrity of the tubal serosa by the
precise intraoperative description noted in the operative
report.
The provisional diagnosis of EP in each institution was
based on clinical method and confirmed surgically as
quantitative b-hCG estimations or transvaginal ultrasound
facilities were not available during the study period. At this
time, only transabdominal ultrasonography was accessible
in these hospitals but its use was only restricted to the
obstetric service where it was located.
Eight hundred and eighty-five cases of EPs were
reviewed. Three patients were not included in the analysis
as the pregnancy was extratubal (one patient had ovarian EP
and two patients had the EP located in the pouch of
Douglas). Data on tubal status were unknown in three cases.
As a result, the total population assessed was composed of
879 pregnancies. The following determinants were analysed
to evaluate whether they were related to tubal rupture: age,
parity, miscarriage, termination of pregnancy, previous EP,
history of pelvic inflammatory disease and previous use of
intrauterine contraceptive device. On the basis of the
surgical details, patients were consequently allocated into
two groups for comparison: those with a ruptured tubal
pregnancy (259) and those with an intact tubal pregnancy
(620).
We performed a univariate analysis for each factor
studied by calculating the odds ratios and 95% confidence
interval. In accordance with the statistical approach adopted
by Job-Spira et al. [3], we evaluated risk factors for tubal
rupture by increasing the P-value threshold up to 0.20 to
avoid a possible exclusion of important determinants. In
order to assess the mutual dependencies between possible
contributing factors, a multivariate analysis was subse-
quently carried out using logistic regression. Therefore, the
multivariate analysis included all the selected variables with
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a P-value of <0.20 in the univariate analysis. SPSS1 version
11.0.0 (Chicago, Illinois, USA) was used for all statistical
analysis. Permission to conduct the study was provided by
the Vilnius University Hospital.
3. Results
The overall prevalence of tubal rupture was 29.5% (259/
879), being highest in 1993 at 39.3% (57/145), 34.1% (59/
173) in 1994, 29.2% (54/185) in 1995, 26.4% (52/197) in
1996 and falling to 20.7% (37/179) in 1997.
The univariate analysis, presented in Table 1, showed a
strong association between tubal rupture and advancing age
(P < 0.001). The occurrence of ruptured tube, with respect
to parity, was higher in patients who had one or more
children than in nulliparous women (P = 0.006). Similarly,
the rupture rate was seen more frequently in women who
terminated one or more pregnancies than in patients who
never underwent the same procedure (P = 0.061). On the
other hand, patients who had one or more miscarriages were
less prone to tubal rupture than the control group
(P = 0.094). None of the known risk factors for EP occurred
more frequently in women with tubal rupture. The rate of
rupture did not seem to be influenced by previous EP and
previous use of intrauterine contraceptive device. In
contrast, history of pelvic inflammatory disease was
observed significantly less often in patients with a ruptured
tube than in women with an intact tubal pregnancy
(P = 0.023). As far as implantation is concerned
(Table 2), ruptured pregnancies occurred more frequently
at the isthmic site than at the distal part of the tube
(P < 0.001).
Multivariate logistic regression analysis (Table 3) iden-
tified that tubal rupture occurred more often in patients who
are 35 (P = 0.001) and in women whose EP is implanted in
the isthmic site (P < 0.001).
4. Comment
We believe this report describes for the first time in the
English speaking scientific literature observations on tubal
rupture in a total population from a former Eastern European
bloc country. In addition, this analysis expands the
information available on the occurrence of tubal rupture
in EP.
The proportion of tubal pregnancy affected by this event
is still high, ranging from 18.0% to 34.0% as reported in
previous large population based studies with more than 200
EPs [3–6]. Curiously, the rate of tubal rupture reported in
Vilnius (29.5%) is within this range.
None of the previous authors [3–5] found older age to be a
risk factor for tubal rupture. Only recently, a North
American investigation [6] showed, for the very first time,
that increasing age is related to loss of tubal integrity. In our
 P. Berlingieri et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 131 (2007) 85–88 87

Table 1
Assessment of risk factors for tubal rupture by univariate analysis
Variable Ruptured tube (n = 259) Unruptured tube (n = 620) P-value* OR 95% CI
No % No %
Age
<25 36 13.9 143 23.1 1
25–29 63 24.3 172 27.8 <0.001 1.5 0.9 2.3
30–34 72 27.8 169 27.3 1.7 1.1 2.7
35 88 34.0 135 21.8 2.6 1.6 4.1
Parity
Nulliparity 69 26.6 222 36.3 1
Multiparity 190 73.4 390 63.7 0.006 1.6 1.1 2.2
Miscarriage
No 238 92.2 542 88.4 1
Yes 20 7.8 71 11.6 0.094 0.6 0.4 1.1
Termination of pregnancy
No 114 44.2 314 51.1 1
Yes 144 55.8 300 48.9 0.061 1.3 1.0 1.8
Previous ectopic pregnancy
No 223 86.1 518 84.1 1
Yes 36 13.9 98 15.9 0.45 0.9 0.6 1.3
History of PID
No 209 81.0 455 73.7 1
Yes 49 19.0 162 26.3 0.023 0.7 0.5 0.9
Previous use of IUCD
No 236 93.3 561 92.4 1
Yes 17 6.7 46 7.6 0.66 0.9 0.5 1.6
Site of implantation
Ampulla + Fimbria 63 29.6 285 57.6 1
Cornua + Isthmus 150 70.4 210 42.4 <0.001 3.2 2.3 4.6
OR = odds ratio; 95% CI = 95% confidence interval; PID = pelvic inflammatory disease; IUCD = intrauterine contraceptive
*
P < 0.20.

population women with age of 35 years were significantly was consistent with previous reports [3,7], confirming that
at higher risk (odds ratio 1.9 [1.3–2.8]). It is rather the narrow characteristic of this tubal segment and its least
challenging to shed any light on this correlation since age is distensible feature could provide the ground for an elevated
a possible surrogate measure of exposure to unknown probability of rupture.
factors; as a result, we feel it is appropriate to share the view No relationship was demonstrated between known risk
of Bickell et al. [6] who advocated that this relationship may factors for EP and tubal rupture, this observation being in
be simply due to chance and that further studies are needed. accord with previous investigations [3–5]. It is likely that EP
The unexpected higher rate of isthmus location in our was suspected more frequently in these women, avoiding
study is possibly caused by lack of documentation in 170 unnecessary delay and, therefore, decreasing the likelihood
cases, given that the most common site of implantation for a of rupture; in fact, as previously demonstrated, early
tubal EP is usually the ampulla [3,4,7]. Our finding diagnosis in patients at high risk of EP reduces the
concerning the significant association of isthmic location probability of tubal rupture due to increased clinical
with increased risk of ruptured EP (odds ratio 3.2 [2.2–4.5]) alertness [8,9].
Surprisingly, the occurrence of tubal rupture in our
population was 29.5%; it is worth mentioning that in Vilnius,
Table 2 during the study period, ultrasound scan was not readily
Occurrence of tubal ectopic pregnancy in relation to its implantation site in accessible; moreover we might have expected that lack of
709 cases transvaginal ultrasound availability should have led to
Site Ruptured tube Unruptured tube higher rates of tubal rupture as its use can reduce the risk of
Fimbrial 5 35 tubal rupture by assessing the fluid in the pouch of Douglas
Ampullar 58 250 and by detecting an ectopic gestational sac as well as an
Isthmic 150 208 ectopic mass [10]. Furthermore, b-hCG serum measure-
Cornual 0 2
ments were also not available in Vilnius at that time, making
Contiguous site 0 1
this result even more striking.

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Table 3 Acknowledgement
Assessment of risk factors for tubal rupture by multivariate analysis
Variable P-value * ORa 95% CI The authors thank Dr. Richard Morris for his statistical
Age analysis support.
<35 1
35 0.001 1.9 1.3 2.8
Parity
Nulliparity 1
References
Multiparity 0.12 1.4 0.9 2.1
[1] Coste J, Job-Spira N, Aublet-Cuvelier B, et al. Incidence of ectopic
Miscarriage pregnancy. First results of a population-based register in France. Hum
No 1 Reprod 1994;9:742–5.
Yes 0.07 0.5 0.3 1.1 [2] Bogdanskiene G, Dirsaite I, Grudzinskas JG. Incidence of ectopic
Termination of pregnancy pregnancy: preliminary results of a population-based register in
No 1 Lithuania. In: Genazzani AR, Petraglia F, Ambrogio G, Genazzani
Yes 0.82 1.0 0.7 1.5 AD, Artini PG, editors. Recent developments in gynaecology and
obstetrics. London: The Parthenon Publishing Group; 1996 . p. 631–
History of PID 5.
No 1 [3] Job-Spira N, Fernandez H, Bouyer J, Pouly JL, Germain E, Coste J.
Yes 0.18 0.8 0.5 1.1 Ruptured tubal ectopic pregnancy: risk factors and reproductive out-
Site of implantation come. Am J Obstet Gynecol 1999;180:938–44.
Ampulla + Fimbria 1 [4] Saxon D, Falcone T, Mascha EJ, Marino T, Yao M, Tulandi T. A
Cornua + Isthmus <0.001 3.2 2.2 4.5 study of ruptured tubal ectopic pregnancy. Obstet Gynecol 1997;90:
46–9.
OR = odds ratio; 95% CI = 95% confidence interval; PID = pelvic inflam- [5] Falcone T, Mascha EJ, Goldberg JM, Falconi LL, Mohla G, Attaran M.
matory disease. A study of risk factors for ruptured tubal ectopic pregnancy. J Womens
*
P < 0.05. Health 1998;7:459–63.
a
Adjusted variables introduced into model: age, parity, miscarriage, [6] Bickell NA, Bodian C, Anderson RM, Kase N. Time and risk of
termination of pregnancy, history of PID and site of implantation. ruptured tubal pregnancy. Obstet Gynecol 2004;104:789–94.
[7] Bouyer J, Coste J, Fernandez H, Pouly JL, Job-Spira N. Sites of
In conclusion, we make the observation that women with ectopic pregnancy: a 10-year population-based study of 1800 cases.
Hum Reprod 2002;17:3224–30.
age of 35 years are probably at higher risk of tubal rupture; [8] Cacciatore B, Stenman UH, Ylostalo P. Early screening for ectopic
moreover we confirm that patients with EP located in the pregnancy in high-risk symptom-free women. Lancet 1994;343:
isthmus could be more prone to rupture and that known risk 517–8.
factors for EP did not increase the risk. In addition, we [9] Mol BWJ, Hajenius PJ, Engelsbel S, Ankum WM, Bossuyt PMM, Van
believe the rate of tubal rupture in the Vilnius population der Veen F. Screening for ectopic pregnancy in symptom-free women
at increased risk. Obstet Gynecol 1997;89:704–7.
represents a remarkable finding considering that it had [10] Mol BWJ, Hajenius PJ, Engelsbel S, et al. Can non-invasive diagnostic
occurred in absence of transvaginal ultrasound equipment tools predict tubal rupture or active bleeding in patients with tubal
and biochemical assays. pregnancy? Fertil Steril 1999;71:167–73.

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