|Year : 2020 | Volume
| Issue : 3 | Page : 177-183
Ectopic pregnancy at the Lagos University Teaching Hospital, Lagos, South-Western Nigeria: Temporal trends, clinical presentation and management outcomes from 2005 to 2014
Joseph Ayodeji Olamijulo1, Babasola Oluwatomi Okusanya1, Muisi Alli Adenekan2, Aloy Okechukwu Ugwu2, Gbenga Olorunfemi3, Osemen Okojie2
1 Department of Obstetrics and Gynecology, College of Medicine, University of Lagos; Department of Obstetrics and Gynecology, Lagos University Teaching Hospital, Lagos, Nigeria
2 Department of Obstetrics and Gynecology, Lagos University Teaching Hospital, Lagos, Nigeria
3 Division of Epidemiology and Biostatistics, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
|Date of Submission||15-Feb-2020|
|Date of Decision||27-Apr-2020|
|Date of Acceptance||02-May-2020|
|Date of Web Publication||17-Jul-2020|
Dr. Joseph Ayodeji Olamijulo
Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos, Lagos
Source of Support: None, Conflict of Interest: None
Background: There is uncertainty in the trend of ectopic pregnancy incidence in the Southwest region, though the region has a lower fertility rate and a higher contraceptive use than some other regions of Nigeria. The study objective was to determine the temporal trends, presentation and management outcome of ectopic pregnancy at the Lagos University Teaching Hospital (LUTH), Lagos, South-Western Nigeria over a decade. Subjects and Methods: This is a retrospective study of ectopic pregnancies at LUTH, Lagos, Nigeria, from January 2005 to December 2014. Participants' medical records were used to extract socio-demographic, clinical characteristics, management and outcome data. Joinpoint regression modelling (version 4.7.1) was used to evaluate the trends while descriptive statistics were conducted using Stata version 14 software. Results: There were 434 cases of ectopic pregnancies giving an overall incidence of 2.2/100 deliveries and 3.50/100 gynaecological admissions. Overall, there was a 59.7% increase in the ectopic pregnancy rate from 1.81/100 deliveries in 2005 to 2.89/100 deliveries in 2014. Join point regression revealed two trends. There was an initial non-significant decrease in incidence of ectopic pregnancy from 2005 to 2010 (annual percent change [APC] = -1.5%, 95% confidence interval [CI]: -8.1% to 5.6%, P = 0.6). However, there was a statistically significant increase in incidence of ectopic pregnancy at an average of 11.6% per annum from 8.6/100 deliveries in 2011 to 25.4/100 deliveries in 2014 (APC = 11.6%, 95% CI: 1.2% to 23.1% P < 0.001). About one-third (33.9%) of the patients with ectopic pregnancy were within the age range 25–29 years while the majority (68.0%) presented at 9–10 weeks of gestational age. The most common identifiable risk factor was previous pelvic infection (35.71%). Majority (96.5%) had tubal pregnancy and all the cases had laparotomy. There were six maternal deaths giving a case fatality rate of 1.4%. Conclusion: The hospital had an increased trend in the incidence of ectopic pregnancy from 2005 to 2014. Frontline health workers need high index of suspicion in the prompt diagnosis and intervention of ectopic pregnancy among women in the reproductive age.
Keywords: Ectopic pregnancy, extra-uterine gestation, join point regression, maternal mortality, maternal near-miss, temporal trends
|How to cite this article:|
Olamijulo JA, Okusanya BO, Adenekan MA, Ugwu AO, Olorunfemi G, Okojie O. Ectopic pregnancy at the Lagos University Teaching Hospital, Lagos, South-Western Nigeria: Temporal trends, clinical presentation and management outcomes from 2005 to 2014. Niger Postgrad Med J 2020;27:177-83
|How to cite this URL:|
Olamijulo JA, Okusanya BO, Adenekan MA, Ugwu AO, Olorunfemi G, Okojie O. Ectopic pregnancy at the Lagos University Teaching Hospital, Lagos, South-Western Nigeria: Temporal trends, clinical presentation and management outcomes from 2005 to 2014. Niger Postgrad Med J [serial online] 2020 [cited 2020 Oct 20];27:177-83. Available from: https://www.npmj.org/text.asp?2020/27/3/177/289910
| Introduction|| |
Ectopic pregnancy is a life-threatening early pregnancy complication., It is a leading cause of maternal morbidity and mortality in the first trimester of pregnancy., The incidence of ectopic pregnancy continues to rise globally, due to various factors including high prevalence of sexually transmitted infections (STIs), postabortal sepsis, puerperal sepsis, increased access to improved diagnostic facilities and assisted reproductive technology, leading to the diagnosis of some ectopic pregnancy cases that may otherwise have been missed.,, These factors share a common mechanism of action which compromise the ciliary function of the Fallopian tube More Detailss.,,
Over 95% of ectopic pregnancies occur in the fallopian tubes; other sites of ectopic pregnancy include the abdominal cavity, ovary, cervix, caesarean section scar and abdominal cavity.,,,,, The incidence of ectopic pregnancies in Nigeria is 1.5–2.7/100 deliveries, and the condition is associated with significant mortality.,,, Ectopic pregnancy accounted for 5.2% of maternal deaths at the Lagos University Teaching Hospital (LUTH) between 2002 and 2006. Poor awareness of the early signs of ectopic pregnancy, poor health seeking behaviour of women and suboptimal diagnostic tools for early pregnancy complications contributed to the high rate of ectopic pregnancy and its sequelae in Nigeria.,,5],,
In high-income countries, mortality from ectopic pregnancies has decreased due to several improved diagnostic and therapeutic protocols that facilitate early diagnosis and treatment.,, Early diagnosis of ectopic pregnancies allow conservative therapeutic modalities to be employed, which reduces associated morbidity and improves future fertility prospects.,, In contrast, morbidity and mortality from ectopic pregnancies are higher in the low- and middle-income countries (LMICs), because majority of the women present late to the hospital with ruptured ectopic pregnancies and associated features of haemodynamic instability.,,,5],, Common risk factors of ectopic pregnancy include the previous history of ectopic pregnancy, previous history or treatment for pelvic inflammatory disease (PID), unsafe abortion, puerperal sepsis, assisted reproductive technology, intrauterine contraceptive devices, prior fallopian tube surgery and previous caesarean section.,,,,,,,,,,, Southwest Nigeria has a lower fertility rate of 3.9% and Lagos state has the highest prevalence (29%) of modern contraceptive use by married women probably due to higher level of education and social exposure.
This study is aimed to determine the temporal trends, pattern of presentations and management outcome of ectopic pregnancy at LUTH, Lagos, South Western Nigeria from 2005 to 2014.
| Subjects and Methods|| |
This was a retrospective cross-sectional study of women admitted for ectopic pregnancy at LUTH, Lagos, South-Western Nigeria from 1st January 2005 to 31st December 2014. The hospital receives referrals from other hospitals within the South Western region of Nigeria. Socio-demographic, clinical characteristics and management outcomes were extracted from medical records using a structured proforma. The presenting clinical features, operation findings, treatment modalities and complications were recorded. The total birth and gynaecological admissions were also recorded for the study period.
Ethical approval for this study was obtained from the human research and ethics committee of LUTH, Lagos (Ref. No: ADM/DCST/HREC/APP/3242).
The data were analysed using the Stata version 16 (Statacorp, College Station, TX, USA) statistical software. Categorical variables were presented as frequencies and percentages. Join point regression modelling (version 4.7.1, National Cancer Institute) was used to evaluate the trends in the incidence of ectopic pregnancy per 100 deliveries in the hospital. Log-linear model with one maximum join point and 4499 permutation tests was conducted for the trends using the Join point software. An average annual percent change (APC) (with 95% confidence interval) was calculated. Join point regression modelling was conducted for ectopic pregnancy rate per 100 deliveries and by absolute numbers, respectively. A statistically significant positive or negative APC was, respectively, described as statistically significant increased or decreased trends. Statistically significant level was set at value of P < 0.05. Two-tailed test of hypothesis was assumed.
| Results|| |
Four hundred and thirty-four (434) cases of ectopic pregnancy were managed during the 10-year period. There were 19,569 deliveries and 12,494 gynaecological admissions during the study period.
Sociodemographic characteristics of ectopic pregnancy patients
[Table 1] shows that about one-third (33.9%) of the women were aged 25–29 years. Ectopic pregnancy occurred in almost same proportion in single (45.9%) and married women (53.2%). Almost half (n = 200, 46.1%) of the patients were nulliparous.
|Table 1: Socio-demographic characteristics of ectopic pregnancy patients|
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Trends in ectopic pregnancy cases
Averagely, there was about 43 (mean ± standard deviation: 43.4 ± 27.6) ectopic pregnancy cases per year during the study period. Overall, there was a 478.9% increase in the number of ectopic pregnancy cases from 19 cases in 2005 to 110 cases in 2014 [Table 2] and [Supplementary Figure 1]a.
|Table 2: Annual incidence of ectopic pregnancy in Lagos University Teaching Hospital, Lagos|
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|Figure 1:(a) Join point trends in the number of cases of ectopic pregnancy. (b) Join point trends in incidence per 100 deliveries.|
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[Table 2] shows annual incidence of ectopic pregnancy at a tertiary hospital in South Western Nigeria (2005–2014).
Join point regression showed two trends in ectopic pregnancy cases as shown in [Figure 1]a. There was an initial significant rise in the number of ectopic pregnancies from 19 cases in 2005 to 38 cases in 2011 (P = <0.001). Furthermore, ectopic pregnancy cases increased abruptly at the rate of 41.4% per annum from 38 cases in 2011 to 110 cases in 2014 (APC = 41.4% 95% confidence interval [CI]: 8.8% to 83.7%, P < 0.001) [Table 3].
|Table 3: Join point estimates of incidence of ectopic pregnancy at a tertiary Hospital in South Western Nigeria (2005- 2014)|
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The trends in incidence of ectopic pregnancy per 100 deliveries
Overall there was a 59.7% increase in the ectopic pregnancy rate per 100 deliveries from 1.81/100 deliveries in 2005 to 2.89/100 deliveries in 2014 [Table 2] and [Supplementary Figure 1]b.
Join point regression revealed two trends in the ectopic pregnancy rate per 100 deliveries as shown in [Figure 1]b: The incidence per 100 deliveries showed a slight non-significant decline (APC = -1.5%, 95% CI: -8.1 to 5.6%, P = 0.6) from 1.81/100 deliveries in 2005 to 1.52/100 deliveries in 2010. Subsequently, there was a statistically significant increase in ectopic pregnancy rate at an average of 11.6% per annum from 1.52/100 deliveries in 2010 to 2.89/100 deliveries in 2014 (APC = 11.6%, 95% CI: 1.2% to 23.1% P < 0.001) [Table 3].
Clinical characteristics, management and complications of ectopic pregnancy
[Table 4] shows the clinical characteristics, management and complications of ectopic pregnancy. Missed menstrual flow (19.8%), abdominal pain (20.9%) and vaginal bleeding (15.7%) were the most common presenting symptoms. About one-tenth (11%) of the patients presented with fainting attacks. The most common clinical signs elicited were abdominal tenderness 365 (67.1%) followed by positive abdominal paracentesis 316 (58.0%). Many (68.0%) of the cases of ectopic pregnancy presented at between 9- and 10-week gestational age, whereas very few (2.3%) presented at >13 weeks. A slightly higher proportion of ectopic gestation (55.0%) occurred in the right fallopian tube compared with 41.5% that occurred in the left fallopian tube. There were 9 cases (2.1%) of abdominal pregnancy accounting for 2.1% of all cases of ectopic pregnancy during the study period. Majority (74.2%) had hypovolemic shock.
|Table 4: Clinical characteristics, management options and complications of ectopic pregnancy|
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All the patients had exploratory laparotomy, with majority (91.0%), having total salpingectomy. There were 6 maternal mortalities with a case fatality rate of 1.4% for the 10-year period.
Identifiable risk factors of ectopic pregnancy
The most common identifiable risk factor among our cohort of patients was previous pelvic infections (35.7%), followed by previous pelvic surgery (25.1%), while previous ectopic pregnancy occurred in 9.9% of the cases. In 7.4% of patients, there were no identifiable risk factors [Table 5].
| Discussion|| |
The objective of the study was to evaluate the trends, clinical presentation, management and outcome of ectopic pregnancies at LUTH, Lagos, South Western Nigeria, over a period of 10 years. We report an incidence of 2.2/100 deliveries. Our finding is comparable to that of Akaba et al. from Abuja, Federal Capital Territory, Lawani et al. from South Eastern Nigeria and Nzaumvila et al. from South Africa who respectively reported an ectopic pregnancy incidence of 2.7%, 2.1% and 2.2%. However, the incidence of ectopic pregnancy from our report is higher than the incidence of ectopic pregnancy reported in some centres in Nigeria (1.1%–1.5%),, Western Tanzania (1.3%) and in the United states of America (0.6%–1.6%)., Our centre is a tertiary hospital and is expected to manage more cases of ectopic pregnancy as compared to a secondary health facilities from Tanzania.
This study revealed a dramatic annual increase in the number of ectopic pregnancy cases from 38 in 2011 to 110 in 2014 giving an average increase of 41.4% per annum. Similarly, the incidence per 100 deliveries increased by 11.6% from 2011 to 2014. The increased incidence of ectopic pregnancy in LMICs has been attributed to a rising prevalence of STIs, PID, unsafe abortions and use of assisted reproductive technique.,,,,,,. Furthermore, increased use of potent antibiotics might preserve tubal patency but with residual luminal damage which would increase the risk of ectopic pregnancy.,, This study also found that previous pelvic infection (35.7%) was the most common risk factor for ectopic pregnancy. Preventive strategies against increased incidence of ectopic pregnancy should therefore target the scourge of STI, unwanted pregnancy, unsafe abortion and poor maternity care. Such strategies should include health education, promotion of safe sex including use of condom, legislation regarding safe abortion and provision of good maternity care.
On the other hand, the increased incidence of ectopic pregnancy at our centre may indicate that there was increased awareness by patients and healthcare practitioners, thereby leading to diagnosis and referral of more cases of ectopic pregnancy to tertiary institutions such as ours for acute care. However, the pattern of acute or late presentation would suggest a lack of high index of suspicion among health-care practitioners and poor health seeking behaviour in the general populace.,, There is also a need to train primary and secondary level health workers to build capacity in the hospitals for early diagnosis, resuscitation, management of ectopic pregnancies and prompt referral to a centre that is equipped to manage if such health facilities cannot cope with such cases in order to save more lives.,,,, The increased number of ectopic pregnancy cases and gynaecological admissions from our study may be a reflection of the growing population of Lagos state.
The peak age from this study was 25–29 years followed closely by the age group 30–34 years. This age pattern is similar to the findings from Akaba et al. and Panti et al. The relatively high frequency of ectopic gestation in the age group 25–34 years (of about 63.8%) may be because this age group is the peak period of reproductive and sexual activity.,,,
Slightly more than half of the cases of ectopic pregnancy in this study occurred among married patients (53.2%) which is similar to some other reports.,,,, However, report from South Africa showed a higher proportion of ectopic pregnancy among single women, but this may be due to a higher proportion of married women in Nigeria as compared to South Africa. Although, married women may have less multiple sexual partners, and theoretically have a reduced risk of sexually transmitted disease as compared to single women, some women may be in a polygamous relationship that may lead to increased risk of STIs. Married women may also indulge in unsafe abortion that may increase their risk of pelvic infections and ectopic pregnancy. Moreover, the patient might have had the risk factors for ectopic pregnancy (such as PID, induced abortion or pelvic surgeries) before marriage and not necessarily be related to the marital status. The parity range in this series was 0–6 and nearly half of patients were nulliparous; and this was similar to the findings from other studies.,,,,
The fallopian tube was the most common site of ectopic pregnancy in this study accounting for 96.5% of cases. Other sites were abdominal (2.1%) and ovarian (0.9%). This was similar to findings by other authors.,,,,,,,, Our finding of a higher prevalence of right sided ectopic pregnancy (55%) is consistent with the notion that tubal ectopic pregnancy is more common on the right side than the left probably due to the location of the appendix.,, Although the direct link between appendicitis and right sided ectopic pregnancy is not clear, it is postulated that appendicitis might be associated with a higher chance of pelvic infections, inflammation, adhesion and tubal compromise on the right side., However, history of appendicitis and/or appendectomy was not identified as a risk factor in the present study. The most common site of ectopic pregnancy is the ampulla of the fallopian tube and its frequency is nearly 70% of cases in some studies.,,,,,, In this study, 68.0% of patients presented at gestational age of 9–10 weeks with ruptured tubal pregnancies, consistent with the location being in the ampulla of the tube. This also underscores the need for education to increase awareness among health workers and the population at large to aid early presentation, diagnosis and treatment. This will in turn reduce the short- and long-term complications associated with ectopic pregnancy. Early pregnancy assessment units can also be established, where women in the reproductive age group presenting with amenorrhoea, vaginal bleeding and pain can be promptly evaluated using standard protocols., Modern diagnostic tools such as quantitative assessment of serum beta human chorionic gonadotrophins (β-hCG), ultrasound scan and laparoscopy should be more widely available to enable early intervention and minimise morbidity and mortality.,
Abdominal pain was the most common symptom in this study. This is similar to reports from other studies.,,,,,, There should be heightened index of suspicion of ectopic pregnancy in any woman of reproductive age presenting with abdominal pain or bleeding, especially with a background history of a missed period., The presence of shoulder tip pain (2.4% in our study) resulting from irritation of the diaphragm is suggestive of intra-abdominal bleeding.
The most common findings on physical examination were abdominal tenderness (67.1%), positive abdominal paracentesis (58.2%), pallor (26.2%) and shock (14.7%). This is in line with findings of other Nigerian and African authors.,,,,,, The diagnosis of ectopic pregnancy is usually made by a combination of history and clinical examinations, aided by qualitative β-hCG and abdomino-pelvic ultrasound scan in most cases.,,,,,,,,, Akaba et al. reported that diagnosis of ectopic pregnancy was made solely on clinical findings in 36.7% of cases. A multimodal approach consisting of serial measurement of quantitative serum β-hCG level, transvaginal ultrasonography, laparoscopy and occasionally laparotomy is more commonly operational in high-income countries.,,,, This diagnostic algorithm applies only to haemodynamically stable women, which is the usual pattern of presentation in high-income countries. This contrasts with the typical scenario in LMICs where many cases present late with acute clinical features of haemodynamic instability.,,,,,,
All the cases in this study had laparotomy and 96.1% had salpingectomy, with about 74% having features of hypovolemic shock. This suggests that the patients generally presented late with ruptured ectopic pregnancy making conservative/less invasive management virtually impossible. Furthermore, the facility and skill for laparoscopic treatment is limited in our centre. There is a need to invest in procurement of laparoscopic equipment and staff training. A study from the United States showed that the use of methotrexate to treat ectopic pregnancy increased from 11.1% in 2002 to 35.1% in 2007 (P < 0.001); while surgical management with laparotomy decreased from 40.0% to 33.1% during the study period (P < 0.001). Early diagnosis will enable a more conservative management to be employed which will lead to reduction in morbidity, shorter hospital stay and improved future fertility prospects.,
In this study, although majority had favourable outcome, complications such as hypovolaemic shock (70.8%), cardiopulmonary arrest (4.6%) and massive blood transfusion (2.2%) were noted. There were six maternal deaths over the 10-year period of review, resulting in a case fatality rate of 1.4%. Our result is similar to the report from Sokoto (1.4%) and Abakaliki (1.4%), but higher than reports from Abuja (0.6%), Owerri (1.3%), and Sagamu (1.5%). It is much higher than that reported by a study in Washington state of the United States of America (0.16%). However, the trends in ectopic pregnancy related mortality is decreasing as several studies from secondary and tertiary health institutions in Nigeria,,,, and Tanzania reported no mortality in their series of ectopic pregnancy patients. In order to reduce such fatal complication, our centre has a policy that all patients with ruptured ectopic pregnancy must be resuscitated and be in theatre within 30 minutes of the diagnosis being made. Furthermore, processing of compatible blood is usually prioritised for patients with a diagnosis of ectopic pregnancy. Our study highlights the significant contribution of ectopic pregnancy to maternal mortality in the country. We suspect that these reported institutional fatality rates represent a tip of the iceberg as more ectopic pregnancy cases might have died before getting to the hospital, because of poor heath seeking behaviour and late referral from less equipped health facilities.
Strength and limitations
The strength of this study is that an objective methodology for evaluating trends (join point regression modelling) was utilised to evaluate the ectopic pregnancy trends at our centre. This has helped to quantify the change in trends and show the direction of the trends including testing hypothesis of a lack of significant trends, with associated confidence interval of the estimates. To our knowledge, our study is the first to utilise join point regression modelling for evaluating ectopic pregnancy trends in Nigeria. However, the study is limited by being a retrospective cross-sectional study as some clinical and missing data could not be assessed. In addition, it is a tertiary hospital facility-based study and may not reflect what happens in the lower level facilities or indeed the general population.
| Conclusion|| |
Ectopic pregnancy remains an important cause of morbidity and mortality at LUTH, Lagos, South Western Nigeria. This study showed an increasing trend in the incidence of ectopic pregnancy between 2005 and 2014. Strategies should be developed to mitigate the scourge of PID and tubal damage. Frontline health workers need high index of suspicion of ectopic pregnancy among women of reproductive age group with missed menstrual flow, abdominal pain and vaginal bleeding. This group of women should have early diagnosis and prompt referral and intervention. Provision of facilities and training of healthcare professionals on modern management of ectopic pregnancy will lead to improved treatment outcome.
We thank the medical records staff for retrieving the case files for review.
Financial support and sponsorship
GO was funded by the GSK/DELTAS Africa Initiatives Grant No. 107754/z/15/z-DELTAS Africa SACCAB to study for a PhD in Public Health (Biostatistics) at the University of Witwatersrand. The views expressed in this publication are those of the authors and not necessarily those of the funders.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]