**4. Research methodology**

#### **4.1 Study design**

114 Ectopic Pregnancy – Modern Diagnosis and Management

gynaecological emergencies (Anorlu et al, 2005). In another study in the same Lagos, Nigeria, it was responsible for 30 % of emergency gynaecological admissions with a case fatality rate of 3.7 % (Abudu, 1999). It was also found to be responsible for 8.6% of maternal deaths in Lagos, Nigeria (Abudu & Olatunji, 1996). Data obtained from various studies from different parts of Nigeria, showed that the perceived lower prevalence of chronic pelvic inflammation in the northern part of Nigeria might explain the comparatively lower incidence of ruptured tubal pregnancy (Essel et al, 1980). The incidence of ectopic pregnancy in two cities in northern Nigeria is 18.1 / 1000 deliveries in Sokoto (Airede & Ekele, 2005) and 1.14 % in Zaria (Adesiyun et al, 2001). It is 1.7% in Jos (Olarewaju et al, 1994) and 1.68 % in Benin City, Nigeria (Gharoro & Igbafe, 2002). A previous study on ectopic pregnancy done at Benin City, Nigeria revealed an incidence of 3.5 % of the total hospital births. In Markudi, Nigeria, ruptured tubal pregnancy of 0.87 % accounted for foetal births and 94.6 % of all ectopic pregnancies. There is a rising trend in the incidence of ruptured tubal pregnancy from 0.65 % in 2004 to 1.09 % in 2006 (Jogo & Swende, 2008). At the Nnamdi Azikiwe Teaching Hospital in southern Nigeria, ectopic pregnancy was responsible for 6.5 % of gynaecological admissions with an incidence of 1.3 % (Udigwe et al, 2010), 3.30 per 100 deliveries in Calabar (Ekanem et al, 2009). It increased from 0.4 % to 1.7 % between 1977 to 1987 at the Obafemi Awolowo University Teaching Hospital, Ile-Ife (Makinde & Ogunnniyi, 1990). While it decreased at the University of Nigeria Teaching Hospital, Enugu between 1978 to 1981 to 0.53 % to 0.21% of deliveries (Egwuatu & Ozumba, 1987). These observations suggest that the incidence of ectopic pregnancy in developing countries especially on the

African continent has probably increased in recent decades (Thoneau et al, 2002).

Multiple factors contribute to the relative risk of ectopic pregnancy although some patients may not have any risk factor yet developed ectopic pregnancy. In theory, any thing that hampers or delays the migration of the embryo to the endometrial cavity could predispose women to ectopic pregnancy. Age, marital status, and parity have been found not to be significant risk factors for ectopic pregnancy (Anorlu et al, 2005). The reported aetiological factors for ectopic pregnancy include pelvic inflammatory disease, post abortal sepsis, postpartum sepsis, previous ectopic pregnancy, reversal of previous tubal sterilization, tubal spasm, long defects of the fallopian tubes and psychological and emotional factors (Doyle et

**Pelvic inflammatory disease**: Pelvic inflammatory disease from inappropriate obstetric care or from unsafe abortion is a risk factor for ectopic pregnancy (Onwuhafua et al, 2001). These infection causes distortion in the genital tract and the fallopian tube in particular. Unsafe abortion leads to post abortal sepsis. Induced abortion and sexually transmitted disease increases the risk four fold and nine-fold respectively (Anorlu et al, 2005). Also, multiple sexual partners predispose the patient to acquiring sexually transmitted disease. Pelvic inflammatory disease is a major risk factor for developing ectopic pregnancy in Nigeria (Olarewaju, 1994, Egwuatu & Ozumba, 1987). Induced abortion as a significant risk factor for ectopic pregnancy was not observed in studies from countries where abortion is legalised (Atrash et al, 1997). This is because qualified medical personnel carry it out under aseptically clean environment with sterile instruments. Biologically the adolescent is particularly at risk of sexually transmitted disease because the columnar epithelium, which is susceptible to *Chlamydia* and *gonococci* organism extends from the endocervical canal to

**3. Risk factors** 

al, 1991).

This is a prospective study carried out at General Hospital Aliero, Kebbi State, Nigeria from February 2006 to January 2007. General Hospital Aliero is a general hospital and a secondary health facility that was upgraded from a primary health centre. At the time of the study, the three doctors at the hospital were general practitioners with no specialist training in obstetrics and gynaecology. The hospital manages patients with various illnesses and cases requiring specialist care are referred to the nearest tertiary health facility. The hospital does not have a gynaecological ward therefore patients with gynaecological problems are admitted into the female medical ward and those who had surgeries are admitted into the female surgical ward. The hospital is a general hospital, which does not have an active gynaecological unit as the patients are being managed by general practitioners posted to the hospital.

#### **4.2 Study area**

General hospital Aliero is located in Kebbi State of Nigeria. The capital of Kebbi State is Birnin Kebbi. The state was formed from part of the former Sokoto State in 1991. Kebbi State

Management and Outcome of Ectopic Pregnancy in Developing Countries 117

There is no pelvic condition that gives rise to more diagnostic errors than ectopic pregnancy. There are no specific signs and symptoms that are pathnognomonic but a condition of findings may be suggestive of an ectopic pregnancy. Therefore, there should be high index of suspicion all the time when symptoms of early pregnancy are followed by irregular vaginal bleeding, lower abdominal pain, tenderness, fainting attack, shoulder tip pain, signs and symptoms of massive blood loss and diarrhoea and vomiting. The signs and symptoms depend on the amount and pattern of bleeding. In slowly leaking ectopic pregnancy, the bleeding occurs slowly. A delayed period is followed by spotting to continuous bleeding and unilateral pelvic pain with an adnexal mass. Rupture is signalled by hypotension, marked tenderness and severe pain radiating to the shoulder. A ruptured ectopic pregnancy typically presents with abdominal pain and can be in hypovolaemic shock. Some patients may have a paradoxical bradycardia despite a large amount of blood loss. Syncope or collapse is also common. An unruptured ectopic pregnancy presents with abdominal pain

The clinical presentation of ectopic pregnancy depends on whether it has ruptured or not. Ruptured ectopic pregnancy presents usually from 6 to 12 weeks of pregnancy. Ruptured ectopic pregnancy can lead to massive haemorrhage and death. The presentation is variable. The combination of pain, vagina bleeding, and shock is the classical presentation of ruptured ectopic pregnancy. Some patients may have syncope attacks while others may just have a sudden excruciating abdominal pain. This may be associated with severe

Patients usually present with the ruptured variety with attendant peritoneal flooding and its clinical consequence unlike the situation in the developed countries where up to 75 % are unruptured (Kouam et al, 1996, Morcau et al, 1995). This is because they present early to a health facility. Ectopic pregnancy has a protean manifestation (Ilesanmi & Shobowale, 1992). The delayed diagnosis of ruptured ectopic pregnancy is an important cause of death in women (Fowler, 2006). A dilemma may arise when there is a properly and reliable diagnosis of ectopic pregnancy with a live foetus. Nevertheless, the magnitude of complications of ruptured ectopic gestation is enormous. Delaying the patient of an a reliable diagnosis of ectopic pregnancy to a time of rupture or imminent rupture in other to justify not tampering

**Abdominal pain**: Patients with ectopic pregnancy may have abdominal pain. This may be sharp or sudden tearing pain in the patient with ruptured ectopic pregnancy. It may start in any of the flanks or iliac fossa depending on the affected fallopian tube if the ectopic pregnancy is implanted in the fallopian tube. This gradually moves towards the umbilical region and becoming generalised. When it is an unruptured ectopic pregnancy, or slowly leaking, the abdominal pain is dull and continuous. Depending on the intensity of the pain, some patients may seek medical attention now. Ectopic pregnancy can lead to massive haemorrhage or death. It mimics virtually every condition that causes acute abdomen in women of the reproductive age group (Kigbu et al, 2006). Abdominal pain is the commonest symptom of ectopic pregnancy. The pain may be present even prior to rupture. When there is a rupture, the pain becomes sudden with each bleeding continuous and extensive intraperitoneal bleeding, the pain becomes generalized because of irritation of the diaphragm by the haemoperitoneum can cause shoulder tip pain. The abdominal pain is caused by distension of the gravid tube, by its efforts to contract and expel the ovum and by

**6. Clinical manifestations** 

cardiovascular compromise.

with or without vagina bleeding (Wagner & Promes, 2007).

with life may be considered unethical and illegal (Dickens at al, 2003).

irritation of the peritoneum by leakage of blood.

is bordered by Sokoto State, Niger State, Dosso region in the Republic of Niger and the Nation of Benin. Kebbi state is traditionally considered to belong to the Banza Bakwai States of Hausa land. Kebbi State has the slogan 'Land of Equity'. At the time of the study, General Hospital Aliero is located in Aliero, which is the capital of Aliero Local Government Area. The study was conducted during the author's National Youth Service Corps at Kebbi State, Nigeria. National Youth Service Corps is a one-year compulsory posting of Nigerian graduates outside the area of there abode within the country to serve their fatherland for one year.

#### **4.3 Study population**

All patients managed for ectopic pregnancy during the study period were included in this study. The patients were admitted through the casualty department as they all presented as emergencies. Once a patient is diagnosed with ectopic pregnancy, blood sample was sent to the laboratory for haemoglobin estimation and whole blood is grouped and cross-matched against the patients' serum as blood products are not available at the centre. The patient is counselled for surgery and informed consent obtained. At presentation, a brief history was obtained and physical examination carried out for pallor, jaundice, cyanosis and any form of bleeding and pain. History of any previous ectopic pregnancy and tubal and pelvic infections are obtained. Including any previous treatment for pelvic inflammatory disease. Urinalysis is done and venous intravenous access established.
