**1. Introduction**

Ectopic pregnancy is a common life-threatening emergency in the developing world and its frequency is still high. Ectopic pregnancy is the commonest cause of maternal morbidity and mortality in the first trimester of pregnancy (Airede & Ekele 2005, Grimes 1994, Okunlola et al 2006). Complications of early pregnancy are common clinical conditions that often require emergency care. The patient may or may not be aware that she is pregnant at the time of evaluation at the emergency department (Complications of pregnancy, 2007). Diagnosis is frequently missed and should be considered in any woman in the reproductive age group presenting with abdominal pain or vaginal bleeding especially when combined with an episode of collapse or syncope. Ectopic pregnancy is a complication of pregnancy in which the products of conception develop outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. By far the commonest site is the fallopian tube (Hanretty, 2004). It is a tragedy of reproduction and a form of reproductive failure in the index pregnancy of affected women. Such women have a 7-15% chance of recurrence and only 40-60% chance of conceiving after surgery (Aboyeji et al, 2002). Ectopic pregnancy remains a major gynaecological problem in contemporary gynaecological practice. Not only do women die from this disease but also of greater clinical importance is the indirect morbidity of poor fertility prognosis and adverse outcome in subsequent pregnancies (Musa et al, 2009). Ectopic pregnancy may not necessarily be managed by a gynaecologist especially in hospitals in rural settings where there are no specialist doctors or if present are limited in number. In such district hospitals, general practitioners with surgical and gynaecological skills manage them in low-income countries where most patients present late as emergencies.

Gynaecological emergencies form a large proportion of the workload of a gynaecologist. Gynaecological emergencies, diagnosis, and treatment have progressed in the light of evidence-based medicine combined with a good clinical assessment. This allows for appropriate management. Any primary health care doctor should be prepared to encounter and to handle gynaecological emergencies in patients even those in critical ill states. Ectopic pregnancy is a condition that occurs in all races, in all countries and in any socio-economic class of women during the reproductive years. It is a life threatening surgical gynaecological emergency in our environment (Nwagha et al 2007, Adesiyun et al 2001). Whilst there are many conditions that may lead to an emergency presentation, there are four emergencies, which account for the great majority. These are spontaneous abortion, pelvis sepsis

Management and Outcome of Ectopic Pregnancy in Developing Countries 111

pregnancy. Often the intrauterine pregnancy is discovered later than the ectopic pregnancy mainly because of the painful emergency nature of the ectopic pregnancies. The ectopic pregnancies are normally discovered and removed early in the pregnancy. Naturally occurring heterotopic pregnancy is rare (Odewale & Afolabi, 2008). Heterotopic pregnancy is on the increase because of increasing incidence of ectopic pregnancy. Heterotopic pregnancy is associated with a high maternal morbidity and foetal loss. This is probably due to delayed diagnosis resulting from confusing clinical features especially when diagnostic

The importance of ectopic pregnancy in our environment is peculiar because rather than join the global trend of early diagnosis and conservative approach in management, we are challenged by late presentations with rupture in more than 80% in most cases (Igbarese et al, 2005). We are also challenged by poor diagnostic tools, limited capacity to handle emergencies and consequent burden of increased maternal morbidity and mortality and

The ectopic pregnancy may be ruptured or unruptured at the time of diagnosis. The unruptured variety may be intact or the slowly leaking type. The rupture can occur early in the gestation and a delay in diagnosis, potentially limits conservative treatment option

Cervical ectopic pregnancy is the implantation of a pregnancy in the endocervical canal (Leeman & Wendland, 2000). Interstitial pregnancies represent a small fraction of ectopic gestations; they are especially feared due to their often devastating outcomes. The standard treatment for interstitial pregnancies have been laparatomy and cornual resection with hysterectomy required in many cases in order to control bleeding (Fisch et al, 1998). Interstitial implantation is rare but very dangerous because it ends in rupture of the uterine

Ipsilatetral ectopic pregnancy occurs rarely and may be difficult to diagnose in low resource settings where there are no diagnostic tools (Bode-Law et al, 2008). Bode-law et al reported an ipsilateral ectopic pregnancy ectopic pregnancy occurring in the stump of a previous

Heterotopic pregnancy is the simultaneous occurrence of an ectopic pregnancy with an intrauterine pregnancy. Assisted fertilization is a major risk factor for heterotopic pregnancy. Its presentation is similar to ectopic pregnancy with simultaneous evidence of an intrauterine pregnancy. Laparatomy is preformed to selectively remove the ectopic pregnancy. The intrauterine pregnancy survives to delivery in 66% of cases after treatment of the ectopic pregnancy (Wagner & Promes, 2007). Maternal deaths may occur and morbidity rates are high usually resulting from complications such as haemoperitoneum and peritonitis due to rupture of the extra uterine pregnancy site (Abedi et al, 2010). In 2008, Odewale and Afolabi in Nigeria published a report of heterotopic pregnancy, an ectopic pregnancy at the ampullary portion of the right fallopian tube and co-existent intrauterine pregnancy, which spontaneously aborted on the 10th postoperative day. Abasiattai et al reported a case of spontaneous heterotopic pregnancy with tubal rupture and delivery of a

The implantation of a pregnancy within the scar of a previous caesarean delivery is the rarest form of ectopic pregnancy. Ibekwe in 2004 reported a case of ruptured ectopic pregnancy presenting as uterine rupture at 23 weeks. Mutihir and Nyango in 2010 reported a 34-year-old nullipara managed for ruptured ectopic pregnancy from endometriosis. This work was carried out at a general hospital located in a rural setting in northern Nigeria.

facilities are not available.

(Fylstra, 2002).

muscle.

ectopic site.

live baby at term (Abasiattai et al, 2010).

consequent reproductive failure (Udigwe et al, 2010).

including bartholin's abscess, ectopic pregnancy, and accidents to an ovarian cyst. These common conditions should be at the forefront of the doctors' mind when asked to see a patient presenting as a gynaecological emergency whether she is referred by her general practitioner or presents herself to the casualty department. It is only when these diagnosis have been excluded should one consider alternative less common gynaecological emergencies.

Ectopic pregnancy presents a major health problem for women of childbearing age. If not treated vigorously and early enough, it may be fatal. It is of immerse concern to reproductive health and it is associated with significant maternal morbidity and mortality and is fatal to the embryo. The future reproductive potential of the woman after an ectopic pregnancy is compromised. Ectopic pregnancy accounts for 73 % of early pregnancy mortalities. Ectopic pregnancy is derived from the Greek word 'Ekpos' meaning out of place and it refers to implantation of a fertilised egg in a location outside of the uterine cavity. In many parts of the world, there has been a dramatic increase in the incidence over recent decades with studies showing at least a doubling of the rate (Rajkhowa et al, 2000). Ectopic pregnancy is one of the most critical and life threatening emergencies in gynaecological practice (Olarewaju, 1994). It is also known as extra uterine pregnancy.

Sites where an ectopic pregnancy can occur are the fallopian tube which is the commonest site, ovary, cervix, and the abdomen. When it occurs in the fallopian tube, it is known as tubal pregnancy. Implantation can occur at any point along the tube, although the ampulla is the commonest site. The isthmus is the next in frequency and the interstitial portion least common. While interstitial pregnancies represent a small fraction of ectopic gestations, they are especially feared due to their devastating outcomes (Fisch et al, 1998). Ectopic pregnancies that involves implantation in the cervix, the interstitial portion of the fallopian tube, the ovary, the abdomen or a scar from a caesarean section account for less than 10 % of all ectopic pregnancies. These unusual ectopic pregnancies are difficult to diagnose and are associated with high morbidity (Barnhart, 2009). The risk of reoccurrence of ectopic pregnancy is approximately 10% among women with 1 previous ectopic pregnancy and at least 25% among women with 2 or more previous ectopic pregnancies. Women in whom the affected fallopian tube has been removed are at increased risk for ectopic pregnancy in the remaining tube. Case series have suggested that approximately 60% of women who receive a diagnosis of an ectopic pregnancy are subsequently able to have an intrauterine pregnancy (Barnhart, 2009). Ipsilateral ectopic pregnancy occurs rarely and may be difficult to diagnose in low resource settings where there are no diagnostic tools. Few cases have been reported (Faleyimu, 2008). When the ectopic pregnancy is located in the abdomen, it is known as abdominal pregnancy. Patient with ectopic pregnancies are widely reported to be of low parity (Onwuhufua et al, 2001, Abdul, 1999, Baffoe & Nkyekyer, 1991). In a study in Benin city, Nigeria, majority of the patients with ectopic pregnancies were nulliparous and in their mid twenties (Gharoro & Igbafe, 2002). It remains a major challenge to the reproductive performance of women worldwide. The abnormally implanted gestation grows and draws its blood supply from the site of abnormal implantation. As the gestation enlarges, it creates the potential for organ rupture because only the uterine cavity is designed to expand and accommodate foetal development. Ectopic pregnancy can lead to massive haemorrhage, infertility, or death. Of all ectopic pregnancies, 97 % occur in the fallopian tube. Of all tubal pregnancies, 55 % are at the ampulla, 25 % at the isthmus, and 17 % at the fimbria (Complications of pregnancy, 2007). In rare cases of ectopic pregnancy, there may be two fertilized eggs one outside the uterus and the other inside. This is called heterotopic

including bartholin's abscess, ectopic pregnancy, and accidents to an ovarian cyst. These common conditions should be at the forefront of the doctors' mind when asked to see a patient presenting as a gynaecological emergency whether she is referred by her general practitioner or presents herself to the casualty department. It is only when these diagnosis have been excluded should one consider alternative less common gynaecological

Ectopic pregnancy presents a major health problem for women of childbearing age. If not treated vigorously and early enough, it may be fatal. It is of immerse concern to reproductive health and it is associated with significant maternal morbidity and mortality and is fatal to the embryo. The future reproductive potential of the woman after an ectopic pregnancy is compromised. Ectopic pregnancy accounts for 73 % of early pregnancy mortalities. Ectopic pregnancy is derived from the Greek word 'Ekpos' meaning out of place and it refers to implantation of a fertilised egg in a location outside of the uterine cavity. In many parts of the world, there has been a dramatic increase in the incidence over recent decades with studies showing at least a doubling of the rate (Rajkhowa et al, 2000). Ectopic pregnancy is one of the most critical and life threatening emergencies in gynaecological

Sites where an ectopic pregnancy can occur are the fallopian tube which is the commonest site, ovary, cervix, and the abdomen. When it occurs in the fallopian tube, it is known as tubal pregnancy. Implantation can occur at any point along the tube, although the ampulla is the commonest site. The isthmus is the next in frequency and the interstitial portion least common. While interstitial pregnancies represent a small fraction of ectopic gestations, they are especially feared due to their devastating outcomes (Fisch et al, 1998). Ectopic pregnancies that involves implantation in the cervix, the interstitial portion of the fallopian tube, the ovary, the abdomen or a scar from a caesarean section account for less than 10 % of all ectopic pregnancies. These unusual ectopic pregnancies are difficult to diagnose and are associated with high morbidity (Barnhart, 2009). The risk of reoccurrence of ectopic pregnancy is approximately 10% among women with 1 previous ectopic pregnancy and at least 25% among women with 2 or more previous ectopic pregnancies. Women in whom the affected fallopian tube has been removed are at increased risk for ectopic pregnancy in the remaining tube. Case series have suggested that approximately 60% of women who receive a diagnosis of an ectopic pregnancy are subsequently able to have an intrauterine pregnancy (Barnhart, 2009). Ipsilateral ectopic pregnancy occurs rarely and may be difficult to diagnose in low resource settings where there are no diagnostic tools. Few cases have been reported (Faleyimu, 2008). When the ectopic pregnancy is located in the abdomen, it is known as abdominal pregnancy. Patient with ectopic pregnancies are widely reported to be of low parity (Onwuhufua et al, 2001, Abdul, 1999, Baffoe & Nkyekyer, 1991). In a study in Benin city, Nigeria, majority of the patients with ectopic pregnancies were nulliparous and in their mid twenties (Gharoro & Igbafe, 2002). It remains a major challenge to the reproductive performance of women worldwide. The abnormally implanted gestation grows and draws its blood supply from the site of abnormal implantation. As the gestation enlarges, it creates the potential for organ rupture because only the uterine cavity is designed to expand and accommodate foetal development. Ectopic pregnancy can lead to massive haemorrhage, infertility, or death. Of all ectopic pregnancies, 97 % occur in the fallopian tube. Of all tubal pregnancies, 55 % are at the ampulla, 25 % at the isthmus, and 17 % at the fimbria (Complications of pregnancy, 2007). In rare cases of ectopic pregnancy, there may be two fertilized eggs one outside the uterus and the other inside. This is called heterotopic

practice (Olarewaju, 1994). It is also known as extra uterine pregnancy.

emergencies.

pregnancy. Often the intrauterine pregnancy is discovered later than the ectopic pregnancy mainly because of the painful emergency nature of the ectopic pregnancies. The ectopic pregnancies are normally discovered and removed early in the pregnancy. Naturally occurring heterotopic pregnancy is rare (Odewale & Afolabi, 2008). Heterotopic pregnancy is on the increase because of increasing incidence of ectopic pregnancy. Heterotopic pregnancy is associated with a high maternal morbidity and foetal loss. This is probably due to delayed diagnosis resulting from confusing clinical features especially when diagnostic facilities are not available.

The importance of ectopic pregnancy in our environment is peculiar because rather than join the global trend of early diagnosis and conservative approach in management, we are challenged by late presentations with rupture in more than 80% in most cases (Igbarese et al, 2005). We are also challenged by poor diagnostic tools, limited capacity to handle emergencies and consequent burden of increased maternal morbidity and mortality and consequent reproductive failure (Udigwe et al, 2010).

The ectopic pregnancy may be ruptured or unruptured at the time of diagnosis. The unruptured variety may be intact or the slowly leaking type. The rupture can occur early in the gestation and a delay in diagnosis, potentially limits conservative treatment option (Fylstra, 2002).

Cervical ectopic pregnancy is the implantation of a pregnancy in the endocervical canal (Leeman & Wendland, 2000). Interstitial pregnancies represent a small fraction of ectopic gestations; they are especially feared due to their often devastating outcomes. The standard treatment for interstitial pregnancies have been laparatomy and cornual resection with hysterectomy required in many cases in order to control bleeding (Fisch et al, 1998). Interstitial implantation is rare but very dangerous because it ends in rupture of the uterine muscle.

Ipsilatetral ectopic pregnancy occurs rarely and may be difficult to diagnose in low resource settings where there are no diagnostic tools (Bode-Law et al, 2008). Bode-law et al reported an ipsilateral ectopic pregnancy ectopic pregnancy occurring in the stump of a previous ectopic site.

Heterotopic pregnancy is the simultaneous occurrence of an ectopic pregnancy with an intrauterine pregnancy. Assisted fertilization is a major risk factor for heterotopic pregnancy. Its presentation is similar to ectopic pregnancy with simultaneous evidence of an intrauterine pregnancy. Laparatomy is preformed to selectively remove the ectopic pregnancy. The intrauterine pregnancy survives to delivery in 66% of cases after treatment of the ectopic pregnancy (Wagner & Promes, 2007). Maternal deaths may occur and morbidity rates are high usually resulting from complications such as haemoperitoneum and peritonitis due to rupture of the extra uterine pregnancy site (Abedi et al, 2010). In 2008, Odewale and Afolabi in Nigeria published a report of heterotopic pregnancy, an ectopic pregnancy at the ampullary portion of the right fallopian tube and co-existent intrauterine pregnancy, which spontaneously aborted on the 10th postoperative day. Abasiattai et al reported a case of spontaneous heterotopic pregnancy with tubal rupture and delivery of a live baby at term (Abasiattai et al, 2010).

The implantation of a pregnancy within the scar of a previous caesarean delivery is the rarest form of ectopic pregnancy. Ibekwe in 2004 reported a case of ruptured ectopic pregnancy presenting as uterine rupture at 23 weeks. Mutihir and Nyango in 2010 reported a 34-year-old nullipara managed for ruptured ectopic pregnancy from endometriosis. This work was carried out at a general hospital located in a rural setting in northern Nigeria.

Management and Outcome of Ectopic Pregnancy in Developing Countries 113

and North America, the incidence of ectopic pregnancy is estimated at 2 % of livebirths (Moore et al, 2000). A study in Norway found out that the incidence of ectopic pregnancy in that country increased from 1.4% to 2.2% of livebirths between 1976 and 1993 (Bergsjo et al, 1990). In England and Wales, the incidence of ectopic pregnancy increased by five times between 1966 and 1996 from 0.3% to 1.6% of livebirths (Rajkhowa et al, 2000). The incidence also increased from 1.9 % to 2.3 % of livebirths between 1981 and 1991 in the United States (Berg, 1999). In another study conducted in the United States, the annual incidence of ectopic pregnancy increased from 0.37 % of pregnancies in 1948 to 1.97 in 1992 (Lipscomb et al, 2000). At the Royal Commission Medical Centre, Yanbe Industrial city in the Kingdom of Saudi Arabia the incidence between 2005 to 2008 was found to be 1 in 171 deliveries that is 0.58 % (Aziz et al, 2011). In India, the incidence of ectopic pregnancy is 1 in 161 (0.6%)

In recent decades majority of methodological limitations in various African published literature make it impossible to draw formal conclusions concerning the incidence of ectopic pregnancy in Africa (Goyaux et al, 2003). In African developing countries, a majority of hospital-based studies have reported ectopic pregnancy case fatality rates of around 1-3 %, ten times higher than that reported in industrialised countries (Goyaux et al, 2003). Late presentation to a health facility, late diagnosis leading in almost all cases to majority of complications and emergency surgical treatment are the key factors accounting for such high fatality rates in women suffering from ectopic pregnancy in Africa. The incidence of ectopic pregnancy was found to be 0.79% in Yaoundé, Cameroun (Leke et al, 2004). This value may be considered a minimum due to probably underestimation. Nevertheless, this rate is lower than currently observed in industrialised countries. Late diagnosis, low percentage of conservative treatment and subsequent maternal deaths are important findings that should encourage African gynaecologists to promote ectopic pregnancy prevention programs and to improve the care given to women with ectopic prevention. The case fatality rate of ectopic pregnancy in Ghana was found to be 27.9/ 1000 (Baffoe & Nkyekyer, 1999). A study conducted in 1992 and 1993 at the Umtata General Hospital in Transkei, South Africa reported an ectopic incidence of 1.1% (Amoko et al, 1995). Between 1993 to 1995, the hospital based ectopic pregnancy incidence at Nosy Be Hospital, Madagascar was 2.9 % (Ratinahirana et al, 1997). It was 4 % at the gynaecology and obstetrics clinic of the national teaching hospital in Cotonou republic of Benin (Perrin et al, 1997). In Gabon University Medical Centre, Libreville it doubled between 1977 and 1989 from 1 % to 2.3 % (Picaud et al, 1990). At Yaoundé University Teaching Hospital, Cameroon, the incidence of ectopic pregnancy increased from 0.9% to 1.7 % between 1984 and 1992 (Kouam et al, 1996). The incidence of ectopic pregnancy increased in two maternities in Conakry at the Donka and Ignace Dean University Hospital, Guinea from 0.41 % to 1.5 %

In Nigeria, an incidence of 1:287 deliveries or 0.35 %( Egwuatu & Ozumba, 1987) and 1:43 deliveries or 2.31% (Oronsange & Odiase, 1984) were reported from two institutions. These incidences may probably be an underestimation as many cases are managed in private hospitals and are not reported. A study by Oloyede et al in Sagamu, Nigeria over a 12-year review reported an incidence by 3.1% or 1 in 32 of all births (Oloyede et al, 2002). Ectopic pregnancy is an important cause of maternal death in Nigeria and in other developing countries. In Lagos, Nigeria, ectopic pregnancy was found to be responsible for 8.6 % of maternal deaths and had a case fatality rate of 3.7%. An incidence of 23.1 / 1000 deliveries was reported and ectopic pregnancy was found to be responsible for 48.5% of

deliveries (Arup et al, 2007).

from 1995-1999 (Thoneau et al, 2002).

## **2. Incidence of ectopic pregnancy**

There have been different hospital based studies in Nigeria and other developing countries on ectopic pregnancy. The incidence of ectopic pregnancy varies from country to country and within the same country, it varies from one community to another. In Nigeria, there are several private hospitals owned by individuals where patients can seek for medical treatment. Most Nigerian studies on ectopic pregnancies were carried out in the government owned hospitals; hence, this may not give a true picture of the incidence, as those in the private hospitals are not included. Also, some women may have died at home, as many people seek medical care late in Nigeria.

Some of these ectopic pregnancies may be terminated spontaneously before they give rise to notable clinical symptoms. There is currently an increased incidence of ectopic pregnancy globally. This incidence may be related to a higher incidence of tubal disease notably salpingitis. Other reasons for the rising incidence of ectopic pregnancy are adequate treatment for pelvic inflammatory disease, which in the past rendered women sterile. The use of intrauterine contraceptive device, increase in surgical procedures for tubal disease and improved diagnostic technique. The increase in the incidence of ectopic pregnancy is also associated with advances in assisted reproductive technology, tubal surgeries, and sterilizations and earlier diagnosis with more sensitive methods of cases that otherwise could have resolved without causing any symptoms (Arup et al, 2007). There is evidence that the overall incidence of ectopic pregnancy has been rising in many countries depending on the prevalence of risk factors and the methods of diagnosis available while the case fatality have been decreasing (Jurkovic, 2007, Morcau et al, 1995, Thonneau et al, 2002). Ectopic pregnancy is a global problem and has shown a rising incidence during the last three decades the world over (Arup et al, 2007). The incidence of recurrent ectopic pregnancy is approximately 15 % and this rises to 30 % following two previous ectopic pregnancies (Tulandi, 1988). A figure of 1 in 4000 to 7000 pregnancies is currently quoted for heterotopic gestation (Jurkovic, 2007). The incidence of a simple ectopic gestation varies from 1 in 300 pregnancies in Europe to as high as 1 in 20 to 50 pregnancies in Africa and West Indies (Piam & Otubu, 2006). Only a few reports of heterotopic pregnancy are reported (Aliyu et al, 2008, DeVoe & Pratt, 1998). The once extremely rare condition of heterotopic pregnancy is now more common with the advent of in vitro fertilization and embryo transfer. It is 1-3 % of all pregnancies and 10-15% of all ectopic pregnancies following in vitro fertilization and embryo transfer (Aliyu et al, 2008).

Ectopic pregnancy occurs approximately in 1.5 to 2.0 of pregnancies and is potentially life threatening (Barnhart, 2009). Despite the continued increase in the incidence of ectopic pregnancy, the rate of death from ectopic pregnancy has declined in developed countries primarily because of earlier diagnosis before tubal rupture. The incidence of ectopic pregnancy depends on the population studied and ranges from 1 % in rural general practice to 13 % in urban emergency department (Kaplan et al, 1996, Erondu et al, 2010).

The incidence of ectopic pregnancy in western countries has generally shown a rising trend with a decreased mortality mainly because of availability of modern diagnostic methods, which makes early diagnosis before tubal rupture, occurs in over 70 % of cases (Rajkhowa et al, 2000). The incidence of ectopic pregnancy was found to be 2.0 % in France (Coste et al, 1994), 2.8 % in Finland (Markinen, 1993) and 2.2 % in the United States (CDC, 1992). Another study over an 18-year period in America reported a rising incidence from 0.45 % to 1.68 % (Ory, 1992). It was reported to 1.24% in England (Rajkhowa et al, 2000). In most of Europe

There have been different hospital based studies in Nigeria and other developing countries on ectopic pregnancy. The incidence of ectopic pregnancy varies from country to country and within the same country, it varies from one community to another. In Nigeria, there are several private hospitals owned by individuals where patients can seek for medical treatment. Most Nigerian studies on ectopic pregnancies were carried out in the government owned hospitals; hence, this may not give a true picture of the incidence, as those in the private hospitals are not included. Also, some women may have died at home, as many

Some of these ectopic pregnancies may be terminated spontaneously before they give rise to notable clinical symptoms. There is currently an increased incidence of ectopic pregnancy globally. This incidence may be related to a higher incidence of tubal disease notably salpingitis. Other reasons for the rising incidence of ectopic pregnancy are adequate treatment for pelvic inflammatory disease, which in the past rendered women sterile. The use of intrauterine contraceptive device, increase in surgical procedures for tubal disease and improved diagnostic technique. The increase in the incidence of ectopic pregnancy is also associated with advances in assisted reproductive technology, tubal surgeries, and sterilizations and earlier diagnosis with more sensitive methods of cases that otherwise could have resolved without causing any symptoms (Arup et al, 2007). There is evidence that the overall incidence of ectopic pregnancy has been rising in many countries depending on the prevalence of risk factors and the methods of diagnosis available while the case fatality have been decreasing (Jurkovic, 2007, Morcau et al, 1995, Thonneau et al, 2002). Ectopic pregnancy is a global problem and has shown a rising incidence during the last three decades the world over (Arup et al, 2007). The incidence of recurrent ectopic pregnancy is approximately 15 % and this rises to 30 % following two previous ectopic pregnancies (Tulandi, 1988). A figure of 1 in 4000 to 7000 pregnancies is currently quoted for heterotopic gestation (Jurkovic, 2007). The incidence of a simple ectopic gestation varies from 1 in 300 pregnancies in Europe to as high as 1 in 20 to 50 pregnancies in Africa and West Indies (Piam & Otubu, 2006). Only a few reports of heterotopic pregnancy are reported (Aliyu et al, 2008, DeVoe & Pratt, 1998). The once extremely rare condition of heterotopic pregnancy is now more common with the advent of in vitro fertilization and embryo transfer. It is 1-3 % of all pregnancies and 10-15% of all ectopic pregnancies following in

Ectopic pregnancy occurs approximately in 1.5 to 2.0 of pregnancies and is potentially life threatening (Barnhart, 2009). Despite the continued increase in the incidence of ectopic pregnancy, the rate of death from ectopic pregnancy has declined in developed countries primarily because of earlier diagnosis before tubal rupture. The incidence of ectopic pregnancy depends on the population studied and ranges from 1 % in rural general practice

The incidence of ectopic pregnancy in western countries has generally shown a rising trend with a decreased mortality mainly because of availability of modern diagnostic methods, which makes early diagnosis before tubal rupture, occurs in over 70 % of cases (Rajkhowa et al, 2000). The incidence of ectopic pregnancy was found to be 2.0 % in France (Coste et al, 1994), 2.8 % in Finland (Markinen, 1993) and 2.2 % in the United States (CDC, 1992). Another study over an 18-year period in America reported a rising incidence from 0.45 % to 1.68 % (Ory, 1992). It was reported to 1.24% in England (Rajkhowa et al, 2000). In most of Europe

to 13 % in urban emergency department (Kaplan et al, 1996, Erondu et al, 2010).

**2. Incidence of ectopic pregnancy** 

people seek medical care late in Nigeria.

vitro fertilization and embryo transfer (Aliyu et al, 2008).

and North America, the incidence of ectopic pregnancy is estimated at 2 % of livebirths (Moore et al, 2000). A study in Norway found out that the incidence of ectopic pregnancy in that country increased from 1.4% to 2.2% of livebirths between 1976 and 1993 (Bergsjo et al, 1990). In England and Wales, the incidence of ectopic pregnancy increased by five times between 1966 and 1996 from 0.3% to 1.6% of livebirths (Rajkhowa et al, 2000). The incidence also increased from 1.9 % to 2.3 % of livebirths between 1981 and 1991 in the United States (Berg, 1999). In another study conducted in the United States, the annual incidence of ectopic pregnancy increased from 0.37 % of pregnancies in 1948 to 1.97 in 1992 (Lipscomb et al, 2000). At the Royal Commission Medical Centre, Yanbe Industrial city in the Kingdom of Saudi Arabia the incidence between 2005 to 2008 was found to be 1 in 171 deliveries that is 0.58 % (Aziz et al, 2011). In India, the incidence of ectopic pregnancy is 1 in 161 (0.6%) deliveries (Arup et al, 2007).

In recent decades majority of methodological limitations in various African published literature make it impossible to draw formal conclusions concerning the incidence of ectopic pregnancy in Africa (Goyaux et al, 2003). In African developing countries, a majority of hospital-based studies have reported ectopic pregnancy case fatality rates of around 1-3 %, ten times higher than that reported in industrialised countries (Goyaux et al, 2003). Late presentation to a health facility, late diagnosis leading in almost all cases to majority of complications and emergency surgical treatment are the key factors accounting for such high fatality rates in women suffering from ectopic pregnancy in Africa. The incidence of ectopic pregnancy was found to be 0.79% in Yaoundé, Cameroun (Leke et al, 2004). This value may be considered a minimum due to probably underestimation. Nevertheless, this rate is lower than currently observed in industrialised countries. Late diagnosis, low percentage of conservative treatment and subsequent maternal deaths are important findings that should encourage African gynaecologists to promote ectopic pregnancy prevention programs and to improve the care given to women with ectopic prevention. The case fatality rate of ectopic pregnancy in Ghana was found to be 27.9/ 1000 (Baffoe & Nkyekyer, 1999). A study conducted in 1992 and 1993 at the Umtata General Hospital in Transkei, South Africa reported an ectopic incidence of 1.1% (Amoko et al, 1995). Between 1993 to 1995, the hospital based ectopic pregnancy incidence at Nosy Be Hospital, Madagascar was 2.9 % (Ratinahirana et al, 1997). It was 4 % at the gynaecology and obstetrics clinic of the national teaching hospital in Cotonou republic of Benin (Perrin et al, 1997). In Gabon University Medical Centre, Libreville it doubled between 1977 and 1989 from 1 % to 2.3 % (Picaud et al, 1990). At Yaoundé University Teaching Hospital, Cameroon, the incidence of ectopic pregnancy increased from 0.9% to 1.7 % between 1984 and 1992 (Kouam et al, 1996). The incidence of ectopic pregnancy increased in two maternities in Conakry at the Donka and Ignace Dean University Hospital, Guinea from 0.41 % to 1.5 % from 1995-1999 (Thoneau et al, 2002).

In Nigeria, an incidence of 1:287 deliveries or 0.35 %( Egwuatu & Ozumba, 1987) and 1:43 deliveries or 2.31% (Oronsange & Odiase, 1984) were reported from two institutions. These incidences may probably be an underestimation as many cases are managed in private hospitals and are not reported. A study by Oloyede et al in Sagamu, Nigeria over a 12-year review reported an incidence by 3.1% or 1 in 32 of all births (Oloyede et al, 2002). Ectopic pregnancy is an important cause of maternal death in Nigeria and in other developing countries. In Lagos, Nigeria, ectopic pregnancy was found to be responsible for 8.6 % of maternal deaths and had a case fatality rate of 3.7%. An incidence of 23.1 / 1000 deliveries was reported and ectopic pregnancy was found to be responsible for 48.5% of

Management and Outcome of Ectopic Pregnancy in Developing Countries 115

the ectocervix making it fully exposed to pathogens. Adolescents also lack immunity to certain pathogens. Early sexual debut may also lead to adolescent pregnancy which is often unwanted and which usually end up with induced abortion in unsafe places and in the hands of quacks. Late age of sexual debut on the other hand, significantly reduces the risk of ectopic pregnancy (Anorlu et al, 2005). In a study in France by Coste J et al, found that *Chlamydia trachomatis* seropositively appeared to be an important risk factor in the development of ectopic pregnancy. Pelvic inflammatory disease is a risk factor for ectopic pregnancy especially salpingitis. A case control study conducted showed that the risk of ectopic pregnancy was showed that the risk of ectopic pregnancy was increased four fold

**Assisted conception**: Ectopic pregnancy is one of the recognised complications of in-vitro fertilization and embryo transfer (Okohue et al, 2010). Ectopic pregnancy can present following an in vitro fertilization procedures. A high index of suspicion is necessary even in

**Intrauterine contraceptive device (IUCD):** The use of intrauterine contraceptive device increases the risk of developing an ectopic pregnancy almost four fold (Anorlu et al, 2005). **Previous history of ectopic pregnancy**: Previous history of an ectopic pregnancy increases the risk for another ectopic pregnancy. The risk of recurrent ectopic pregnancy is 12-18 % (Jurkovic, 2007). Every woman with a previous ectopic pregnancy would be at a high risk of recurrence of another ectopic pregnancy. This should be excluded when a patient with a

**Tubal surgery**: Scarring following tubal surgery causes anatomical abnormalities of the fallopian tube, which presents abnormal embryo transport increase the risk of ectopic

**Previous caesarean delivery**: There has not been any evidence of increased risk of ectopic pregnancy related to previous caesarean section (Kendrick et al, 1996). However, there are reports of ectopic pregnancies implanting on previous caesarean section scars. Endometrial and myometrial disruptions or scaring can predispose to abdominal pregnancy

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

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

patients are being managed by general practitioners posted to the hospital.

with induction of ovulation (Fernandez et al, 1991).

previous ectopic pregnancy presents in early pregnancy.

pregnancy (Doyle et al, 1991).

implantation (Fylstra, 2002).

**4. Research methodology** 

**4.1 Study design** 

**4.2 Study area** 

cases with previous bilateral salpingectomies or easy embryo transfer.

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).
