EP are amongst the major cause of pregnancy associated morbidity and mortality (6) despite their reducing incidence. Moreover, this adversity seems to be higher amongst black population due to a restrained access to good quality medical care for early diagnosis and treatment (10). The present study set out to determine the prevalence, incidence and risk factors of surgically managed ectopic pregnancies at a tertiary referral hospital in Nairobi, Kenya. It forms the index publication of our research study that outlines surgically managed EP in our population.
In the study period, a total of 347 ectopic pregnancies were surgically managed at our facility. This represented an ectopic pregnancy rate (surgically managed) of 1.78 per 100 live births that occurred between 2011 and 2020. This rate is an underestimation since the present study only considered surgically managed ectopic pregnancies and not the ones that were conservatively or medically managed. This was by design so as to only consider the “true” EP since some of the conservatively and medically managed ones may be false positives. The above rate is not in keeping with previous studies which describes lower incidences of 0.64–1.24 ectopic pregnancies per 100 live births(1, 2, 9). This can be attributed to the fact that most expectant mothers come for check-up later in the pregnancy and hence most of these ectopic pregnancies would be surgically managed hence picking out a higher prevalence. The other factor that may impact on this prevalence can be attributed to the fact that not all patients who come for care at the hospital eventually deliver at the hospital which may reduce the denominator in the calculation depicting a higher prevalence.
There was also a large increase in the number of surgically managed ectopic pregnancies throughout the study period. In the 1st 5 years of the study period, the unit only surgically managed 26.6 EP per year as compared to a rate of 42.8 EP per year for the last 5 years of the study period. This represents at 60.9% increase in surgically managed EP in the period. This trend is in keeping with the general trend of surgical management of EP with an increase in the number of surgically managed patient being shown to increase over time (11). This is attributed to increased professional competency in laparoscopic management of ectopic pregnancies(11) which has also been the trend in out unit.
The median age of patients with EP in the present study was 31 years with only 28.2% of patients being over 35 years of age. This trend is not in keeping with previous studies (3). Generally a larger proportion of pregnancies are ectopic as age progresses which is attributed to the accumulation of risk factors towards ectopic pregnancy as age progresses (3, 9). The observed trend could be due to the catchment population of the study which is an urban centre whose population is largely composed of women who are mostly below 35 years of age and also the fact that most pregnancies occur in the region at an age younger than 30 years (12).
The present study also looked at the risk factor profile of patients presenting with ectopic pregnancies. Most of the patients (70.5%) had no identifiable risk factor. This in keeping with literature which outlines that most patients with EP don’t actually have a discernible risk factor (8). This is attributed to the fact that EP occur in index pregnancies and most of these women wont have a preceding risk factor (8, 9).
The commonest identifiable risk factor was history of a previous tubal EP with 7.8% of patients identified as having this. Previous tubal ectopic has been described as the commonest risk factor for ectopic pregnancy with a risk of 3–8 times the normal being described in these patients (13, 14). This risk is attributable to the underlying tubal condition which led to an EP in the same patient being present as well as the fact that the patient would have had a pelvic surgery due to previous EP(13).
The second commonest risk factor was history of pelvic inflammatory disease or a positive Chlamydia trachomatis (CT) test. This accounted for 7.5% of patient in the present study. This is in keeping with previous studies which show that patient with these conditions may have up to a 3 fold rise in the risk of EP(7, 14, 15). The identifiable explanation is that these conditions alter tubal function, cause tubal obstruction and cause pelvic adhesive disease all which contribute to the occurrence of an ectopic pregnancy(15). CT in particular has been associated with an increased production of PROKR2, a protein that increases the likelihood of tubal EP(16). The same factors may impact on the high rate of these predisposing factors in this population.
Current intrauterine device(IUD) use was found in 6.6% of patients with surgically managed EP. Failure of an IUD has been shown to have an added risk of EP (14). This rate is higher in Levonorgesterol (LNG) IUD compared with Copper IUD users (14). The present study did not differentiate between the 2 types however we can posit that most of the users had copper IUD due to the low uptake rates of the LNG IUD (12).
Patients with infertility and recurrent miscarriages(EPL) accounted for 3.9% of the present study. This is in keeping with previous studies where higher rates of EP have been seen in these patients(7, 14). This has been attributed to the higher rates of tubal defects seen in these patients that may contribute to their infertility or recurrent EPL and consequently rates of EP(7). A smaller proportion of patients (2.4%) had multiple factors which can be connected to all the risk factors discussed above. Only 0.9% of the patients had emergency contraceptive(EC) use as a risk factor. Progestin only contraceptives have been associated with a significant increase in EP (17). This associated has been shown to be impacting to an incidence as high as 15.2 EP in woman years (17). Lastly, 0.3% of the patients were concurrent or previous smokers. Cigarette smoking, pre-conceptionally, has been associated with a 2–3 fold increase in EP (18) .This has been attributed to the impaired tubal motility or impaired immunity predisposing to pelvic infection amongst cigarette smokers (7, 18).
Study limitations:
Being a retrospective study, some of the earlier patients’ files had to be excluded due to missing data. This was for 24 patients which represented less than 0.7% of the data collected. This represented a low proportion that is within acceptable limits.