IBEROAMERICAN JOURNAL OF MEDICINE 04 (2021) 293-299

Journal homepage: www.iberoamjmed.com

Original article

Risk Factors for Ectopic Pregnancy: A Case-Control Study in

Tertiary Care Hospitals of Jammu and Kashmir
Neha Mahajan a, Rohit Raina b, Pooja Sharma a,*

a
Department of Obstetrics and Gynaecology, SMGS Hospital, Jammu, India
b
Department of Obstetrics and Gynaecology, Indraprastha Apollo Hospital, New Delhi, India

ARTICLE INFO ABSTRACT

Article history: Introduction: An ectopic pregnancy occurs when a fertilized egg attaches somewhere outside the
Received 20 May 2021 uterus.There are many risk factors for ectopic pregnancy. This study will help us to prepare a list
Received in revised form of risk factors associated with ectopic pregnancy in our state. In addition, it will help implement
26 June 2021 a risk-reduction counseling program before conception, which will help us screen high-risk
Accepted 18 July 2021 patients and reduce and manage ectopic pregnancy.
Materials and methods: The present study was conducted in our department for two years, from
Keywords: August 2018 to July 2019. Cases included all patients with ectopic pregnancy admitted in labor.
Ectopic pregnancy A total of 192 cases were taken, out of which 8 cases refused to participate in the study, so 184
Pelvic inflamatory disease patients were included in the study.
Risk factors Results: Patients with previous ectopic pregnancy have 6.34 times increased risk of a repeat
ectopic pregnancy (odds ratio 6.34, confidence interval 1.40-28.77), and this association was
highly significant (p = 0.006). The risk of ectopic pregnancy is 3.02 times increased (odds ratio
3.10; 95% confidence interval, 1.16-7.84) if the patient once had the pelvic inflammatory disease
and is statistically significant (p = 0.01). The study also revealed that 17 (10.3%) patients with
ectopic pregnancy had a history of tubal ligation or some other tubal surgery done in the past
compared to 3 (2.2%) patients among controls, and this finding is statistically highly significant
(p = 0.001).
Conclusions: In the present study, we found that the main risk factors for incidence of ectopic
pregnancy are prior ectopic pregnancy, prior tubal ligation, and prior pelvic/abdominal surgery.
In addition, ectopic pregnancy was positively related to the previous history of ectopic
pregnancy, abortion, cesarean section, and infertility. These findings can be helpful for early
diagnosis of ectopic pregnancy to pursue proper medical therapy instead of unnecessarily
surgical treatment.
© 2021 The Authors. Published by Iberoamerican Journal of Medicine. This is an open access article under the
CC BY license (http://creativecommons. org/licenses/by/4.0/).

* Corresponding author.
E-mail address: [email protected]
ISSN: 2695-5075 / © 2021 The Authors. Published by Iberoamerican Journal of Medicine. This is an open access article under the CC BY license
(http://creativecommons. org/licenses/by/4.0/).
https://doi.org/10.53986/ibjm.2021.0048
294 IBEROAMERICAN JOURNAL OF MEDICINE 04 (2021) 293-299

Factores de riesgo para el embarazo ectópico: un estudio de casos y controles en

hospitales de atención terciaria de Jammu y Cachemira

INFO. ARTÍCULO RESUMEN

Historia del artículo: Introducción: Un embarazo ectópico ocurre cuando un óvulo fertilizado se adhiere en algún
Recibido 20 Mayo 2021 lugar fuera del útero. Existen muchos factores de riesgo para el embarazo ectópico. Este estudio
Recibido en forma revisada nos ayudará a preparar una lista de factores de riesgo asociados con el embarazo ectópico en
26 Junio 2021 nuestro estado. Además, ayudará a implementar un programa de asesoramiento para la
Aceptado 18 Julio 2021 reducción de riesgos antes de la concepción, que nos ayudará a evaluar a las pacientes de alto
riesgo y reducir y controlar el embarazo ectópico.
Palabras clave: Materiales y métodos: El presente estudio se realizó en nuestro servicio durante dos años, de
Embarazo ectópico agosto de 2018 a julio de 2019. Los casos incluyeron a todas las pacientes con embarazo ectópico
Enfermedad inflamatoria ingresadas en trabajo de parto. Se tomaron un total de 192 casos, de los cuales 8 casos se
pélvica negaron a participar en el estudio, por lo que se incluyeron 184 pacientes en el estudio.
Facvtores de riesgo Resultados: Las pacientes con un embarazo ectópico previo tienen un riesgo 6,34 veces mayor de
un embarazo ectópico repetido (razón de probabilidades 6,34, intervalo de confianza 1,40-
28,77), y esta asociación fue muy significativa (p = 0,006). El riesgo de embarazo ectópico
aumenta 3,02 veces (razón de posibilidades 3,10; intervalo de confianza del 95%, 1,16-7,84) si la
paciente tuvo una vez la enfermedad inflamatoria pélvica y es estadísticamente significativa (p =
0,01). El estudio también reveló que 17 (10,3%) pacientes con embarazo ectópico tenían
antecedentes de ligadura de trompas o alguna otra cirugía de trompas realizada en el pasado en
comparación con 3 (2,2%) pacientes entre los controles, y este hallazgo es estadísticamente muy
significativo (p = 0,001).
Conclusiones: En el presente estudio, encontramos que los principales factores de riesgo de
incidencia de embarazo ectópico son embarazo ectópico previo, ligadura de trompas previa y
cirugía pélvica/abdominal previa. Además, el embarazo ectópico se relacionó positivamente con
la historia previa de embarazo ectópico, aborto, cesárea e infertilidad. Estos hallazgos pueden
ser útiles para el diagnóstico temprano de embarazo ectópico para buscar una terapia médica
adecuada en lugar de un tratamiento quirúrgico innecesario.
© 2021 Los Autores. Publicado por Iberoamerican Journal of Medicine. Éste es un artículo en acceso abierto
bajo licencia CC BY (http://creativecommons. org/licenses/by/4.0/).
HOW TO CITE THIS ARTICLE: Mahajan N, Raina R, Sharma P. Risk Factors for Ectopic Pregnancy: A Case-Control Study in
Tertiary Care Hospitals of Jammu and Kashmir. Iberoam J Med. 2021;3(4):293-299. doi: 10.53986/ibjm.2021.0048.

multiple sexual partners, miscarriage, induced conception

1. INTRODUCTION period, current intrauterine contraceptive device (IUCD)
use, prior caesarian section (CS), and cigarette smoking at
Becoming a mother is a wish or a dream that every woman the time of conception are all factors to consider [3]. Other
in the world possesses universally and implicitly. But this factors are prior tubal surgery, tubal sterilization, and
dream of motherhood is not always pleasant for all, as history of abortions [4], maternal age, and parity, pelvic
some may experience few nightmares through their and abdominal surgeries [5]. Despite these facts and
journey. Ectopic pregnancy (EP) is one of them, and it can knowledge, there is a lot to be learned about these factors.
be fatal. When a fertilized ovum is implanted outside the For example, these factors' exact role and strength have not
usual uterine cavity, it is called an ectopic pregnancy. [1]. been definitively determined in our area. Moreover,
Worldwide the ectopic pregnancy accounts for 1-2% of all extrapolation of results from studies conducted before but
pregnancies, and it is a thoughtful cause of maternal at other regions is difficult, owing to the variation in
morbidity and mortality [1, 2]. Ectopic pregnancy risk incidence and risk factors associated with EP among
factors are closely linked to conditions that alter the normal different populations studied. This study will help us to
function of fallopian tubal transport. It is thought that the prepare a list of risk factors associated with ectopic
more damage to the fallopian tube, the greater the chance pregnancy in our state. It will help implement a risk-
of an ectopic pregnancy occurring. There are many risk reduction counselling program before conception, which
factors for ectopic pregnancy, including Prior ectopic will help us screen high-risk patients and further reduce
pregnancy, h/o infections in the reproductive system, and manage EP.
 IBEROAMERICAN JOURNAL OF MEDICINE 04 (2021) 293-299 295

2. MATERIALS AND METHODS 2.1. STATISTICAL ANALYSIS

The present study was conducted over a period of two MS Excel and SPSS Version 21.0 were used to conduct the
years in the Department of Obstetrics and Gynecology, Lal data analysis. Age was described using mean and standard
Ded Hospital, an associated hospital of Government deviation. For two classes, the means were compared using
Medical College, Srinagar, from September, 2016 to the student's t-test. The proportions were compared using
August, 2017 and in the Department of Obstetrics and either the chi-square or Fisher's exact test. Odds ratios with
Gynecology, Sri Maharaja Gulab Singh Hospital, 95% confidence interval were calculated. To estimate the
Government Medical College Jammu from August, 2018 to risk factors for ectopic pregnancies, logistic regression
July 2019. Cases included all patients with ectopic analysis was applied.
pregnancy admitted in labor. A total of 192 cases were
taken, out of which 8 cases refused to participate in the
study, so 184 subjects were included. Age-matched women 3. RESULTS
with a typical intrauterine pregnancy of the same
As is evident from Table 1, maximum females were in the
gestational age reported to the Outpatient Departments of
age group of 25 to 30 years, but both the groups were
both hospitals served as controls.
almost similar in characteristics on age, parity, and
The inclusion criteria were: 1) histologically proven
religion.
diagnosed cases of ectopic pregnancy; 2) both newly
diagnosed and chronic ectopic pregnancy cases were taken; Table 1. Demographic profile of cases and controls
c) the findings were history-based and available previous Cases Controls
records. In addition, the exclusion criteria were: 1) the Parameter (n=184) (n=184) p-value
cases which were not histologically proven were not taken n (%) n (%)
Age in years
in the study; 2) those patients who left the study or had not < 25 46 (25) 50 (27.2)
reported with the histopathology report were excluded 25-30 116 (63) 122 (66.3) 0.19
from the study. > 30 22 (12) 12 (6.5)
All subjects (both cases and controls) were interviewed, Mean ± SD 27.07 ± 3.99 26.56 ± 3.06
Religion
records were checked, and complete history pertaining to Hindu 100 (54.3) 200 (54.3)
the following were recorded:-Infertility, any pelvic 0.13
Muslim 79 (42.9) 71 (38.6)
inflammatory disease (PID), abortions: spontaneous or Sikh 5 (2.7) 113 (7.1)
induced, previous ectopic pregnancy, intrauterine Parity
Nullipara 54 (29.3) 72 (39.1)
contraceptive device usage, oral contraceptive pills usage, Primipara 34 (18.5) 32 (17.4) 0.23
induced conception cycle, tubal sterilization or other tubal Multipara 63 (34.2) 55 (29.9)
surgery, prior CS, cigarette smoking at the time of Grand mult. 33 (17.9) 25 (13.6)
conception, tuberculosis (TB) in the past (also, TB-PCR of
histopathology sample is positive) and endometriosis. In As depicted in Table 2, Patients with previous ectopic
addition, detailed clinical examination was done in dorsal pregnancy have 6.34 times increased risk of a repeat
position after the evacuation of the bladder, including ectopic pregnancy (odds ratio 6.34, confidence interval
general physical examination, systemic examination, per 1.40-28.77), and this association was highly significant (p
abdomen, per speculum, and per vaginal examination. = 0.006). The risk of having an ectopic pregnancy is 3.02
Following investigations were done as per the proforma times increased (odds ratio 3.10; 95% confidence interval,
designed for the study:- Blood for Hemoglobin (Hb), 1.16-7.84) if patient once had PID and is statistically
Bleeding time (BT), Clotting time (CT), Urine routine significant (p = 0.01) It is also seen that 17 (10.3%)
examination, ABO/Rh blood typing, X-ray chest patients with ectopic pregnancy had a history of tubal
(Posteroanterior view), electrocardiogram (ECG), blood ligation or some other tubal surgery done in the past
urea, creatinine, Na+, K+, and sugar, urine for -human compared to 3 (2.2%) patients among controls. This
chorionic gonadotrophin (using a commercially available finding is statistically highly significant (p = 0.001).
kit) and ultrasonography abdomen and pelvic organs. In addition, more patients with IUCD insertion had an
Histopathological examination was done in cases where ectopic pregnancy and more controls were on continuous
laparoscopy or laparotomy was done. hormonal pills (OCPs), but the results were found to be
statistically not significant (p = 0.07; p = 0.26)
respectively.
296 IBEROAMERICAN JOURNAL OF MEDICINE 04 (2021) 293-299

Table 2. Risk factors of ectopic pregnancy

Cases (n=184) Controls (n=184)
Parameter OR (95%CI) p-value
n (%) n (%)
Previous ectopic pregnancy
Yes 12 (6.5) 2 (1.1) 6.34 (1.40-28.77) 0.006*
No 172 (93.5) 182 (98.9) 1.0 (Ref)
Pelvic inflammatory disease
Yes 17 (9.2) 6 (3.3) 3.02 (1.16-7.84) 0.01*
No 167 (90.8) 178 (96.7) 1.0 (Ref)
Tubal surgeries
Yes 19 (10.3) 4 (2.2) 5.18 (1.72-15.54) 0.001*
No 165 (89.7) 180 (97.8) 1.00 (Ref.)
Intrauterine conceptive device
Yes 15 (8.2) 7 (3.8) 2.24 (0.89-5.64) 0.07
No 169 (91.8) 177 (96.2) 1.00 (Ref.)
Continuous hormonal pills
Yes 31 (16.8) 39 (21.2) 2.24 (0.89-5.64) 0.28
No 153 (83.2) 145 (78.8) 1.00 (Ref.)
Smoking
Yes 2 (1.1) 0 (0.0)
No 182 (98.9) 184 (100) 1.00 (Ref.)
Tuberculosis
Yes 8 (4.3) 1 (0.5) 8.31 (1.03-67.19) 0.01*
No 176 (95.7) 183 (99.5) 1.00 (Ref.)
Endometriosis
Yes 2 (1.1) 0 (0.0)
No 182 (98.9) 184 (100) 1.00 (Ref.)
Infertility
Yes 23 (12.5) 8 (4.3) 3.14 (1.36-7.22) 0.005*
No 161 (87.5) 176 (95.7) 1.00 (Ref.)
Abortions
Yes 50 (27.2) 30 (16.3) 1.91 (1.15-3.18) 0.01*
No 134 (72.8) 154 (837) 1.00 (Ref.)
Previous caesarean
Yes 29 (15.8) 30 (16.3) 0.96 (0.55-1.67) 0.88
No 155 (84.2) 154 (83.7) 1.00 (Ref.)
Induced conception
Yes 23 (12.5) 10 (5.4) 0.96 (0.55-1.67) 0.01*
No 161 (87.5) 174 (94.6) 1.00 (Ref.)
Attending to TB, endometriosis and infertility, there are of maternal mortality and morbidity. In our study, the mean
8.31 times increased risk of ectopic pregnancy in patients age ± Standard Deviation) of the ectopic pregnancy group
with tuberculosis (odds ratio 8.31; confidence interval was 27.07 ± 3.99 years, and that of controls was 26.56 ±
1.03-67.19), .and this is statistically significant. Whereas 3.06 years. Based on our results, the average maternal age
only two patients with endometriosis had ectopic was higher for women with EP than controls, which was
pregnancy, and none of the patients in the control group similar to other studies [6, 7]. “Some previous studies
had increased odds ratio. But with infertility as risk factor, found that the risk of EP increases with advancing maternal
there is 3.14 times increase risk of ectopic pregnancy, age, but the existing evidence on how advanced maternal
which is statistically significant age has an effect on EP risk remains unclear.”
Finally, abortions and induced conception pose a Our study found, 80.99% of females were multigravidae.
significant risk factor for ectopic pregnancy, whereas In our study, we specifically noted that younger
previous cesarean sections were not found to increase the multigravidae were particularly affected. However, this
risk factor for ectopic pregnancy. distribution has not been compared in other similar studies
[8]. The higher incidence in multigravidae could be
explained due to the previous infection or trauma.
4. DISCUSSION The results of our study showed that the history of previous
ectopic pregnancy was a significant risk factor for the
Ectopic pregnancy is a common obstetrical emergency in subsequent development of an ectopic pregnancy, which
early pregnancy worldwide that remains a significant cause was also clear from a meta-analysis [9] and studies in
 IBEROAMERICAN JOURNAL OF MEDICINE 04 (2021) 293-299 297

Germany and India [9-11]. These results confirm the fact According to a meta-analysis, they found a 2.5–23-fold
that recurrent ectopic pregnancies likely reflect increased risk of ectopic pregnancy associated with a
perseverance in tubal pathology and tubal dysfunction [12]. history of infertility [9]. Another similar large case-control
“Similar to other studies [5, 9-12] we found that, among all population study found that the risk of ectopic pregnancy
the possible risk factors of EP, the strongest evidence is for increased with the duration of infertility [13]. The findings
an association between previous EP and sequent EP. of the present study on induced conception cycle are
According to our results, the risk of EP was almost 6 times consistent with previous studies [16, 17]. A study on
higher for women who had prior EP compared to controls controlled ovarian hyperstimulation as a risk factor for
(OR = 6.34, 95% CI = 1.40-28.77). A study on risk factors ectopic pregnancy found that Ovulation induction alone
for ectopic pregnancy in women with symptomatic first- was associated with an increased risk of ectopic pregnancy
trimester pregnancies indicated that the risk of facing a (adjusted odds ratio = 3.98; 95% confidence interval 1.10-
repeat EP increases intensely with the number of prior EP 14.30). “An association between history of infertility and
(OR = 2.98 for one prior EP and OR = 16.04 for 2 or more) risk of EP detected in our study may be due to a significant
[12]. Other research studies also estimated the risk of role of hyperstimulation, with high estrogen levels.”
facing a repeat EP to be between 2.4 and 25.0 [5]. These In contrast, Oelsner et al. found that the cause of ectopic
results confirm the fact that recurrent ectopic pregnancies pregnancy treated with gonadotrophins lies in the patient,
likely reflect perseverance in tubal pathology and tubal likely due to underlying tubal disease and not in the drug
dysfunction [12]”. [18]. Large and comprehensive studies are needed. The
“Pelvic infection is one of the most common, serious results of the present study on contraceptive methods are
infections in non-pregnant women or reproductive age. similar to those previously reported.
Pelvic infections are usually the result of infection In the present study, we found an association between
ascending from the endocervix causing endometritis, abortion and ectopic pregnancy. However, conflicting
salpingitis, parametritis, oophoritis, tubo-ovarian abscess results have been reported. “Some studies suggest that
and/or pelvic peritonitis. PID is reported to occur in 1% of induced abortion may be a risk factor for ectopic
the 15-25 year age group of young adults around the world pregnancy [19], whereas many studies in contradictions
and affects around 24-32% of women in India. In showed no significant association between induced
developed countries, the annual incidence is estimated to abortion and ectopic pregnancy [20, 21]. With regard to the
be 10–13 per 1000 women, with 20 per 1000 women being available evidence, the cause of this relationship is most
in the age group of 20–24 years. Neisseria gonorrhea and likely due to infection, hormonal imbalance, or
Chlamydia trachomatis have been identified as the immunologic factors [11].” Analysis among women with
causative agents [1, 3, 4, 9-11]. The results of our study no previous history of ectopic pregnancy showed after
found a strong independent association between prior PID controlling main risk factors, prior induced abortion was
and EP occurrence. The risk of having an ectopic associated with an increased risk of ectopic pregnancy,
pregnancy is 3.02 times increased if the patient once had which is quite comparable to other studies [22-25].
PID (p = 0.01). These findings are similar to other studies The strength of our study was that, it was carried out across
done in France and Nigeria [13-15]. Adult females have the the two main referral hospitals for gynecologic and
highest incidence of Neisseria gonorrhea and Chlamydia obstetric emergencies. The cases and controls were from
trachomatis among any sexually active age group. This the same source of population, which makes this
population also has an elevated risk of subsequent sexually comparison valid. There were few limitations in our study.
transmitted infections (STIs) after initial PID, thus putting The first limitation of the study was that the history of
them at increased risk of associated reproductive health pelvic infection was by interview only. Because pelvic
sequelae such as infertility, ectopic pregnancy and chronic infections are asymptomatic in a large proportion of
abdominal pain.” women, interview data may be an insensitive means of
“It has been reported that previous tubal surgery is a major determining the occurrence of prior infection. A second
risk factor for EP with an estimated OR of 4.7 (2.4-9.5) limitation of this study was that its sample size was limited.
according to a meta-analysis [9]. Similarly, we found a
significant relationship between previous tubal surgery and
EP. We could not ascertain whether the increased risk is 5. CONCLUSIONS
arising from a surgical procedure or from the underlying
problem.” Since the incidence of ectopic pregnancy is likely to be
considered as an essential role for future fertility, we
298 IBEROAMERICAN JOURNAL OF MEDICINE 04 (2021) 293-299

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