Pregnancy is special and let us make it safe. Childbirth is a biological phenomenon which gives joy to the mother and the family, but it turns into tragedy when the women or her child loses life while performing this social obligation. The blastocyst normally implants in the endometrial lining of the uterine cavity. Implantation anywhere else is an ectopic pregnancy. The clinical findings associated with ectopic pregnancy has a wide spectrum, ranging from a completely asymptomatic status to peritoneal irritation resulting from rupture and bleeding into peritoneal cavity and hypovolemic shock¹.

Patients of ectopic pregnancy usually present with clinical triad of amenorrhoea, abdominal pain and vaginal bleeding. Pelvic and abdominal pain is seen in 95% of cases and amenorrhoea with vaginal bleeding has been reported in 60–80% of women. When ectopic pregnancy ruptures, there will be tenderness during abdominal and vaginal examination, especially with cervical motion, which is seen in three-fourth of the patients².

Patients with ectopic pregnancy can be diagnosed on the basis of history, examination, beta human chorionic gonadotropin measurements and by ultrasonography. In making diagnosis, a combination of trans-vaginal sonography and beta Human Chorionic Gonadotrophin levels³ have shown a sensitivity of 100% and specificity of 96%.

In spite of the advances in diagnostic methods and management, ectopic pregnancy still remains a very serious threat to maternal safety and the mortality rate from an ectopic pregnancy is higher in rural areas, where patients are less likely to receive early medical care; hence, obstetricians need to study this topic widely.

The present study was conducted at the Department of Obstetrics and Gynaecology, Kamla Nehru State Hospital for Mother and Child, Indira Gandhi Medical College, Shimla, for a period of 1 year from March 2011 to February 2012.

In this case-control study, all the diagnosed cases of ectopic pregnancy were taken as cases and controls were the age-matched women with normal intrauterine pregnancy of same gestation age.

All the patients with diagnosed ectopic pregnancy were admitted and a detailed history was taken. A rapid initial assessment of the patient was made and cases were managed accordingly. A detailed examination was performed. Routine and special investigations (serum beta hCG and ultrasonography) were carried out. Details were noted and data obtained were analysed using chi square test.

This case-control study was undertaken at the Department of OBG, KNSH, IGMC, Shimla, from 1 March 2011 to 29 February 2012. A total of 110 cases of ectopic pregnancy were diagnosed over this period. The incidence of ectopic pregnancy was 18.62 per 1000 deliveries. Mean age of cases with ectopic pregnancy was 28.72 years

In the present study, it was observed that majority of cases presented with pain in the abdomen (90.90%) followed by amenorrhoea (82.72%) and bleeding per vaginum (75.45%) as shown in Table 1. A total of 41 (37.27%) cases presented with gastrointestinal symptoms and 28 (25.45%) cases had syncopal attacks, while in the control group, amenorrhoea was the most common symptom. Difference in symptomatology in both groups, i.e. study as well as control groups, was statistically significant (P<0.001).

Table 2 shows that 74 (67.27%) cases had cervical motion tenderness in the study group. Pallor was present in 62 (56.36%) cases. Abdominal tenderness was observed in 78 (70.90%) cases, adnexal mass was a feature in 55 (50%) cases and fullness in POD was present in 27 (24.54%) cases. Rigidity and guarding were observed in 60 (54.54%) cases and shock was the presenting feature in 10 (9.09%) cases, while in the control group, 10 cases had pallor, 1 case had abdominal tenderness, adnexal mass was observed in 1 case (which was due to ovarian cyst) and 1 case had rigidity and guarding. Signs were significantly higher in the study group when compared with the control group (P<0.001).

Moderate anaemia was noticed in 66 (60%) cases and severe anaemia in 44 (40%) cases in the study group as shown in Table 3

The UPT was positive in 106 (96.36%) cases, as compared with controls, which had positive UPT in 110 (100%) cases as shown in Table 4.

As shown in Table 5, haemoperitoneum was present in 76 (70.37%) cases, adnexal mass in 49 (45.37%) cases, gestational sac in adnexa in 26 (24.07%) cases and foetus in the abdominal cavity in 1 (0.92%) case. The USG findings were not significant in 7 (6.48%) cases and in 2 (1.81%) cases, the USG was not done.

Ectopic pregnancy is a common obstetrical disorder in early pregnancy all over the world that remains to be an important cause of maternal mortality and morbidity. The present study showed the incidence of ectopic pregnancy as 18.62 per 1000 deliveries, which was comparable to the incidence shown by Anorlu et al.⁴. Mean age of the cases with ectopic pregnancy was 28.72 years, which was similar to studies conducted by Anorlu et al.⁴ (27.8±6.21 years), Kopani et al.⁵ (30.38 years) and Aziz et al.⁶ (30±4 years).

The studies conducted by Alsuleiman et al.⁷, Kopani etal.⁵ and Panchal et al.⁸ showed that the pain in the abdomen was the commonest presentation noticed in 98.6, 90 and 98.33% cases, respectively, which was in concurrence with the present study.

Amenorrhoea was noticed in 82.72% cases in the present study, which was similar to the results shown by Kopani et al.⁵ and Panchal et al.⁸, who found amenorrhoea in 81 and 85% cases, respectively. In the present study, 75.45% cases had BPV. This was in concurrence with the studies by Kopani et al.⁵ and Panchal et al.⁸, who noticed BPV in 78 and 68.33% cases, respectively.

Abdominal tenderness was the most common sign observed in the present study in 70.90% cases, which was similar to studies conducted by Khaleeque et al.⁹ and Panchal et al.⁸. They also found abdominal tenderness as the commonest sign. Cervical motion tenderness was a feature in 67.27% cases in the present study, which was comparable to the studies by Khaleeque et al.⁹ and Panchal et al.⁸, who noticed cervical motion tenderness in 64 and 76.66% cases, respectively.

In the studies conducted by Chhabra et al. ^10, Khaleeque et al.⁹ and Majhi et al. ^11, shock was noticed in 7.14, 11.62 and 9.4% cases, respectively, which was in concurrence with the present study (9.1% cases).

Sensitivity of USG in the present study was 93.5%. In seven cases, no significant findings suggestive of ectopic pregnancy were noted. USG was not done in two cases as the patients reported late to the hospital and were in shock, so we proceeded with laparotomy.

Ectopic pregnancy still remains a dreadful condition which has always challenged the clinical acumen of obstetricians and gynaecologists. Clinical findings associated with ectopic pregnancy have a wide spectrum, ranging from a completely asymptomatic status to hypovolemic shock. The classical pattern of period of amenorrhoea and abdominal pain may be a provisional diagnosis which can be made in the light of clinical features along with the sonological findings. Delayed diagnosis may lead to disasters in the form of mortality or morbidity. So, this emphasises the importance of a thorough clinical evaluation and appropriate investigations for patients with high suspicions so that the patients can be benefited.

Footnote-BPV –bleeding per vaginum

Hb, haemoglobin.

UPT, Urine pregnancy test.

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