Ectopic pregnancy is a condition where the fertilized ovum implants outside the uterine cavity, most commonly in the fallopian tube. It accounts for 1-2% of all pregnancies globally(1). It is a potentially life-threatening condition & is a leading cause of maternal mortality in the first trimester. In India, its incidence is reported to be 0.5-2% of all pregnancies (1)(2).

The pathophysiology of EP includes impaired tubal transport of the fertilized ovum, due to predisposing factors like pelvic inflammatory disease (PID), previous tubal surgeries, previous ectopic pregnancy, Intrauterine contraceptive devices (IUCDs) usage, assisted reproductive techniques(3). Early diagnosis is possible through serum beta-HCG estimation and transvaginal sonography. Despite these recent advances, many cases present late, often after rupture, leading to haemorrhagic shock and emergency surgical interventions.

This study was thus undertaken to evaluate the demographic characteristics, parity, risk factors of patients diagnosed with ectopic pregnancy at GGH, Siddipet, over a period of two years. The findings aim to contribute to early recognition and better understanding of regional trends, and risk factors, ultimately improving maternal outcomes.

AIMS AND OBJECTIVES

Primary Objective:

1. To analyse the demographic characteristics (age, parity) and diagnostic findings in patients diagnosed with ectopic pregnancy.

Secondary Objectives:

1. To study the common presenting symptoms.
2. To identify associated risk factors (if available).
3. To assess the type of ectopic pregnancy and its management modality.

METHODOLOGY

1. a) Study Design: Retrospective observational study.
2. b) Place Of Study: Department of Obstetrics and Gynaecology, Government General Hospital, Siddipet
3. c) Study Duration: 2 years [ January 2023 to December 2024].
4. d) Study Population: All patients diagnosed and managed for ectopic pregnancy during the study period.
5. Inclusion Criteria: Women diagnosed with ectopic pregnancy confirmed clinically and/or radiologically and managed in the hospital during the study period.
6. Exclusion Criteria: Suspected ectopic pregnancies that were ruled out.
7. e) Sample Size: 27
8. f) Method: A preformed questionnaire was prepared including the following data: Age, Parity, Risk factors (e.g., prior ectopic pregnancy, previous caesarean section, previous surgeries), Site of ectopic pregnancy, Type (ruptured/unruptured), Diagnostic modality used (USG, urine/blood hCG), Management (medical/surgical). Data was collected from medical records and entered into the pre-designed data collection form.
9. g) Statistical Analysis: Data will be entered into Microsoft Excel and analysed using SPSS or R. Descriptive statistics (mean, median, standard deviation) for continuous variables. Frequencies and percentages for categorical variables. Chi-square test or Fisher’s exact test to assess associations between variables, if needed. Significance set at p < 0.05.
10. h) Ethical Considerations: Approval was obtained from the Institutional Ethics Committee. As this is a retrospective study, patient consent may be waived off but confidentiality strictly maintained.

Samantaray et al. (4) reported that 70% of cases had identifiable risk factors, particularly previous pelvic inflammatory disease and tubal surgeries.

Sharvari et al.(7) reported that more than 40% of their ectopic pregnancy patients had a history of tubal pathology or prior surgery. The increasing number of caesarean sections has led to a rise in rare forms of ectopic pregnancies such as scar ectopics, which carry high morbidity.

OUTCOMES

Early diagnosis is important as it significantly improves outcomes and helps to preserve future fertility.

A study by Shetty et al. (5) emphasized that increased awareness, patient education, and access to diagnostic facilities are key to reducing complications associated with ectopic pregnancy

A total of 27 cases of ectopic pregnancy were admitted and managed at GGH, Siddipet over a period of 2 years i.e. from January 2023 to December 2024.

AGE DISTRIBUTION

10 cases (37%) belonged to 25-30years age group followed by 9 cases (33.3% belonged to 20-25 years age group. Only 1 woman was below 20years age and 3 were above 35years age.

PARITY:

16 women (59.3%) were multiparous (Para2 or more), while nulliparous women accounted for 18.5%.

GESTATIONAL AGE AT DIAGNOSIS:

Most ectopic pregnancies were diagnosed at 6weeks of gestation (11cases, 40.7%), followed by 7cases (25.9%) diagnosed at 7weeks gestation. Only one case was diagnosed at 10weeks of gestation.

PREVIOUS OBSTETRIC AND SURGICAL HISTORY

Among the 27 women diagnosed with ectopic pregnancy:

• 9 (33.3%) women had no history of any previous surgeries.
• Out of 5 (18.5%) nulliparous women, 2 women had history of unilateral salpingectomy for previous ectopic pregnancy.
• 13 (48.14%) women had previous LSCS. Among them,
  • 3 women had also undergone tubectomy
  • 2 underwent salpingectomy for previous ectopic pregnancy.
• 9 (33.3%) women had previous normal vaginal deliveries
  • 2 underwent interval sterilisation with bilateral tubectomy
  • one had previous ectopic pregnancy.
• Thus, in total, 6 (22.2%) women had undergone tubectomy previously, and 5 (18.5%) had unilateral salpingectomy for previous ectopic pregnancy.

SITE OF ECTOPIC PREGNANCY

The fallopian tube was the most common site (22 cases, 81.5%). Cornual and scar ectopics were seen in 2 patients each (7.4%). Cervical and ovarian ectopic pregnancies were rare (1 case each, 3.7%).

PRESENTING COMPLAINTS

Pain abdomen was seen in 23 cases. 2 patients presented with syncopal attack, 2cases were detected incidentally in routine early antenatal USG.

DIAGNOSIS:

Ultrasound was the main diagnostic tool, used in 24 cases (88.9%). 3 cases were diagnosed by combined serum β-HCG and ultrasound.

RUPTURED vs UNRUPTURED: 21 cases (77.8%) presented with ruptured ectopic pregnancy, and 6 cases (22.2%) were unruptured at diagnosis.

MANAGEMENT: 25 patients (92.6%) underwent laparotomy (as laparoscopy was unavailable).

1 patient with unruptured ectopic pregnancy received methotrexate.

1 patient with cervical ectopic pregnancy was managed with methotrexate and evacuation.

Most patients were in their late twenties and multiparous. Pain abdomen was a consistent symptom. A large proportion (77.8%) presented with rupture, highlighting delay in diagnosis. Ultrasound was the primary diagnostic tool. Surgical management via laparotomy was the mainstay, as laparoscopy was not available.

In the current study, EP is found to be most common in 25–30 years (37.0%) and 20–25 years (33.3%). A similar Indian study of 182 cases reported 43.9% cases in 25–30 years age and 24.2% in 20–25 years(10)(11). Thus, finding of the current study aligns closely with regional data, indicating that majority of EP cases occur in women during mid-reproductive years.

In the current study, EP predominantly occurred in multiparous (para ≥2) women (59.3%), and nulliparas (18.5%). In study by Manju Lata et al.(12), EP is found in primigravidae 18.7%, second gravida 24.7%, third gravida 31.3%, and multigravidas combined ~55.3%. Thus, parity profile of current study is consistent with published data, suggesting higher EP risk with increasing parity.

Diagnosis of EP in this study, was mostly at 6 weeks (40.7%) and 7–8 weeks (48.1% combined). In literature, most ectopics are detected between 5–8 weeks(13).

This analysis highlights the significant contribution of prior reproductive surgeries to the risk of ectopic pregnancy. 48.14% of patients had undergone caesarean section, and a considerable subset of these, also had tubal surgeries such as tubectomy or salpingectomy. Prior caesarean section is an established risk factor for scar ectopic pregnancies, which, though rare, carries a high risk of rupture and morbidity. In the present study, 22.2% of patients had undergone tubectomy and 18.5% had previous salpingectomy. Previous studies in Indian populations have reported tubectomy in 6–15% of ectopic pregnancy cases. Salem, et al. reported tubal surgery and PID were present in 6.6% and 8.8%, respectively, among 182 cases(14). Thus, there is a relatively higher rate of previous tubal related surgeries in the current study, contributing to EP risk, possibly due to regional sterilization trends or surgical techniques used. History of previous ectopic pregnancy in 2 out of 5 nulliparous women, underlines the importance of close monitoring in this subgroup, as they are at high risk for recurrence. Moreover, even among women with normal deliveries, the presence of interval sterilization and past ectopic pregnancies emphasizes the need for risk assessment regardless of parity.

In the current study, 81.5% were tubal ectopic, 7.4% cornual ectopic, 7.4% were scar ectopic, and 3.7% each of ovarian and cervical ectopics. Global data shows 84.7–87% of ectopic pregnancies in fallopian tube; scar and cervical ectopics are each <1%, and cornual ~2.4%(15)(16). Thus, while tubal ectopics predominates as expected, the current study reports a slightly higher rates of scar (7.4%) and cervical (3.7%) cases—likely reflecting hospital-specific surgical profiles and referral patterns.

In the current study, 77.8% presented with ruptured EP. Previous studies in India show rupture in about 31.25% of cases(17). In Meta-analysis, pooled prevalence of rupture in EP across studies is ~56.4%(18). Thus, rupture rate in the present study is notably higher, indicating delayed presentation, which may reflect referral delays or lower access to early diagnostics.

TVS is recommended as the primary tool, complemented by serial β-hCG monitoring for diagnosis of EP(19). In the current study, 88.9% diagnosed by ultrasound alone; 11.1% by both β-hCG and ultrasound combined. Thus, our diagnostic approach is in alignment with standard practice and evidence-based guidelines.

In the current study, 92.6% underwent surgical management through laparotomy, and medical treatment was used in only 2 cases. Sharvari et al. (7) noted that 60% of their cohort underwent laparotomy due to rupture at presentation, while 20% received methotrexate. Globally, there is a shift towards laparoscopy and medical management is more common where available(20)(21). High laparotomy rate reflects limited laparoscopy capacity in our centre. This underscores disparities in treatment options and potential resource constraints.

Ectopic pregnancy remains a critical cause of early pregnancy morbidity. Although the overall incidence is stable, the pattern of presentation is influenced by awareness, access to healthcare, and the availability of diagnostic and surgical modalities. High rate of rupture and reliance on laparotomy in a semi-urban tertiary care setting, reflects need for early diagnosis (routine early pregnancy ultrasound by 6weeks gestation), increased community awareness about the signs and symptoms of EP, strengthening of referral systems to reduce delayed presentation and complications, improved access to diagnostic modalities and intervention. The high proportion of cases with prior tubal surgeries and caesarean deliveries, highlights the importance of identifying high risk women early in gestation. Timely diagnosis using ultrasonography and beta-HCG, coupled with access to minimally invasive management, can significantly reduce maternal morbidity and preserve fertility.  Additionally, the high rate of laparotomy (92.6%) reflects institutional limitations in laparoscopic capacity, underscoring the need for training and resource enhancement, infrastructure upgrades.

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