{"paper_id":"ef651927-7c2c-4ded-b1ad-58f3e597cce5","body_text":"~ 153 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2020; 4(3): 153-157 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com  \n2020; 4(3): 153-157 \nReceived: 14-03-2020 \nAccepted: 18-04-2020 \n \nUfaque Muzaffar \nSenior Resident, Department of \nObstetrics and Gynaecology, GMC \nSrinagar, Jammu and Kashmir, \nIndia \n \nSabahat Rasool \nLecturer, Department of Obstetrics \nand Gynaecology, GMC Srinagar, \nJammu and Kashmir, India \n \nKaiser Ahmad  \nPostgraduate, Department of \nObstetrics and Gynaecology, GMC \nSrinagar, Jammu and Kashmir, \nIndia \n \nMuzamil Rasool \nPostgraduate, Department of \nObstetrics and Gynaecology, GMC \nSrinagar, Jammu and Kashmir, \nIndia \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nUfaque Muzaffar \nSenior Resident, Department of \nObstetrics and Gynaecology, GMC \nSrinagar, Jammu and Kashmir, \nIndia \n \nRisk factors for ectopic pregnancy in women: A case \ncontrol study \n \nUfaque Muzaffar, Sabahat Rasool, Kaiser Ahmad and Muzamil Rasool \n \nDOI: https://doi.org/10.33545/gynae.2020.v4.i3c.596  \n \nAbstract \nIntroduction: Ectopic pregnancy can mimic practically each and every gynaecological disorder as well as \nmany surgical catastrophes. It has always challenged ingenuity of the obstetricians and gynaecologists by \nits bizarre clinical picture. If it is not diagnosed attended in time, it may lead to maternal morbidity and \nmortality.  \nMethodology: This stu dy was conducted on 440 patients at Government Medical College, Srinagar \nbetween Jan 2018 and March 2020. All study participants consented in writing. The study was approved by \nthe Institutional Ethics Committee. Study participants were grouped into A and B. 220 ectopic pregnancy \ncases were designated as Group A and their 220 postnatal controls designated as Group B. The aim of this \nstudy was to assess the risk factors of ectopic pregnancy and to determine an association between the \nstudied risk factors and ectopic pregnancy. Both groups were compared for various risk factors for ectopic \npregnancy by means of detailed history wit h focus on socio economic characteristics like education, \noccupation, smoking status , age, gynaecological history, pelvic inflamma tory disease (PID), parity, prior \nabortions, prior ectopic, surgical histories, use of assisted conception and contraception.  \nResults: In this study the main risk factors for ectopic pregnancy were Tuberculosis (OR=11.87), history \nof infertility ( P< 0.001), abortions (P=0.01) and a history of prior ectopic pregnancy (OR=8.129). Other \nrisk factors found to be associated with an  increased risk for ectopic pregnancy were PID (OR=2.856) / \nChlamydia infection (OR=0.29), endometriosis (P=5.40), induced conceptio n cycle (OR=3.142), \nintrauterine device usage (OR=3.7 5), prior Caesarean section (OR=3.85) and appendectomy (OR=2.42). \nOn the contrary, barrier methods (OR=0.25) and oral contraceptive use (OR=0.26) were protective from \nectopic pregnancy.  \nConclusion: PID particularly TB and Chlamydia are major etiological factors for ectopic pregnancy in our \nsetup. Furthermore, prior ectopic pregnancy and infertility may be the result of a PID that might have \ncaused tubal sequalae. As a preventive strategy screening a nd ea rly treatment for TB and chlamydia in \nreproductive age group should be done so that tubal damage can be prevented. Advancing maternal age and \nlow socioeconomic status are risk factor for ectopic pregnancy possibly due to increased chances of \nexposure to sexually transmitted infections (STIs) and PID. Patients with risk factors like pelvic surgeries, \nendometriosis, induced conception cycle, intrauterine contraception device (IUCD) users should be \ncounselled about the possible risk of ectopic pregnancy o nce they conceive. So that they are kept under \nsurveillance for early detection. \n \nKeywords: Ectopic pregnancy, PID, Chlamydia, TB, IUCD \n \nIntroduction  \nDetection of ectopic pregnancy in early gestation has been achieved mainly due to enha nced \ndiagnostic capability. Despite all the notable successes in diagnostics and detection techniques \nectopic pregnancy remains a source of serious maternal morbidity and mortality worldwide \nespecially in countries with poor prenatal care. Ectopic pregnanc y was the 4th most commo n \ncause of maternal death in the most recent confidential enquiry into maternal deaths (CEMD) in \nUK 2000 – 2002, accounting for 73% of early pregnancy deaths  [1, 2, 3]. Furthermore, it is still the \nmost common cause of maternal deaths in the 1st trimester. \nEctopic pregnancy is 10 and 50 times as dangerous as vaginal delivery and induced abortion \nrespectively and an important cause of maternal mortality  [4]. The vast majority of ectopic \npregnancies implant in the fallopian tube (95 -98%). Preg nancies can grow  in the fimbrial end \n(5%), the ampullary section (80%), the isthmus (12%) and the cornual and interstitial part of the \ntube (2%) [5]. A review published in 2010 concludes that tubal ectopic pregnancy is caused by a \ncombination of retention of the embryo within the fallopian tube due to impaired embryo-tubal \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 154 ~ \ntransport and alterations in the tubal environment allowing early \nimplantation to occur. \nRemaining of ectopic pregnancies occur in the ovary, cervix, \nabdomen (primary or secondary), rudimentary horn of  \nbicornuate uterus, caesarean scar  [6]. Other very rare types of \nectopic pregnancy are heterotopic pregnancy, multiple ectopic \npregnancy [7] and ectopic after hysterectomy  [8]. Rarely, ectopic \npregnancy is reported retroperitoneally and in liver  [9, 10]. John \nBard of New York City performed the 1st abdominal surgery for \nectopic pregnancy [11]. \nTubal pregnancy presents as a chronic or an acute illness or as \nan acute on chronic illness. The former is much more common \nbut the acute picture is so dramatic that it tends to rece ive more \nattention. Signs and symptoms include classical triad of \namenorrhea (5 -9 weeks), pain and vaginal bleeding, acute \nabdominal pain (dull, cramps or colicky pain). There is evidence \nof hemodynamic instability (hypotension, collapse, signs and \nsymptoms of shock), adnexal mass (with or without tenderness), \nsigns of peritoneal irritation and absence of gestational sac in \nuterus on ultrasound wi th a BHCG of 2500 mIU/ml. The \ndiagnosis is based on the classical clinical triad  with positive \npregnancy test (5 0%), TVS with empty uterus, thickened \nendometrium, pseudo gestational sac and extra uterine findings \nof live tubal pregnancy, complex adnexal m ass, fluid in POD or \nring of fire on colour Doppler and HCG levels in discriminatory \nzone. A laparoscopic confirmation of diagnosis is useful at times \n[6].  \nDuring the past two decades, incidence of ectopic pregnancy has \ndoubled to tripled in many parts of th e world12 and as per Centre \nfor Disease Control USA, incidence has quadrupled from 1970 \nto 1983, 21 from 4.5% to 16.18% per 1000 pregnancies  [13, 14]. \nHowever, the fatality rates have decreased by 90%. As per \nAmerican College of Obstetricians and Gynaecologis ts (2008), \n2% of all 1st trimester pregnancies in United States are ectopic \nand accounts for 6% of all pregnancy r elated deaths 15. In a \nmulticentric case control study in India the incidence was  \n3.12/1000 pregnancies [16].  \n \nMethodology \nThis study was conducted on 220 ectopic pregnancy cases \ndesignated as Group A and their 220 postnatal controls \ndesignated as Group B, i n Government Medical College \nSrinagar. The aim of this study was to  assess the frequency of \nrisk factors of ectopic pregnancy and to determine an association \nbetween the studied risk factors and ectopic pregnancy. Both \ncases and controls were compared for various risk factors for \nectopic pregnancy by means of detailed his tory on socio \neconomic characteristics like education, occupation, smoking \nstatus, age, gynaecological history, PID, parity, prior abortions, \nprior ectopic, surgical histories, use of assis ted conception and \ncontraception. \n \nResults \n \nTable 1: Socio demographic, gynaecological and surgical histories \n \nRisk Factors Group A (%) Group B (%) Results \nAge >30 years 60.4% 40.2% P=0.011 \nLow Socioeconomic Status 54.6% 6.9% P< 0.001 \nTB 8.1% 0.79% OR=11.87 \nSmoking 4.0% 1.5% OR=2.45 \nChlamydia 15.8% 2.9% OR=5.29 \nParity >1 67.3% 52.5% P=0.007 \nEndometriosis 12.3% 1.5% P=0.041 \nAbortions 24.5% 9.8% P=0.01 \nInfertility 22.6% 2.9% P< 0.001 \nPID 23.6% 8.9% OR=2.856 \nOvulation Induction 14.3% 4.8% OR=3.142 \nBarrier Contraception 4.5% 18.1% OR=0.25 \nPost Coital Pill 2.5% 0% P=0.233 \nOral Contraceptive Pills (OCPs) 3.6% 12.4% OR=0.26 \nIUCD 12.9% 3.4% OR=3.75 \nCesarean Section 24.6% 8.2% OR=3.85 \nAppendectomy 21.4% 10.6% OR=2.42 \nMyomectomy 4.8% 1.1% OR=4.097 \nOvarian Surgery 6.1% 0.8% OR=4.121 \nPrevious Ectopic 12.7% 1.5% OR=8.129 \n \nFollowing results were drawn from the study \n1. The risk of ectopic pregnancy statistically significantly \nincreased with age (p-0.011).  \n2. Ectopic pregnancy occurred more in lower socioec onomic \nstatus as compared to controls with ( p< 0.001) which is \nstatistically highly significant.  54.6% of Group A  belonged \nto lower socioeconomic classes compared to only 6.9 % of \nGroup B.  \n3. 4% Group A and 1.5% of Group B patients  were smokers in \nour study w ith OR 2.45. the risk of ectopic pregnancy is \n2.45 times higher in smokers, indicating that smoking is  a \nrisk factor for ectopic pregnancy. \n4. 24.5% of Group A and 9.8% of Group B had prior abortion \n(spontaneous/induced). This association was found \nstatistically significant (p=0.01) suggesting that prior \nabortions is a risk factor of ectopic pregnancy. \n5. 67.3%of Group A were multipara whereas 52.5% of Group \nB were primiparas. Increasing parity increases the risk of \nectopic pregnancy (p=0.007). \n6. 23.6% of Group A and 8.9% of Group B had history of PID. \nOdds Ratio was found to be 2.856, making PID a risk factor  \nfor ectopic pregnancy. \n7. Among 220 patients in group A 8.1%  and out of 220 \npatients in group B only 0.79% had history of TB with an  \nOR of 11.87. TB was a very s trong risk factor for ectopic \npregnancy in our study. \n8. IgG anti Chlamydia antibody testing  using ELISA kits was \ndone in all 220 patients in group A and 220 patients in \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 155 ~ \ngroup B, out of them 15.8% and 2.9% were positive, \nrespectively. Chlamydia infection was found to be strongly \nassociated with ectopic pregnancy in our study with an OR \nof 5.29. \n9. Out of 220 patients in group A, 12.3% had endometriosis \nand out of 220 patients in group B 1.5% had endometriosis.  \nEndometriosis is found to increase risk of ectopic \npregnancy.  \n10. Of 220 patients in group A, 22.6% were treated for primary \ninfertility whereas of 220 patients in group B studies, only \n2.9% had history of primary infertility This association was \nstatistically found to be significant (p value <0.001) \n11. Out of 220  patients in group A 14.3% and out of 220 \npatients in group B only 4.8% had un dergone OI for the \npresent pregnancy. Ovulation induction predisposes to \nectopics with an OR of 3.142. \n12. 4.5% patients in group A had history of use of barrier \ncontraception wherea s 18.1% of patients in group B had \nhistory of use of Barrier contraception . Barrier \ncontraception was found to be protective for ectopic \npregnancy with an OR of 0.25 \n13. 3.6% had history of OCP use whereas of 220 controls \nstudied, 12.4% had similar history. As per this study the rate \nof ectopic pregnancy among pill users was lo wer than non \nusers with OR =0.28  \n14. 24.6% and 8.2% respectively had previous caesarean \nsections in Groups A and B. \n15. In present study 21.4% of patients in group A and 10.6 % of \npatients in group B had history of Appendicectomy with OR \nof 2.42. \n16. 4.8% of patients in group A and 1.1% of patients in group B \ngave history of myomectomy with OR of 4.097. \n17. Out of 220 patients in group A  6.1%, 0.8% had history of \novarian Surgery with OR = 4.121  \n18. In this study 12.7% of Group A  and 1.5% of Grou p B \nparticipants had prior ectopic pregnancy with an OR of  \n8.129. \n \nOur study demonstrates that in 35% of ectopic pregnancies had \nno identifiable known risk factor. In remaining cases, the \npredominant risk factors were  history of TB (OR=11.87), \ninfertility (p=0.001), abortions (p=0.01) and prior ectopic \npregnancy (OR=8.129). Other risk factors found to be associated \nwith an increased risk for ectopic pregnancy are PID / \nChlamydia infection (OR=2.856), endometriosis (P=0 .041), \ninduced conception cycle (OR=3. 142), intrauterine device usage \n(OR=3.75), prior Caesarean section (OR=3.85) and \nAppendectomy (2.42). Barrier contraception and OCPs were \nprotective from ectopic pregnancy with ORs of 0.25 and 0.26, \nrespectively. \n \nDiscussion \nAge: In our study, we found a s ignificant relationship between \nage and ectopic pregnancy. The risk of ectopic pregnancy \nincreased with increasing age and it remained statistically \nsignificant (p-0.012) as observed by Coste J, et al. Duncan WC \net al. and Archibong EI et al. in their studies [17, 18, 19]. \n \nSocio economic status:  Our study concluded that ectopic \npregnancy occurred more frequently in lower socioeconomic \nstatus as also observed by, Kim YJ et al . Aboyeji AP,  and \nBanerjee B et al. in their studies [20, 21, 22]. \n \nSmoking: In our stud y smoking had an OR of 2.45 for ectopic \npregnancy. Similar observations were made by Davis F et al . \nLucantoni Vat el, Saraiya M, et al . and Coste J et al . in their \nstudies [23, 24, 25, 26]. \n \nAbortions: In our study , the association o f prior abortion was \nfound sta tistically significant as a risk factor for ectopic \npregnancy. (p 0.01). This observation was similar to those made \nby Jobspira N et al., Bouyer J et al. and Parazzini F et al. [27, 17, \n28]. \n \nPrior deliverie s: Our study concluded  that ectopic pregnancy \nincreased with increasing parity. These observations were \nsimilar to those by Alswadi H et al. R.C Karki et al. [29, 39]. \n \nPID: In our study out of 220 cases and their equal mumber of \ncontrols, 23.6% of cases a nd 8.9 % of controls had eviden ce of \nPID. OR was found to be 2.856. These observations were similar \nto the Observations made by Van der Veen F et al., Coste J et al. \nand Karaer A et al. [31, 32, 17]. \n \nTB: In our study of 220 cases 8.1% had confirmed TB and out \nof 220 co ntrols only 0.79% had TB.  OR was 11.87.  These \nobservations were similar to Chowdhury JR  Khan NH and  \nNabang W et al. in their studies [33, 34, 35]. \n \nChlamydia: In the our study IgG anti chlamydial antibody \ntesting using ELISA kits was done and  15.8% of ectopic  \npregnancies and 2.9% postnatal patients were positive with and \nOR of 5.29. These observations were comparable to the \nobservations made by W.J. Ankum W M et al., Omo Aghoja L \net al. and Treqoning SK, et al. [31, 36, 37]. \n \nEndometriosis: In our study, out of 220  cases, 12.3 % had \nendometriosis and out of 220 controls 1.5%) had endometriosis. \nThis correlation was similar to observation made by other \nauthors Collect P, et al . (1993), Malak M, et al . (2011), \nVercellini P, et al. (2012) in their study [38, 39, 40].  \n \nInfertility: 22.6% of ectopic pregnancies had history of primary \ninfertility compared to 2.9 % postnatals. This association was \nstatistically significant (pvalue <0.001).  This result was similar \nto Bouyer J et al. Malak M et al. Ankum WM et al. [17, 39, 41]. \n \nOvulation induction: 14.3% in Group A ve rsus 4.85 in Group \nB had conceived the present pregnancy after ovulation \ninduction, with OR of 3.142. Following observations were \nsimilar to ones made by Avsar FA et al . Coste J et al . \nMarchbanks PA et al. [32, 42, 43]. \n \nBarrier contraception: barrier contracept ion was found to be \nprotective against ectopic gestations with an OR of 0.25. These \nobservations matched those made by Oluwole A  et al . Avsar \nFA, R.C Karki in their studies [44, 32, 30]. \n \nPostcoital pill: In our study only 2.5 % of Group A took \npostcoital pill o f levonorgestrel in index pregnancy whereas \nnone of the controls gave such a history.  Possible association of \nlevonorgestrel with ectopic pregnancy has been supported by \nCandelier C, Jain S H et al. and Jian Z et al. [45, 45, 47]. \n \nOral contraceptive pills : 3.6% of ectopic pregnancies group \nhad history of OCP use compared to 12.4% postnatals. As per \nthis study the rate of ectopic pregnancy among pill users was \nlower than non users wi th OR =0.26. These observations \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 156 ~ \nmatched w ith the  observations made by Bouyer J,  et al . Mol \nBWJ et al., Wong MT et al. and Franks AL et al. [17, 48]. \n \nIUCD: 12.9% of Group A patients and 3.5% of Group B \npatients had history of IUCD usage with an OR of 3.75.  These \nobservations matched similarly wit h the observations made by \nOluwole A et al., Avsar FA et al. [42, 44]. \n \nLSCS: In our study of 220 cases, 24.6% had previous history of \nLSCS and of 220 controls, 8.2%  had previous history of LSCS. \nthis study shows 2 to 3 fold rise of ectopic pregnancy with \nprevious LSCS. OR was 3.85. These observations match ed with \nthe observations o Avsar FA,  et al . (2006), Lucantoni V et al . \n(1998) in their study [32, 51]. \n \nAppendectomy: In our study 21.6% of ectopic pregnancies \ncases and 8.2% of controls gave history of Appendecectomy \nwith OR of 2.42. These observations matched wi th the \nobservations made by Job-Spira et al. (1991) Minaretzis D. et al. \n(1992) in their study [49]. \n \nMyomectomy: In our study 4.8% of cases and 1.1 % of controls \ngave history of myomectomy with OR of  4.097. So  as per this \nstudy ectopic pregnancy occurs 4 fold more in women with \nmyomectomy than those with no such history. These \nobservations matched with the observations made by Tawfeeq T  \net al. (2011) Thorburn Jet al. (1999) in their study [39, 50]. \n \nOvarian cystectomy: Out of 220 cases  6.1% and 0.8% controls  \nhad hist ory of ovarian surgery with OR = 4.121. This study \nshows that risk of ectopic pregnancy in women with history of \novarian cystectomy is twice than women with no such history. \nThis association was similar to observations made by other \nauthors are Tawfeeq T  et al. (2011), Szydlowska I et al. in their \nstudy [39, 51]. \n \nPrior Ectopic: In our study 12.7%  cases and 1.5% controls had \nprevious history of ecto pic pregnancies. OR was 8.129. The se \nobservations were consistent with the observations made y. Mol \nBW et al. (2006) Egerup P, et al. (2012) in their study [41, 52]. \n \nConclusion \nPID particularly TB and Chlamydia are major contributing \nfactors for ectopic p regnancy in our setup. Furthermore, prio r \nectopic pregnancy and infertility  also predispose heavily to \nectopic gestations. As a preventive strategy, screening and early \ntreatment for TB as well as Chlamydia in reproductive age \ngroup should be done so that tubal damage can be prevented.  \nAdvancing maternal age and low socioeconomic status are risk \nfactor for ectopic pregnanc y possibly due to increased chances \nof exposure to STIs and PID.  \nThese women should be targetted while counselling for risk of \nectopic pregnancy in their future pregnancies H istory of \nprevious ectopic pregnancy has a strong association with next \npregnancy being ectopic pregnancy. Such women should be kept \nunder surveillance and counselled adequately so that they are \npicked up early and ma naged accordingly, thus reducing their \nmorbidity and mortality. \nPrevious history of abortions either spontaneous or indu ced are \nstrongly incriminated as an etiological risk for ectopic \npregnancy. So importance of effective contraception rather than \nan abor tion for unmwanted pregnancy needs to b e stressed  so \nthat rate of abortions can be reduced and therefore reducing the \nrisk of ectopic pregnancy.  \nDue to increasing trend towards abdominal delivery, risk of \nectopic pregnancy is increasing. Our study depicted an important \nassociation between ca esareans and ectopic pregnancy. So one \nof the preventive measures to decrease the r isk of ectopic \npregnancy is to properly counsel the patients for the future risk \nbefore on-demand cesarean sections. Further, patients w ith risk \nfactors like pelvic surgerie s endometriosis, induced conception \ncycle, post coital pill and IUCD users should b e counselled \nabout the possible risk of ectopic pregnancy once they conceive.  \nIt goes without saying that  medical and conservative meth ods of \nectopic management are suited  for patients detected and \ndiagnosed ealry, thus reducing morbidity and mortality \nassociated with ectopic pregnancy. \n \nReferences \n1. WHO: Maternal and perinatal accessed Dec. 3, 2010. \n2. Drife J, Lewis G. Why mothers die 2000 – 2002. The sixth \nreport Kingdom; London, United Kingdom: Royal College \nof Obstetricians and Gynaecologists, 2004, 1-15. \n3. Condous G. Ectopic pregnancy. Risk factors and diagnosis. \nAust Fam Physician. 2006; 35:854-857. \n4. Howie PW. Abortion and ectopic pregnancy . In Dewhurst \nTextbook of obstetrics and Gynaecology for postgraduates, \nedited by C R Whitefield, 5h Edition, Blackwell Scientific \npublications, 1955, 155-162. \n5. Speroff L, Fritz H. Clinical Gynaecologic endo crinology \nand infertility. Philadelphia: Lippincot t, Williams and \nWilkins, 2004, 1275-1277. \n6. Kumar P, Malhotra N. In Jeffcoates principles of \nGynaecology, 7 Edition revise d and updated by Kumar P \nand Malhotra N. 2008; 9:142-151. \n7. Glassner MJ, Arnon E , Eskin BA. Review ovulation \ninductionwith clomiphene and the rise in heterotopic \npregnancy. A report of  two cases. J Reprod Med. 1990; \n5(2):175-178. \n8. Fylstra DL. Ectopic pregnanc y after hysterectomy: A \nreview andinsight into tiology and prevention. Fertil Steril. \n2010l 94(2):431-435. \n9. Lee JW, Sohn KM , Jung HS. Ret roperitoneal ectopic \npregnancy. American Journal of Roentgenology. 2005; \n184(5):1600-1601. \n10. Heitala SO, Anderson M , Emdin SO. Ectopic pregnancy in \nthe liver, report of a case and angiographic findings. Acta \nchircand. 1983; 149(6):633-635. \n11. Tait RL . Five case s of extrauterine pregnancy oper ated \nupon at the time of rupture. Br. Med. J. 1884; 1:1250-1251. \n12. Chow WH, Daling JR, Cat es W , Greenberg RS. \nEpidemiology of ectopic pregnancy epidemiol Rev. 1987; \n9:70-94. \n13. Centers for disease control. Ectopic pregnanc y - United \nStates, 1988-1989. 1992; 41:591. \n14. Nederlof KP, Lawson HW, Saftlas AF, Atrash HK , Finch \nEL. Ectopic pregnancy surveill ance, United States  1970-\n1987, MMWR. 1990; 39:9. \n15. Cunningham G, Leveno KJ, Bloom SL, Hauth JC, Rouse \nDJ, Spong CY. Ectopic pregnancy in W illiams Obstetrics . \n2010; 10:238-239. \n16. ICMR: ICMR Task Force Project: Multicentre case control \nstudy of Ectopic Pregnanc y in India. J Obstet Gynaecol \nIndia. 1990; 40:425-430. \n17. Bouyer J, Coste J, Shojaei T, Pauly JC, Fernandez H, \nGerbaud L , Job-Spira N. Risk factors for Ectopic \npregnancy: A comprehensive analysis based on a large case \ncontrol, population based study in France. American Journal \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 157 ~ \nof Epidemiology. 2003; 157(3):185-194. \n18. Sivalingam VN, Duncan WC, Kirk E, Shephard LA , \nAndrew W. Diagnosis and manageme nt of ectopic \npregnancy. Journal of  family planning and reproductive \nhealth care. 2011; 37(4):231-240. \n19. Archibong EI, So bande AA. Ectopic pregnancy in Abha, \nSaudi Arabia. Saudi Medical Journal. 2000; 21(4):330-334. \n20. Yuk JS, Kim YJ, Hur JY , Shin JH. Associati on between \nsocioeconomic status and ec topic pregnancy rate in the \nrepublic of Korea. Int. J  Gynaecol Obstet. 2013; \n122(2):104-107. \n21. Aboyeji AP. Trends in Ectopic pregnancy in Ilorin, Nigeria. \nNigeria Medical Practitioner. 2000; 38:4-6. \n22. Poonam, Uprety D, Banerjee B. Ectopic pregnancy two year \nreview from BPKIHS, Nepal. Kathmandu University \nMedical Journal. 2005; 35(12):365-369. \n23. Handler A, Davis F, Ferre C , Yeko T. The relationship of \nsmoking and ectopic pregnancy. Am J Public Health. 1989; \n79(9):1239-1242. \n24. Bastianelli C, Lucantoni V, Valente A, Farris M, Lippa A , \nDionisi B. Risk factors for ectopic pregnancy: a case control \nstudy. Minerva Gynaecol. 1998; 50(11):469-473. \n25. Saraiya M, Berg CJ, Kendrick JS, trauss LT, Atrash HK, \nAhn YW. Cigarette smoking as a risk factor for ectopic \npregnancy. Am J Obstet Gynecol. 1998; 178(3):493-498. \n26. Coste J, Job-Spira N, Fernandez H. Increased risk of ectopic \npregnancy with maternal cigarette smoking.  Am J Public \nHealth. 1991; 81(2):199-201. \n27. Tharaux-Deneux C, Bouyer J, Job -Spira N, Coste J , Spira \nA. Risk of ectopic pregnancy and previous induced \nabortion. Am J Public Health. 1998; 88(3):401-405. \n28. Parazzini F, Ferraroni M, Tozzi L, Ricci E, Mezzopane R , \nLa Vecchia C. Induced abortions and risk of ectopic \npregnancy Oxford Journals, Medicine, Human reproduction. \n1995; 10(7):1841-1844. \n29. Aziz S, Alwafi B , Alswadi H. Frequency of e ctopic \npregnancy in a m edical centre, kingdom of Saudi Arabia. \nJournal of Pakistan Medical Association. 2011; 61(3): 221-\n224. \n30. Karki RCL, Pradhan B, Duwa S. Annual  Analysis of \nEctopic Pregnancy in Tertiary care Hospital. Pos tgraduate \nMedical Journal of NAMS, 2011, 11(1). \n31. Mol BWJ, Ankum WM, Van deer Veen F, Bossuyt PMM. \nRisk indicators for ectopic pregnancy: a meta -analysis \nContraception 1995; 52: 337-41. Obstetric an d \nGynecologically Survey 1996; 51: 363-4. Fertility and \nSterility. 1996; 65:1093-1099. \n32. Karaer A, Avsar FA , Batioqlu S. Risk factors for Ectopic \nPregnancy: A case -Control Study. Australian and New \nZealand Journal of Obstetrics and Gynaecology. 2006; \n46(6):521-527. \n33. Ghosh K, Chowdhury JR. Tuberculosis and female \nreproductive health. Journal of postgraduate medicine. \n2011; 57(4):307-313. \n34. Shah N, Khan NH. Ectopic pregnancy: presentation and risk \nfactors. Journal of the college of physicians and surgeons \nPakistan: JCPSP. 2005; 15(9):535-538. \n35. Nabang W, Nor Hassan A, Sayed DEM , El-Sheikh MA. \nEndometrial tuberculosis and secondary A menorrhea: a \nreport of three cases in Sudan Journal of Minimally \nInvasive Surgical Sciences. 2013; 1(1):30-33. \n36. Agholor K, Omo Aghoja L, Okonofua F. Association of anti \nChlamydia antibodies with ectopic pregnancy in Benin city,  \nNigeria; a case control study . African Health Sciences. \n2013; 13(2):430-440. \n37. Treqoning SK, Ballard RC , Andersson PD, Fehter HG , Van \nder Spay ZM. Antibodies to Chlamydi a trachomatis in \npatients presenting with ectopic pregnancy at Groote Schuur \nHospital. S. Afr Med. J. 2000; 90(7):727-730. \n38. Jobspira N, Collect P, Coste J, Bremond A, Laumon B. Risk \nfactors for ectopic pregnancy. Result of a case control Study \nin the Rhone Alpes region. Contracept Fertile Sex. 1993; \n21(4):307-312. \n39. Malak M, Tawfeeq T, Holzer H and Tulandi T. Risk factors \nfor Ectopic pregnancy after I n vitro Fertilization Treatment. \nJ Obstet Gynaecol Can. 2011; 33(6):617-619. \n40. Vercellini P, Parazzint F, Pietrop aolo G, Cipriani S, \nFrattaruolo MP , Fedele L . Pregnancy outcome in women \nwith peritoneal, ovarian and Rectov aginal end ometriosis: a \nretrospective cohort study. BJOG. 2012; 119 (12):1538-\n1543. \n41. Ankum WM, Mol BW, Vander Veen F , Bossuyt PM. Risk \nFactors for Ect opic Pregnancy: a meta -analysis. Fertir \nSteril. 1996; 65(6):1093-1099. \n42. Fermandez H, Coste J , Job-Spira N. Controlled O varian \nhyper stimulation as a risk factor for Ectopic Pregnaney. \nObstet Gynaecol. 1991; 78(4):656-659. \n43. Marchbanks AP, Annergers JF, Coulam  CB, Strathy JH , \nKurland LT. Ri sk factors for Ectopic pregnancy. The \nJournal of the American Medical Associate. 1988; \n259(12):1823-1827. \n44. Anorlu RI, Oluwole A, Abudu OO, Adebajo S. Risk factors \nfor Ectopic Pregnancy in Lagos, Nigeria. Acta Obstet \nGynaecol scand. 2005; 84(2):184-188. \n45. Basu A, Candelier C. Ectopic Pregnancy with postcoital \nContraception - A case report. Eur J  contracept Reprod \nHealth Care. 2005; 10(1):6-8. \n46. Jain S H, Ghike S, Gawande MS, Joshi SA, Kawt halkar AS, \nSomalwar SA. LNG Emergency contra ceptive pills: Risk \nfactors for pregnancy. J South Asian Feder Obst Gynae. \n2013; 5(2):87-88. \n47. Jian Z, Linan C. Ectopic gestation following emergency \ncontraception with levonorgestrel Eur. 2003; 8(4):225-228. \n48. Franks AL, Beral V, Cates WJR , Hogue CJ. Contrace ption \nand Ectopic Pregnancy risk. Am J Obstet Gynaecol. 1990; \n163(4):1120-1123. \n49. Coste J, Job -Spira N, Fernandez H, Pap iemik E , Spira A. \nRisk factors for ectopic pregnancy: A Case control Study in \nFrance, with special Focus on infectious factors. Am. J  \nEpidemiol. 1991; 133(9):839-849. \n50. Strandell A,  Thorburn J , Hamberger L. Risk factors for \nEctopic pregnancy in assisted Repr oduction. Fertility and \nStertility. 1999; 71(2):282-286. \n51. Brodowska A, Szydlowska I, Starczewski A, Strojny K, \nPuchalski A, Mieczkowska E et al. Analysis of risk factors \nfor ectopic pregnancy in own material in the years  1993-\n2002. Europe Pub Med Central. 2005; 18(103):74-77. \n52. Karnus LL, Egerup P, Skovlund C W, Lidegaard O. Long -\nterm reproductive outc omes in women whose first \npregnancy is ectop ic: a national controlled follow -up study. \nOxford journals, Medicine, Human Reproduction journal. \n2012; 28(1):241-246.","source_license":"CC0","license_restricted":false}