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Ectopic pregnancy after tubal ligation an experience in rural set up.

INTRODUCTION: Ectopic pregnancy is an important cause of obstetric haemorrhage with resultant maternal morbidity and mortality. [1] obstetric haemorrhage accounts for 30.8% of causes of maternal mortality of which ectopic pregnancy accountable to 0.1%. [1] was also observed in united kingdom that maternal deaths were attributed to direct causes like obstetric haemorrhage ectopic pregnancy and venous thromboembolism also there is a rising trend in increase in maternal deaths due to indirect causes. [2] Various etiological factors are listed for the cause of ectopic pregnancy of which tubal ligation is one among them. [3] The authors found the incidence of ectopic pregnancy after failed tubal ligation to be 67% in their study. But literature review quotes an incidence of 5-90%. [3] Chi IC and Siemens et al found an incidence of 10%. [4] Tubal ligation is the most common surgical method of female sterilization for the couples who opt for permanent method of contraception. According to family planning programme 2011 annually 5 million sterilization procedures are performed in India.

Tubal ligations constitute 95.6% and vasectomies 4.4%. Total number of 50 tubal ligations and two vasectomies performed in our hospital during a period of one year. Tubal ligation though an effective method of contraception is associated with a failure rate of 0.3-1.3% resulting in pregnancy. [5] A significant proportion of these pregnancies 15-33% are ectopic. [5] Hence tubal ligation performed for permanent sterilization carries a risk of ectopic pregnancy adding to the maternal morbidity and mortality. There should be high degree of suspicion of ectopic pregnancy even in patients who have undergone tubal ligation. The present study is undertaken to analyse retrospectively ectopic pregnancies which occurred in patients who underwent tubal ligation procedure in the past.

MATERIAL AND METHODS: Twenty cases of ectopic pregnancy occurred in a period of one year from June 2012 to June 2013. Seven out of twenty cases (35%) underwent tubal ligation in the past. A detailed evaluation of these seven cases is done and factors such as age, type of sterilization procedure, time elapsed from tubal ligation type of clinical presentation, site of ectopic pregnancy, are analysed.

RESULTS: Table 1 shows the distribution of patients according to the age. Two out of seven cases were more than 30 years of age, one was 34yrs and the other was 38yrs. Out of seven patients six patients underwent tubal ligation by mini laparotomy technique and one patient underwent laparoscopic sterilization by falope ring application. Majority of patients (57%) underwent postnatal sterilization. The duration from tubal ligation was more than 5 years in 85.7% of patients. One patient presented after 15yrs of tubal ligation.

Pain in abdomen was observed in all cases while delayed period was seen in only 2(28.5%) cases. Ectopic pregnancy has to be suspected even in the absence of amenorrhoea. Of the 3 cases who presented with shock one patient died immediately after surgery. 71% of cases presented with tubal rupture. Ectopic gestation was located at the site of interruption in 71% of cases. Patient having ectopic gestation at cornual region with rupture had severe haemoperitoneum, consumptive coagulopathy and could not be saved.

Of the seven cases laparotomy was done in five cases and two cases underwent laparoscopic salpingectomy. All the patients required blood transfusions. One among them progressed to consumptive coagulopathy requiring transfusion of fresh frozen plasma and platelet concentrate. Post-operative recovery was good in 5(71.4%) patients and discharged within 7 days without any complications. One patient developed intestinal obstruction which was managed conservatively and the patient recovered well without surgical intervention.

DISCUSSION: Ectopic pregnancy indeed is an important risk factor for maternal mortality. [1][2] Tubal ligation is most common method of permanent sterilization. According to family planning programme 2011 94.5% of permanent sterilization procedures are tubal ligation. The rate of pregnancy after tubal ligation is 0.3-1.3% and the rate of ectopic pregnancy after tubal ligation is 15-33%. [5] Tubal ligation carries risk of ectopic pregnancy in small proportion of cases and high index of suspicion is required to diagnose the same in such patients. Coste J, Job Spira et al. [6] observed that prior tubal surgery is a risk factor for ectopic pregnancy with odds ratio of 5.1. In this retrospective analysis numbers of cases of ectopic pregnancy were 20 and seven out of twenty cases occurred after tubal ligation.

It was observed that the occurrence of ectopic pregnancy after tubal ligation has no predilection to age. Patients in reproductive age (20-40years) are predisposed. The median age at the time of sterilization was found to be 30years by Herbert B, Peterson et al. [7] They also observed that failure rate was lesser with postnatal sterilization than within tervaltubectomy. They calculated a 10 year probability of failure of 4.9 per 1000 procedures as against 7.5 per 1000 procedures for interval tubectomy. The difference in our observation can be explained by the greater number of postnatal sterilizations performed in our hospital 85.7% of patients presented after 5 years of tuballigation. One patient presented as

Long as after 15 years of tubalsurgery. This is because of young age at the time of sterilization and impending risk of ectopic pregnancy throughout the reproductive years. [7] Risk of failure after 5 years for partial salpingectomyis 1.2per 1000 procedures and 8.3 for laparoscopic bipolar coagulation. [7] 85.7% of patients underwent tubal ligation by minilaparotomy while one out of seven underwent laparoscopic sterilization by falope ring application. This might lead to a bias that partial salpingectomy is associated with high risk of ectopic pregnancy. But in rural areas the acceptance of laparoscopic sterilization is much lesser when compared to partial salpingectomy. Sudhir Babu Palli, Vijayalakshmi et al. [8] observed that the acceptance of laparoscopic sterilization was lesser in illiterate women than in educated women.

They also observed that acceptance of laparoscopic sterilization was lesser in house wives than in working women. Our hospital caters to the rural population and the acceptance of laparoscopic sterilization is lesser than post-partum sterilization. Fifty tubal ligation surgeries are performed during the year June 2012 to June 2013. Ten (20%) among them are interval tubectomies done by minilaparotomy and three (6%) were performed by laparoscopic route. The numbers of caesarean ligations are 37(74%). In this study 57% of patients with ectopic pregnancy underwent postnatal sterilization and 28% underwent caesarean ligation.

Huggins GR, Sondheimer S J et al. [9] observed that the risk of pregnancy failure was more in the first year and risk decreases in subsequent years. Another study analysed 15 ectopic pregnancies occurring after female sterilization comparing with non-pregnant control patients found that patients with ectopic pregnancy after sterilization procedure had history of induced abortion (matched triplet odds ratio = 9.0, 95% confidence limits = 1.39, 58.26).and previous abdominal surgeries(odds ratio 5.8, 95% confidence limits = 1.78, 18.60). [10] our study reported induced abortion in one patient and there was no history of abdominal surgeries but for caesarean section in two patients.

Shah JP, Parulekar et al. [11] Observed that the incidence of ectopic pregnancy increases after 2 years than intrauterine pregnancy should a failure of sterilization occur. Pain abdomen was a common symptom seeninall patients while delayed period occurred only in 28% of patients. This makes the diagnosis more difficult. 42.8% of patients presented with shock at the time of diagnosis. The history of tubal ligation and near normal monthly period can mislead the diagnosis. [12] 71% of patients with ectopic pregnancy had rupture of the tube while only one patient had tubalabortion. The tubes in this patient were recanalised spontaneously and there was no evidence of previous partial salping ectomy. In majority of patients 71% the site of ectopic was the site of interruption. [12] One patient (14.2%) presented with a corneal pregnancy with massive haemoperitoneum and consumptive coagulopathy.

The patient presented tour hospital 72 hrs after the symptoms developed and was diagnosed the nasectopic pregnancy. Sterilization give sasense of security so the symptoms and signs are over looked, delaying the diagnosis of pregnancy. As a consequence it may result in maternal death. [12] Surgical intervention intervention is required in majority of ectopic pregnancies. Though laparotomy is conventional method of management laparoscopic salpingectomy canal so be performed in selective cases. [13]

CONCLUSION: Tubal ligation is an effective method of contraception but in a small proportion of cases results in pregnancy due to failure of the method. Sterilization failure results in ectopic pregnancy in significant number of cases. History of sterilization procedure and absence of classical symptoms delays the diagnosis adding to the maternal mortality.

DOI: 10.14260/jemds/2015/1836

REFERENCES:

[1.] Say L, Donner A, Gulmezoglu AM, Taljaard M, Piaggio G. The prevalence of stillbirths: a systematic review. Reproductive Health, 2006; 3:1 (doi: 10.1186/1742-4755-3-1).

[2.] Catherine Nelson-Piercy, Sandra Lowe and Karen Rosene-Montella. Maternal deaths: the good, the bad and the ugly. Obstet Med 2011; 4: 43

[3.] Napolitano PG, Vu K, Rosa C. Pregnancy after failed tubal sterilization. J Reprod Med. 1996 Aug; 41(8):609-13.

[4.] Chi IC, Siemens AJ, Champion CB, Gates D, Cilenti D. Pregnancy following minilaparotomy tubal sterilization--an update of an international data set. Contraception. 1987 Feb; 35(2):171-8.

[5.] Awonuga AO, Imudia AN, Shavell VI, Berman J, Diamond MP, Puscheck EE. Failed female sterilization: a review of pathogenesis and subsequent contraceptive options. J Reprod Med. 2009 Sep; 54(9):541-7.

[6.] Coste J, Job-Spira N, Fernandez H, Papiernik E, Spira A. Risk factors for ectopic pregnancy: a case-control study in France, with special focus on infectious factors. Am J Epidemiol. 1991 May 1; 133(9):839-49.

[7.] Herbert B. Peterson, MD, Zhisen Xia, PhD, Joyce M. Hughes, Lynne S. Wilcox, MD. Am J Obstet Gynecol. April 1996; Volume:174; Number: 4

[8.] Sudhir Babu Palli, Vijaya Lakshmi Akkupalli. A study to evaluate the relationship between socioeconomic, demographic characteristics and complications of acceptors in double puncture laparoscopic and conventional tubal ligation procedures. International Journal of Reproduction, Contraception, Obstetrics and Gynecology 2013 Mar;2(1):1-11

[9.] Huggins GR, Sondheimer SJ. Complications of female sterilization: immediate and delayed. Fertil Steril. 1984 Mar; 41(3):337-55.

[10.] Chi IC, Feldblum PJ, Higgins J. Ectopic pregnancies following female sterilization. A matched case-control analysis. Acta Obstet Gynecol Scand. 1984; 63(6):517-21.

[11.] Shah JP, Parulekar SV, Hinduja IN. Journal of Postgraduate Medicine, Year: 1991; Issue:1; Page:17-20

[12.] Iqbal Saleem Mir, Mir Mohsin, Anjum Malik, Basharat Ahad. Successful laparoscopic management of concomitant ectopic pregnancy and acute appendicitis in a patient of failed tubal ligation--case report with a review of the literature. Cases J. 2008; 1: 412.

[13.] Sarath Babu G, Venkata Sujatha V (2013) Adoption of Laparoscopy in a Rural Medical College Hospital: Minimal Access Surgery for Masses a Reality. J Womens Health, Issues Care 2:4. doi:10.4172/2325-9795.1000112.

N. Madhavi (1), V. V. Sujatha (2), Nishita (3)

AUTHORS:

(1.) N. Madhavi

(2.) V. V. Sujatha

(3.) Nishita

PARTICULARS OF CONTRIBUTORS:

(1.) Associate Professor, Department of Obstetrics and Gynaecology, Kamineni Institute of Medical Sciences, Narketpally.

(2.) Professor, Department of Obstetrics and Gynaecology, Pinnemneni Institute of Medical Sciences, Vijayawada.

(3.) Junior Resident, Department of Obstetrics and Gynaecology, Kamineni Institute of Medical Sciences, Narketpally.

FINANCIAL OR OTHER COMPETING INTERESTS: None

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. N. Madhavi, Associate Professor, Department of Obstetrics and Gynaecology, Kamineni Institute of Medical Sciences, Narketpally-508254, Nalagonda District, Telangana State.

E-mail: madhavinacharaju@yahoo.in

Date of Submission: 24/08/2015.

Date of Peer Review: 25/08/2015.

Date of Acceptance: 04/09/2015.

Date of Publishing: 09/09/2015.
Table 1: Distribution of Patients according to the Age

Age of the patient (Years)    Number

21-25                        3(42.8%)
26-30                        2(28.5%)
31-35                        1(14.2%)
36-40                        1(14.2%)

Table 2: Distribution of Patients according type of tubal ligation
and timing of ligation

Type of Tubal Ligation      Number of Patients

Pomeroy technique                6(85.7%)
Laparoscopy(falope ring)         1(14.2%)
Timing of tubal ligation    Number of patients
Postnatal sterilization          4(57.1%)
Caesarean sterilization          2(28.5%)
Interval sterilization           1(14.2%)

Table 3: Distribution of patients according to duration from tubal
ligation

Duration (Years)   Number of Patients

>5                      2(28.5%)
5-10                    4(57.1%)
>10                     1(14.2%)

Table 4: Distribution of patients according to clinical symptoms,
Course of ectopic pregnancy and location of ectopic gestation

Clinical Symptom                Number of Patients

Delayed period                       2(28.5%)
Pain abdomen                         7(100%)
Bleeding per vaginum                 5(71.4%)
Shock                                3(42.8%)
Course of ectopic pregnancy      Number of cases
Unruptured                           1(14.2%)
Tubal abortion                       1(14.2%)
Ruptured                             5(71.4%)
Location of ectopic gestation   Number of patients
Cornual                              1(14.2%)
Isthmic                              1(14.2%)
Site of interruption                 5(71.4%)

Table 5: Management of Ectopic Pregnancies

Management of Ectopic Pregnancy   Number of Patients

Laparotomy                             5(71.4%)
Laparoscopy                            2(28.5%)
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Title Annotation:ORIGINAL ARTICLE
Author:Madhavi, N.; Sujatha, V.V.; Nishita
Publication:Journal of Evolution of Medical and Dental Sciences
Date:Sep 10, 2015
Words:2158
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