Original ArticleMain Risk Factors f

Original Article


Main Risk Factors for Ectopic Pregnancy: A Case-Control Study in A Sample of Iranian Women


Shayesteh Parashi, M.D.1, Somayeh Moukhah, M.Sc.2*, Mahnaz Ashrafi, M.D.1

1. Akbarabadi Hospital, Department of Obstetrics and Gynocology, Collage of Medical Sciences, Iran University of Medical Sciences, Tehran, Iran
2. Department of Midwifery, Collage of Medical Sciences, Tarbiat Modares University, Tehran, Iran

Abstract
Background: Although the risk factors of ectopic pregnancy have been determined in
previous studies, the main risk factors of ectopic pregnancy are different in various coun- tries due to different cultural and social characteristics. Determination of main risk fac- tors of ectopic pregnancy leads to a rapid diagnosis and an improvement in strategies for its prevention. The purpose of this study was to determine the main risk factors of ectopic pregnancy in a sample of Iranian women.

Materials and Methods: We designed a case-control study to include 150 cases and 300 controls and to compare them by the following factors: socio-demographic characteristics, contraceptive methods, prior tubal surgery, tubal pathology, prior ectopic pregnancy, prior caesarean section, prior abortion, prior infertility, and prior abdominal/pelvic surgery.

Results: The case and control groups were significantly similar in term of education and parity. There was an association between ectopic pregnancy and age which was disap- peared after controlling for the main risk factors (adjusted OR=2.45, 95% CI: 0.86-6.97). There was no statistically significant relation between ectopic pregnancy and prior tubal surgery, tubal pathology, prior abortion, prior infertility, assisted reproductive technol- ogy, and oral contraceptive method (p>0.05). However, there was a significant associa- tion between prior ectopic pregnancy, prior tubal ligation, use of intrauterine device, and prior abdominal/pelvic surgery with ectopic pregnancy (p

ผลลัพธ์ (อังกฤษ) 1:

Original ArticleMain Risk Factors for Ectopic Pregnancy: A Case-Control Study in A Sample of Iranian WomenShayesteh Parashi, M.D.1, Somayeh Moukhah, M.Sc.2*, Mahnaz Ashrafi, M.D.11. Akbarabadi Hospital, Department of Obstetrics and Gynocology, Collage of Medical Sciences, Iran University of Medical Sciences, Tehran, Iran2. Department of Midwifery, Collage of Medical Sciences, Tarbiat Modares University, Tehran, IranAbstractBackground: Although the risk factors of ectopic pregnancy have been determined inprevious studies, the main risk factors of ectopic pregnancy are different in various coun- tries due to different cultural and social characteristics. Determination of main risk fac- tors of ectopic pregnancy leads to a rapid diagnosis and an improvement in strategies for its prevention. The purpose of this study was to determine the main risk factors of ectopic pregnancy in a sample of Iranian women.Materials and Methods: We designed a case-control study to include 150 cases and 300 controls and to compare them by the following factors: socio-demographic characteristics, contraceptive methods, prior tubal surgery, tubal pathology, prior ectopic pregnancy, prior caesarean section, prior abortion, prior infertility, and prior abdominal/pelvic surgery.Results: The case and control groups were significantly similar in term of education and parity. There was an association between ectopic pregnancy and age which was disap- peared after controlling for the main risk factors (adjusted OR=2.45, 95% CI: 0.86-6.97). There was no statistically significant relation between ectopic pregnancy and prior tubal surgery, tubal pathology, prior abortion, prior infertility, assisted reproductive technol- ogy, and oral contraceptive method (p>0.05). However, there was a significant associa- tion between prior ectopic pregnancy, prior tubal ligation, use of intrauterine device, and prior abdominal/pelvic surgery with ectopic pregnancy (p<0.05). The risk of ectopic pregnancy increased with the use of intrauterine device and tubal ligation, whereas de- creased with use of oral contraception.Conclusion: This study identified prior ectopic pregnancy, prior tubal ligation, use of intrauter- ine device, and prior pelvic/abdominal surgery as the main risk factors for ectopic pregnancy in a sample of Iranian women. Our findings can be useful for early diagnosis of ectopic pregnancy and for improvement in strategies of its prevention through medical therapy instead of unneces- sarily surgical treatment.Keywords: Ectopic Pregnancy, Risk Factors, Iran Introduction Citation: Parashi Sh, Moukhah S, Ashrafi M. Main risk factors for ectopic pregnancy: a case-control study in a sample of iranian women. Int J Fertil Steril. 2014; 8(2): 147-154. An ectopic pregnancy is a complication of preg- nancy in which the blastocyst implants anywhere outside endometrial cavity of uterine (1). It is the major cause of maternal mortality during early pregnancy and accounts for 10% of all pregnan- cy-related deaths. Furthermore, it increases the chances of infertility as well as incidence of thesubsequent ectopic pregnancy (2).Various risk factors for ectopic pregnancy have been identified (2-5) including previous ectopic pregnancy, previous pelvic surgery, induction of ovulation, intrauterine device usage, history of Received: 13 Nov 2012, Accepted: 6 Jul 2013* Corresponding Address: P.O. Box: 14115-111, Department of Mid- wifery, Collage of Medical Sciences, Tarbiat Modares University, Tehran, IranEmail: [e-mail] Royan InstituteInternational Journal of Fertility and SterilityVol 8, No 2, Jul-Sep 2014, Pages: 147-154 147 pelvic inflammatory disease (PID), and smoking at the time of conception (2, 6-9). To consider that Iranian women have the certain characteristics (cultural, religious, and traditional values), socio- demographic determinants, sexual behavior and beliefs, and contraception preference, they may have different risk factor profile for ectopic preg- nancy compared to women from other countries. Understanding the main risk factors of ectopic pregnancy is valuable due to following factors: rapid diagnosis, less need for surgery, less com- plications, and an improvement in strategies for prevention of ectopic pregnancy. This study was therefore undertaken to determine the main risk factors of ectopic pregnancy in a sample of Iranian women.Materials and MethodsThis case-control study was conducted at Sha- hid Akbarabady Hospital in Tehran, Iran, from March 2006 to May 2011. The data were collect- ed from a total of 300 pregnant women as con- trols and of 150 case-patient women whose di- agnosis of ectopic pregnancy was confirmed by menstrual history, physical examination, serial beta-human chorionic gonadotropin (βhCG), and abdominal/transvaginal ultrasound. There was a history of delayed or skipped menses in women. Initial symptoms were nonspecific, consisting of a period of amenorrhea and ab- dominal pain or tenderness, with or without unexpected vaginal bleeding. New onset pain was reported, dull or sharp in nature, which was generalized or localized to one area. Further- more, they complained about spotty or irregular vaginal bleeding. Early physical examination findings included cervical motion tenderness and abdominal tenderness on abdominal palpa- tion.All data were collected from the hospital’s medi- cal records, while one woman in case group was compared with two women in the control group at the same time. A questionnaire completed by the corresponding author for the patient in case group involved demographic characteristics, menstrual history, present pregnancy status, diagnostic ac- tions, and management, whereas for women in control group, the last two items, i.e. diagnostic actions and management, were omitted from ques- tionnaire.
Several studies (9-12) have categorized the in- tensive risk factors as follows: prior tubal surgery, prior tubal pathology, and prior ectopic preg- nancy, while infertility as moderate risk factor and prior abdominal/pelvic surgery as low-risk factors have been considered for incidence of ectopic pregnancy. Similarly, in the current in- vestigation, such risk factors were categorized, analyzed, and presented.

Statistical analysis

We used Statistical Package for Social Sci- ence (SPSS; SPSS Inc., Chicago, IL, USA) ver- sion 16 for data analysis. Odds ratio (OR) and 95% confidence intervals (CI) obtained after binary logistic regression were used to describe the association between ectopic pregnancy and potential risk factors. Multivariable modeling was employed to determine which factors were associated with ectopic pregnancy, while the association was adjusted for other variables. In this model, we only included variables that were associated with the risk of ectopic preg- nancy in univariate analysis.

Ethical considerations

Our study was a retrospective study including patient files, and we did not directly contact with patient, but our study was confirmed by Ethical Committee of the Shahid Akbarabadi Hospital.

Results

The data for socio-demographic character- istics (age and educational level), parity, and abortion of women in cases and controls are presented in table 1. The average age of wom- en in case and control groups was 28.7 ± 6.0 years (range 16-44 years) and 26.4 ± 5.6 years (range 17-46 years), respectively. The association between ectopic pregnancy and age (Table 1) disappeared after controlling for the main risk factors (Table 2). The case and control group had similar parity as well as educational level (Table 1). The common chief compliance in women with ectopic pregnancy was bleeding and pain.




Table 1: Comparison of age, educational level, parity and abortion of subjects between case and control groups from March 2006 to May 2011

Case (n=150)

N (%) Control (n=300)

N (%) Crude OR 95% CI

Women´s age (Y)

16-20
10 (6.7)
49 (16.3)
0.36
0.18-0.74

21-25
35 (23.3)
102 (34.0)
0.59
0.37-0.92

26-30
50 (33.3)
78 (26.0)
1.42
0.92-2.18

31-35
31 (20.7)
51 (17.0)
1.27
0.77-2.09

≥36
24 (16.0)
20 (6.7)
1
-

Educational level

0-8
79 (52.7)
172 (57.3)
0.88
0.29-2.71

9-12
55 (36.7)
87 (29.0)
1.38
0.44-4.27

13-18
7 (4.7)
12 (4.0)
1
-

Missing
9 (6.0)
29 (9.7)

Parity

0
56 (37.3)
152 (50.7)
1.14
0.54-2.4

1
61 (40.7)
91 (30.3)
1.30
0.66-2.57

≥2
33 (22.0)
57 (19.0)
1

Abortion

0
66 (44)
257 (85.7)
0.13
0.08-0.21

1
63 (42)
32 (10.7)
6.33
3.87-10.35

≥2
21 (14)
11 (3.7)
1
-

OR; Odds ratio and CI; Confidence interval.




The comparison of contraceptive methods among the two groups is shown in table 3. A to- tal number of 34 (22.7%) patients in case group and 14 (4.7%) subjects in control group used in- trauterine device (IUD) at the time of conception. The oral contraceptive method was recorded in 8 (5.3%) and 24 (8.0%) subjects of case and con- trol groups, respectively. The usage of tubal liga- tion (TL) was observed in 12 (8%) and 5 (1.7%) women of case and control groups, respectively. Overall, it was revealed that the usage of IUD and TL significantly increased risk of ectopic preg- nancy (adjusted OR=4.79, 95% CI:1.61-14.21 and

adjusted OR=4.49, 95% CI:1.16-17.28, respec- tively), whereas oral contraceptives decreased risk of ectopic pregnancy (adjusted OR=0.7, 95% CI:0.23-2.15) (Table 2).

Table 3 presents the association of three catego- ries of risk factors (high, moderate, and low) with incidence of ectopic pregnancy. It was observed that the risk factors of ectopic pregnancy in women are previous tubal surgery, tubal pathology, assist- ed reproductive technology (ART), sterilization, previous ectopic pregnancy, IUD usage, infertility, and abdominal/pelvic surgery.







Table 2: Main risk factors of ectopic pregnancy

ผลลัพธ์ (อังกฤษ) 2:

Original Article Risk Factors for Ectopic Pregnancy Main: A Case-Control Study in A Sample of Iranian Women Shayesteh Parashi, MD1, Somayeh Moukhah, M.Sc.2 *, Mahnaz Ashrafi, MD1 1. Akbarabadi Hospital, Department of Obstetrics and Gynocology, Collage of Medical Sciences, Iran University of Medical Sciences, Tehran, Iran 2. Department of Midwifery, Collage of Medical Sciences, Tarbiat Modares University, Tehran, Iran Abstract Background: Although the risk of ectopic Pregnancy factors have been determined in previous Studies, the main risk factors of ectopic Pregnancy are different in Various Coun- tries Due to different. cultural and social characteristics. Determination of main risk fac- tors of ectopic pregnancy leads to a rapid diagnosis and an improvement in strategies for its prevention. The purpose of this Study was to Determine the main risk factors of ectopic Pregnancy in a sample of Iranian Women. Materials and Methods: We designed a Case-Control Study to include 150 Cases and 300 Controls and to compare them by the following factors: Socio. -demographic characteristics, contraceptive methods, prior tubal Surgery, tubal Pathology, prior ectopic Pregnancy, prior caesarean section, prior abortion, prior infertility, and prior abdominal / pelvic Surgery. Results: The Case and Control groups were significantly Similar in term of Education and. parity. There was an association between ectopic pregnancy and age which was disap- peared after controlling for the main risk factors (adjusted OR = 2.45, 95% CI: 0.86-6.97). There was no statistically significant relation between ectopic pregnancy and prior tubal surgery, tubal pathology, prior abortion, prior infertility, assisted reproductive technol- ogy, and oral contraceptive method (p> 0.05). However, there was a significant associa- tion between prior ectopic pregnancy, prior tubal ligation, use of intrauterine device, and prior abdominal / pelvic surgery with ectopic pregnancy (p <0.05). The risk of ectopic Pregnancy Increased use of intrauterine with the tubal ligation and Device, use of oral contraception whereas de-Creased with. Conclusion: This Study identified prior ectopic Pregnancy, tubal ligation prior, use of Intrauter- ine Device, and prior pelvic /. abdominal surgery as the main risk factors for ectopic pregnancy in a sample of Iranian women. Can be useful for our findings Early diagnosis of ectopic Pregnancy and Strategies for Improvement in Medical Therapy of ITS Prevention Through Unneces- Sarily instead of Surgical Treatment. Keywords: Ectopic Pregnancy, Risk Factors, Iran Introduction Citation: Sh Parashi, Moukhah S, M Ashrafi. . Main risk factors for ectopic pregnancy: a case-control study in a sample of iranian women. Int J Fertil Steril. 2014; 8 (2): one hundred forty-seven to one hundred and fifty-four. An ectopic Pregnancy complications of Preg- Nancy is a blastocyst implants in which the endometrial cavity Anywhere Outside of uterine (1). It is the major cause of maternal mortality during early pregnancy and accounts for 10% of all pregnan- cy-related deaths. Furthermore, it increases the chances of infertility As well As the incidence of ectopic Subsequent Pregnancy (2). Various risk factors have been identified for ectopic Pregnancy (2-5) including previous ectopic Pregnancy, previous pelvic Surgery, induction of ovulation, intrauterine Device. usage, history of Received: Nov 13 two thousand and twelve, Accepted: 6 Jul 2013 * corresponding Address: PO Box: 14115 to 111, Department of Mid-Wifery, Collage of Medical Sciences, Tarbiat Modares University, Tehran, Iran Email: @ So.moukhah. gmail.com Royan Institute International Journal of Fertility and sterility Vol 8, No 2, Jul-Sep 2,014th, Pages: one hundred and forty-seven to one hundred and fifty-four 147 pelvic inflammatory disease (PID), and smoking at the time of conception (2, 6-9). To consider that Iranian women have the certain characteristics (cultural, religious, and traditional values), socio- demographic determinants, sexual behavior and beliefs, and contraception preference, they may have different risk factor profile for ectopic preg- nancy compared to women from other. countries. Understanding the main risk factors of ectopic pregnancy is valuable due to following factors: rapid diagnosis, less need for surgery, less com- plications, and an improvement in strategies for prevention of ectopic pregnancy. Study this was therefore undertaken to Determine the main risk factors of ectopic Pregnancy in a sample of Iranian Women. Materials and Methods Case-Control Study This was conducted at SHA HID Akbarabady Hospital in Tehran, Iran, from March to May 2011. The the 2,006th. data were collect- ed from a total of 300 pregnant women as con- trols and of 150 case-patient women whose di- agnosis of ectopic pregnancy was confirmed by menstrual history, physical examination, serial beta-human chorionic gonadotropin (βhCG), and. abdominal / transvaginal ultrasound. There was a history of delayed or skipped menses in women. Initial symptoms were nonspecific, consisting of a period of amenorrhea and ab- dominal pain or tenderness, with or without unexpected vaginal bleeding. New onset pain was reported, dull or sharp in nature, which was generalized or localized to one area. Further- more, they complained about spotty or irregular vaginal bleeding. Early physical Examination findings included cervical and abdominal Motion Tenderness Tenderness on abdominal Palpa- tion. All Collected Data were from the Hospital's Medi-CAL records, while one woman in Case Group was compared with the Control Group in Two Women at the Same time. A questionnaire completed by the corresponding Author for the Patient Demographic characteristics involved in Case Group, menstrual history, present Pregnancy Status, Diagnostic AC tions, and Management, whereas for Women in Control Group, the last Two items, IE Diagnostic and Management Actions,. were omitted from Ques- Tionnaire. Several Studies (9-12) have categorized the risk factors in-Tensive As follows: prior tubal Surgery, Pathology prior tubal, and prior ectopic Preg- Nancy, while moderate risk factor infertility As and prior abdominal /. pelvic surgery as low-risk factors have been considered for incidence of ectopic pregnancy. Similarly, in the current in-Vestigation, such risk factors were categorized, analyzed, and Presented. Statistical Analysis We used Statistical Package for Social Sci ence (SPSS; SPSS Inc., Chicago, IL, USA) VER sion 16 for Data. analysis. Odds ratio (OR) and 95% confidence intervals (CI) obtained after binary logistic regression were used to describe the association between ectopic pregnancy and potential risk factors. Multivariable modeling was employed to determine which factors were associated with ectopic pregnancy, while the association was adjusted for other variables. In this Model, we only included variables that were associated with the risk of ectopic Preg- Nancy in univariate Analysis. Ethical Considerations Our Study Study was a retrospective including Patient Files, and we did not directly Patient Contact with, but was confirmed by our Study. Ethical Committee of the Shahid Akbarabadi Hospital. Results for Socio-Demographic Data The Character- Istics (Age and educational level), parity, and abortion of Women in Cases and Controls are in Table 1. The average Presented Age of Wom- en in Case. and control groups was 28.7 ± 6.0 years (range 16-44 years) and 26.4 ± 5.6 years (range 17-46 years), respectively. The association between ectopic pregnancy and age (Table 1) disappeared after controlling for the main risk factors (Table 2). The case and control group had similar parity as well as educational level (Table 1). The common Chief compliance in Women with ectopic Pregnancy was bleeding and Pain. Table 1: Comparison of Age, educational level, parity and abortion of subjects between Case and Control groups from March 2006th to May 2,011th Case (n = 150) N (%). Control (n = 300) N (%) Crude OR 95% CI Women's Age (Y) 16-20 10 (6.7) 49 (16.3) 00:36 .18-0.74 21-25 35 (23.3) 102 (34.0) 0.59 0.37. -0.92 26-30 50 (33.3) 78 (26.0) 1.42 .92-2.18 31-35 31 (20.7) 51 (17.0) 1.27 .77-2.09 ≥36 24 (16.0) 20 (6.7) 1 - Educational level 0-8 79. (52.7) 172 (57.3) 0.88 0.29 to 2.71 9-12 55 (36.7) 87 (29.0) one thirty-eight 0:44 to 4:27 13-18 7 (4.7) 12 (4.0) 1 - Missing 9 (6.0) 29 (9.7) Parity 0. 56 (37.3) 152 (50.7) 1.14 from 0.54 to 2.4 1 61 (40.7) 91 (30.3) 1.30 from 0.66 to 2.57 ≥2 33 (22.0) 57 (19.0) 1 Abortion 0 66 (44) 257 (85.7) 0.13 0:08 to 12:21. 1 63 (42) 32 (10.7) six thirty-three from 3.87 to 10.35 ≥2 21 (14) 11 (3.7) 1 - OR; Odds ratio and CI; Confidence interval. The comparison of contraceptive methods among the groups is shown in Table 3. Two A to-tal Number of 34 (22.7%) Patients in Case Group and 14 (4.7%) subjects in Group used in-Trauterine Control Device (IUD. ) at the time of conception. The oral contraceptive method was recorded in 8 (5.3%) and 24 (8.0%) subjects of case and con- trol groups, respectively. The usage of tubal liga- tion (TL) was observed in 12 (8%) and 5 (1.7%) women of case and control groups, respectively. Overall, it was revealed that the usage of IUD and TL significantly Increased risk of ectopic Preg- Nancy (adjusted OR = 4.79, 95% CI: 1.61 to 14.21 and adjusted OR = four forty-nine, 95% CI: 1.16 to 17.28, Respec- tively. ), whereas oral contraceptives Decreased risk of ectopic Pregnancy (adjusted OR = 0.7, 95% CI: from .23 to 2.15) (Table 2). Table 3 presents the association of Three Catego- Ries of risk factors (High, moderate, and low). with incidence of ectopic pregnancy. It was observed that the risk factors of ectopic Pregnancy in Women are previous tubal Surgery, tubal Pathology, Assist- ED Reproductive Technology (ART), Sterilization, previous ectopic Pregnancy, IUD usage, infertility, and abdominal / pelvic Surgery. Table 2: Main. risk factors of ectopic pregnancy

ผลลัพธ์ (อังกฤษ) 3:

Original Article


Main Risk Factors for Ectopic Pregnancy: A Case-Control Study in A Sample of Iranian Women


Shayesteh. Parashi M.D.1 Somayeh Moukhah,,,,, M.Sc.2 * Mahnaz Ashrafi M.D.1

1. Akbarabadi Hospital Department of, Obstetrics, and Gynocology. Collage of, Medical Sciences Iran University of, Medical Sciences Tehran Iran
, 2. Department of Midwifery Collage of, Medical. Sciences.Tarbiat, Modares University Tehran Iran


, Abstract Background: Although the risk factors of ectopic pregnancy have been. Determined in
previous studies the main, risk factors of ectopic pregnancy are different in various coun - tries due to different. Cultural and social characteristics.Determination of main risk fac - tors of ectopic pregnancy leads to a rapid diagnosis and an improvement in strategies for. Its prevention. The purpose of this study was to determine the main risk factors of ectopic pregnancy in a sample of Iranian. Women.

Materials and Methods: We designed a case-control study to include 150 cases and 300 controls and to compare them. By the following factors:Socio-demographic, methods characteristics contraceptive, tubal, prior surgery tubal pathology prior ectopic pregnancy,,, Prior Caesarean section prior, infertility, abortion prior, prior and abdominal / pelvic surgery.

Results: The case and control. Groups were significantly similar in term of education and parity.There was an association between ectopic pregnancy and age which was disap - peared after controlling for the main risk. Factors (adjusted OR = 2.45 95%, CI: 0.86-6.97). There was no statistically significant relation between ectopic pregnancy. And prior surgery tubal, pathology tubal, abortion prior, infertility prior, reproductive assisted technol - ogy and oral,, Contraceptive method (P > 0.05).However there was, a significant Associa - tion between prior ectopic pregnancy prior ligation use, tubal, of intrauterine. Device and prior, abdominal / pelvic surgery with ectopic pregnancy (P < 0.05). The risk of ectopic pregnancy increased with. The use of intrauterine device and, tubal ligation whereas de - creased with use of oral contraception.

Conclusion:This study identified prior ectopic pregnancy prior tubal, ligation use of, intrauter - ine device and prior, pelvic / abdominal. Surgery as the main risk factors for ectopic pregnancy in a sample of Iranian women.Our findings can be useful for early diagnosis of ectopic pregnancy and for improvement in strategies of its prevention. Through medical therapy instead of unneces - sarily surgical treatment.

Keywords: Ectopic Pregnancy, Risk Factors, Iran

.





Citation Introduction: Parashi, S Ashrafi Sh Moukhah, M. Main risk factors for ectopic pregnancy: a case-control study. In a sample of Iranian women.Int J Fertil Steril. 2014; 8 (2): 147-154.


An ectopic pregnancy is a complication of preg - Nancy in which the blastocyst. Implants anywhere outside endometrial cavity of uterine (1). It is the major cause of maternal mortality during early pregnancy. And accounts for 10% of all pregnan - cy-related deaths. Furthermore it increases, the

chances of infertility as well as. Incidence of the
.Subsequent ectopic pregnancy (2).

Various risk factors for ectopic pregnancy have been identified (2-5) including previous. Ectopic pregnancy previous surgery, pelvic, ovulation induction of, device, intrauterine usage history of




Received: 13, Nov 2012 Accepted: 6 Jul. 2013
* Corresponding Address: P.O. Box: 14115-111 Department of, Mid - wifery Collage of Medical Sciences,,Tarbiat, Modares University Tehran Iran
, Email: [e-mail] Royan Institute
International Journal of Fertility. And Sterility
Vol 8 No, 2014, 2, Jul-Sep Pages: 147-154












147 pelvic inflammatory disease (PID), and smoking. At the time of, conception (2 6-9). To consider that Iranian women have the certain characteristics (cultural religious,,, And traditional values),