Ectopic pregnancy poses significant risks to maternal health, being a major cause of morbidity and mortality, particularly in the first trimester. It occurs when a fertilized ovum implants outside the uterine cavity, with 97% occurring in the fallopian tubes and the remainder in locations such as the cervix, ovary, peritoneal cavity, or uterine scars. This condition accounts for 3.5–7.1% of maternal deaths in India and has a case-fatality rate 10 times higher in developing countries compared to developed nations [1]. Left untreated, ectopic pregnancy can lead to life-threatening complications, including rupture, internal bleeding, shock, and organ failure. The ampullary region of the fallopian tube is the most common site of implantation. Heterotopic pregnancies, though rare in natural conception cycles (<1/30,000 pregnancies), are more frequent in assisted reproductive technology (ART) cycles (1 in 100 pregnancies) [2]. Risk factors include prior pelvic or abdominal surgery, pelvic infections (e.g., Chlamydia trachomatis), sexually transmitted diseases, tubal sterilization, intrauterine device use, ART, and tubal reconstructive surgeries, all of which increase the likelihood of fallopian tube damage. Clinically, ectopic pregnancy presents a spectrum of symptoms, ranging from asymptomatic cases to acute hemoperitoneum and shock. Common symptoms include pain and vaginal bleeding between 6 and 10 weeks of gestation. Physical findings such as abdominal tenderness, cervical excitation, and adnexal tenderness aid in diagnosis. Complications can include disseminated intravascular coagulation (DIC), renal failure, and pulmonary embolism, often leading to maternal death. Early diagnosis using ultrasonography and serum β-human chorionic gonadotropin (β-hCG) levels significantly reduces the risk of rupture and enables more conservative treatments.[3] Management of ectopic pregnancy depends on clinical presentation, site of implantation, and reproductive goals. Hemodynamically stable patients with unruptured ectopic pregnancies and specific criteria—such as adnexal masses <3.5 cm, absent cardiac activity, and β-hCG levels <1,000 mIU/ml—are eligible for medical management with methotrexate (50 mg/m²). Serial β-hCG measurements monitor treatment efficacy. Failure of medical therapy requires surgical intervention, typically via laparoscopy or laparotomy. Procedures include salpingectomy, salpingo-oophorectomy, or salpingotomy. While conservative surgeries preserve reproductive potential, they carry the risk of persistent ectopic tissue. Recent advancements favor minimally invasive procedures and medical management for unruptured ectopic pregnancies [4]. Laparoscopy and medical therapy have demonstrated reduced morbidity, shorter hospital stays, and better fertility preservation compared to traditional methods. Improved diagnostic tools, advanced surgical techniques, anesthesia, and access to blood transfusions have reduced ectopic pregnancy mortality by 90% over the last decade, significantly improving maternal outcomes [5]. This study aimed to comprehensively analyze the incidence, risk factors, clinical presentation, and management outcomes of ectopic pregnancies.

This prospective observational study was conducted at the Department of Obstetrics and Gynecology, Pacific Medical College and Hospital, Udaipur. A total of 51 patients diagnosed with ectopic pregnancy were enrolled during the study period using convenient sampling, following written informed consent. Data collection involved semi-structured questionnaires, physical examinations, laboratory investigations, and radiological evaluations. Participants were evaluated through detailed history-taking and clinical examination. History included patient identity, symptoms such as amenorrhea, acute abdominal pain, vaginal bleeding (including its duration and nature), syncope, vomiting, urinary or rectal symptoms, fever, and other associated complaints. Menstrual and obstetric histories were reviewed, focusing on infertility, prior ectopic pregnancies, previous surgeries (e.g., dilatation and curettage, tubal surgeries, appendectomies), and pelvic inflammatory disease or tuberculosis. Contraceptive methods used, such as intrauterine devices or oral pills, were also documented. Clinical evaluations comprised general examinations for anemia, shock, and vital signs, followed by abdominal and vaginal examinations to detect masses, tenderness, or signs of intra-abdominal bleeding. Additional assessments included per-rectal examinations when necessary. Investigations included complete blood count, blood grouping, renal function tests, coagulation profiles, random blood sugar, and infectious disease screening. Diagnostic tests included urine pregnancy tests, serum β-hCG levels, and transabdominal or transvaginal ultrasonography. Management was categorized as elective or emergency and included medical or surgical interventions based on clinical presentation and available resources. Treatment modalities aimed to stabilize the patient and resolve the ectopic pregnancy effectively.

The majority of cases (78.43%) were aged 21–30 years, with no cases below 20 years. Multigravida women accounted for 66.67% of cases. Common symptoms included abdominal pain (92.15%) and amenorrhea (80.39%), while 29.41% presented with shock. A small proportion (5.88%) had a history of assisted reproductive technology (ART).[Table 1] Nearly one-third of cases (31.37%) had no identifiable risk factors. IUCD use and a history of pelvic inflammatory disease (PID) were present in 9.8% and 15.68% of cases, respectively. Elevated beta-hCG levels (>8000 mIU/mL) were noted in 45.09% of cases, while hemoglobin levels >10 g/dL were observed in 47.05%, and <6 g/dL in 9.8%. [Table 2] The majority of ectopic pregnancies (84.31%) were tubal, with ampullary pregnancies being the most common (66.66%). Ruptured ectopic cases accounted for 56.86%, while 49.01% had hemoperitoneum <500 mL. Scar ectopic pregnancies were identified in 13.72% of cases. [Table 3] Surgical management was predominant (94.11%), with nearly equal distribution between open salpingectomy (47.05%) and laparoscopic salpingectomy (45.09%). Blood transfusions were required in 52.94% of cases, with the remaining 47.05% not needing transfusion.[Table 4] Postoperatively, 70.58% of cases were stable, and 29.41% experienced anemia or other unstable conditions. Elective and emergency surgeries were nearly evenly split, with elective procedures accounting for 50.98%. [Table 5] Acute ectopic pregnancies dominated the cases (96.07%), with the majority being right tubal ectopics (45.09%) followed by left tubal (41.17%). Scar ectopic pregnancies were noted in 13.72%, and laparotomy (50.98%) was slightly more common than laparoscopy (45.09%). [Table 6] Table 1: Demographics and Clinical Features Parameter Frequency Percentage (%) Age: Age <20 0 0 Age 21–30 40 78.43 Age 31–40 9 17.64 Age ≥40 2 3.92 Gravida: Primigravida 17 33.33 Multigravida 34 66.67 History and symptoms: History of ART 3 5.88 Amenorrhea 41 80.39 Abdominal Pain 47 92.15 Spotting/Bleeding PV 35 68.62 Shock 15 29.41 Table 2: Risk Factors and Investigations Parameter Frequency Percentage (%) No Risk Factors 16 31.37 IUCD History 5 9.80 Treated for PID 8 15.68 Beta hCG Levels (100–1000) 18 35.29 Beta hCG Levels (>8000) 23 45.09 Hemoglobin >10 g/dL 24 47.05 Hemoglobin <6 g/dL 5 9.80 TLC (4000–6000) 14 27.45 TLC (10000–12000) 17 33.33 Table 3: Ectopic Pregnancy Sites and Ultrasound Findings Parameter Frequency Percentage (%) Tubal Ectopic Pregnancy 43 84.31 Ovarian Ectopic Pregnancy 1 1.96 Scar Ectopic Pregnancy 7 13.72 Ampullary Tubal Pregnancy 34 66.66 Ruptured Cases 29 56.86 Unruptured Cases 10 19.60 Hemoperitoneum <500 mL 25 49.01 Hemoperitoneum >1500 mL 6 11.76 Table 4: Management Approaches and Perioperative Findings Parameter Frequency Percentage (%) Medical Management 3 5.88 Surgical Management 48 94.11 Open Salpingectomy 24 47.05 Laparoscopic Salpingectomy 23 45.09 Blood Transfusion (≥1 unit) 27 52.94 No Blood Transfusion 24 47.05 Table 5: Postoperative and Clinical Outcomes Parameter Frequency Percentage (%) Stable Postoperative Condition 36 70.58 Unstable Postoperative Condition 15 29.41 Anemia 15 29.41 Wound Gaping 0 0 Elective Surgery 26 50.98 Emergency Surgery 25 49.01 Table 6: Summary of Findings Parameter Frequency Percentage (%) Acute Ectopic Pregnancy 49 96.07 Chronic Ectopic Pregnancy 2 3.92 Right Tubal Ectopic Pregnancy 23 45.09 Left Tubal Ectopic Pregnancy 21 41.17 Scar Ectopic Pregnancy 7 13.72 Laparotomy 26 50.98 Laparoscopy 23 45.09 Hysteroscopy 2 3.92

The present prospective observational study found the incidence of ectopic pregnancy to be 2.125 per 100 deliveries, which is comparable to the findings of Ranji GG et al. [6] (2.81/100 deliveries), Radhika Pusluri et al. [7] (3/100 deliveries), and Sindura et al. (3.14/100 deliveries) [8]. However, the incidence was higher than that reported by the ICMR task force 1990, Vijay Kalyankar et al [9]. The higher incidence in our study could be attributed to the fact that our institution is a tertiary care center with many referred cases from the periphery. The majority of women in our study were in the age group of 21-30 years, similar to the findings of Swami et al. and Ranji GG et al. [11,8]. This could be due to early marriage and childbearing in our study area. Multigravida accounted for 66.67% of the cases, which is comparable to the results of Sidhura et al. (72.15%), Ranji GG et al. (60.5%), and Swami et al. (64.71%) [6,8,11]]. The higher incidence in multigravida could be explained by the increased prevalence of risk factors such as PID, abortion, MTP pill intake, previous cesarean section, ART, and tubal surgeries. The classic triad of amenorrhea, abdominal pain, and bleeding per vaginum was observed in 68.62% of our cases, highlighting the need for a high index of suspicion in diagnosing ectopic pregnancy. Previous abortions (21.56%), PID (15.68%), MTP pill consumption (13.72%), and IUCD insertion (9.80%) were the most common risk factors identified in our study, which is consistent with the findings of Radhika Pusulori et al. [7] and Shreya Barik et al. [12]. Abdominal tenderness was the predominant clinical finding in our study (76.47%), followed by fullness in the pouch of Douglas (64.70%) and positive cervical excitation test (45.09%). These results are similar to those reported by Tahmina S et al., Ranji GG et al., and Vijay Kalyankar et al. [6,9,13]. Tubal ectopic pregnancy was the most common type (84.31%), with the ampulla being the most frequent site of implantation (66.66%). Scar ectopic pregnancy accounted for 13.72% of the cases, which is higher than the incidence reported in other studies, [6,9] probably due to the rising cesarean section rates globally. The incidence of right and left tubal ectopic pregnancies was almost similar in our study. Surgical management was the primary treatment modality in 94.11% of the cases, with open salpingectomy (47.05%) and laparoscopic salpingectomy (45.09%) being the most common procedures performed. These findings are consistent with the results of Vijay Kalyankar et al., and Radhika Pusulori et al. [7,9]. Medical management was attempted in 5.88% of the cases but eventually failed, leading to surgical intervention. The number of elective and emergency surgeries was almost equal in our study, indicating that early recognition of signs and symptoms and prompt diagnosis can significantly decrease the severity of ectopic pregnancy. Blood transfusion was required in 52.95% of the patients, with 23.52% receiving one unit of packed red blood cells (PRBC) and 19.60% receiving two units. These results are comparable to the data reported by Radhika Pusulori et al., Swami et al., and Ranji GG et al. [7,9,11]. Postoperatively, 70.58% of the patients were stable, while 29.41% had anemia but were later stabilized. No patients had wound gaping, and there was no mortality in the present study due to early diagnosis, modern anesthesia, blood transfusion facilities, immediate resuscitation, and prompt surgery. The absence of mortality in this study underscores the importance of early diagnosis, modern surgical techniques, effective blood transfusion facilities, and prompt intervention. These advancements have shifted the focus from reducing maternal mortality to fertility-preserving surgeries and tubal salvaging, ensuring better long-term reproductive outcomes. This study highlights the critical need for timely management and the importance of public awareness to reduce the severity and complications associated with ectopic pregnancies.

Ectopic pregnancy remains a significant gynecological emergency with potential life-threatening consequences and risks to future fertility if not managed promptly. Most cases occur in reproductive-age women, but vigilance is necessary across all age groups, particularly in those with risk factors. Accurate diagnosis relies on thorough history-taking, clinical examination, and the use of urine pregnancy tests, serum Beta-hCG, and ultrasonography. While surgical management dominates, individualized approaches focusing on hemodynamic stability and fertility preservation are crucial. Preventive measures, including education on safe abortion practices and regulated MTP pill use, are vital. Our study highlights demographic and clinical trends, advocating for early detection, advanced surgical techniques, and fertility-preserving strategies.

1. Sivalingam VN, Duncan WC, Kirk E, Shephard LA, Horne AW. Diagnosis and management of ectopic pregnancy. J Fam Plann Reprod Health Care. 2011 Oct;37(4):231–40. 2. Barrenetxea G, Barinaga-Rementeria L, Lopez de Larruzea A, Agirregoikoa JA, Mandiola M, Carbonero KH. Heterotopic pregnancy: two cases and a comparative review. Fertil Steril. 2007;87(2):417.e9–417.e15. 3. Varma R, Gupta J. Tubal ectopic pregnancy. BMJ Clin Evid. 2009 Apr 20;2009:1406. 4. Mohamed H, Maiti S, Phillips G. Laparoscopic management of ectopic pregnancy: a 5-year experience. J Obstet Gynaecol. 2002;22:411–4. 5. Tozer AJ, Shaxted E. A review of the use of minimal invasive surgery in the management of ectopic pregnancy in a district general hospital. Gynaecol Endosc. 1996;5:21–4. 6. Ranji GG. Ectopic pregnancy: risk factors, clinical presentation and management. J Obstet Gynaecol India. 2018;68(6):487–92. 7. Pusuloori R, Arora KD. A comparative study of ectopic pregnancy at a tertiary care center. Int J Reprod Contracept Obstet Gynecol. 2018 Feb;7(2):694–9. 8. Sindhura M. Trends in ectopic pregnancy: a retrospective clinical study of 79 cases. J Evid Based Med Healthc. 2017 Jul;6(7):79–83. 9. Kalyankar V, Kalyankar B, Gadappa S, Ahire Y. Clinical study of ectopic pregnancy. New Indian J OBGYN. 2022;9(1):148–54. 10. Nahar K. Study on risk factors, clinical presentation & operative management of ectopic pregnancy. Bangladesh J Obstet Gynaecol. 2013;28(1):9–14. 11. Swami MB, Sharma P, Tyagi M, Kuswaha R, Harit J. Clinical study of ectopic pregnancy. J Evol Med Dent Sci. 2015 Oct;4(86):15057–61. 12. Barik S, Malakar A, Laha S. Trends in ectopic pregnancy: a prospective observational study from a tertiary care center in eastern India. J South Asian Feder Obst Gynae. 2022;12(3):172–7. 13. Tahmina S, Daniel M, Solomon P. Clinical analysis of ectopic pregnancies in a tertiary care centre in southern India: a six-year retrospective study. J Clin Diagn Res. 2016 Oct;10(10):QC13–6.