Project – Assessment of Risk Factors Associated with Ectopic Pregnancy among Women of Reproductive Age: A Case Study of Lagos University Teaching Hospital (LUTH), Idi-Araba, Lagos State.

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Ectopic pregnancy is a potentially life-threatening obstetric condition in which a fertilised ovum implants outside the normal endometrial cavity of the uterus. The fallopian tube is the most common site of implantation, particularly the ampullary region, although ectopic pregnancies may also occur in the interstitial portion of the tube, ovary, cervix, caesarean section scar, or abdominal cavity. The condition is a significant concern in reproductive health because the affected pregnancy cannot develop normally within the extrauterine environment, and the growing gestational tissue may cause rupture, internal haemorrhage, and maternal death if diagnosis and treatment are delayed. Ectopic pregnancy also has implications for subsequent fertility and psychological well-being, especially among women who experience pregnancy loss or require surgical removal of a fallopian tube. The clinical importance of the condition is therefore not limited to its immediate danger but extends to women’s reproductive health and quality of life. The American College of Obstetricians and Gynecologists (ACOG, 2018) identifies ectopic pregnancy as an important cause of pregnancy-related morbidity and mortality, while the Royal College of Obstetricians and Gynaecologists (RCOG, n.d.) emphasises the need for prompt recognition and appropriate management to reduce serious complications.

The burden of ectopic pregnancy varies across populations and healthcare settings, reflecting differences in reproductive health conditions, access to early antenatal care, diagnostic capacity, and the prevalence of associated risk factors. Although early diagnosis has improved in many settings through the use of transvaginal ultrasonography and serial measurements of serum beta-human chorionic gonadotropin (β-hCG), some women continue to present with advanced complications because early symptoms may be mild, nonspecific, or mistaken for other conditions. Common clinical manifestations include lower abdominal or pelvic pain, vaginal bleeding, dizziness, and weakness, while tubal rupture may produce severe abdominal pain, circulatory instability, and haemorrhagic shock. ACOG (2018) explains that clinical assessment, ultrasonography, and laboratory investigations are central to identifying ectopic pregnancy and determining appropriate management. Similarly, Kirk et al. (2014) highlight the importance of combining clinical evaluation with ultrasound and biochemical assessment in early pregnancy complications. These findings demonstrate that the outcome of ectopic pregnancy depends not only on its occurrence but also on how quickly the condition is recognised and treated.

Women of reproductive age constitute the principal population affected by ectopic pregnancy because the condition is associated with conception and early pregnancy. The reproductive years encompass different biological and social circumstances, including changes in age-related fertility, sexual and reproductive health practices, contraceptive use, pregnancy intention, and previous obstetric experiences. These factors may influence the likelihood of conception and exposure to conditions associated with abnormal implantation. However, ectopic pregnancy should not be understood as a condition affecting only women with an identifiable risk factor, since it can occur in women without a recognised history of reproductive complications. Among the established risk factors, previous ectopic pregnancy, tubal damage, pelvic inflammatory disease, previous tubal surgery, and assisted reproductive technology are particularly relevant. Bouyer et al. (2003), in a population-based case-control study, identified several factors associated with ectopic pregnancy, including previous ectopic pregnancy, tubal damage, and reproductive history. ACOG (2018) likewise identifies previous ectopic pregnancy, tubal surgery, and certain reproductive health conditions as important considerations in assessing risk. Understanding these factors among women of reproductive age is essential for improving prevention, early detection, and reproductive health counselling.

One of the most consistently recognised risk factors for ectopic pregnancy is a previous ectopic pregnancy. A previous occurrence may indicate underlying damage to the fallopian tubes or other reproductive abnormalities that increase the likelihood of another abnormal implantation. Tubal damage can interfere with the normal transport of a fertilised ovum towards the uterine cavity, thereby increasing the possibility that implantation will occur within the tube. Previous tubal surgery may also alter the structure or function of the fallopian tubes, depending on the nature of the procedure and the extent of the underlying condition. In addition, a history of infertility and the use of assisted reproductive techniques may be relevant when assessing risk, although the relationship depends on the specific cause of infertility and the treatment involved. Bouyer et al. (2003) found associations between ectopic pregnancy and previous reproductive and tubal conditions, while Barnhart (2009) reviewed the clinical significance of ectopic pregnancy and the importance of recognising women who may be at increased risk. Consequently, obtaining an accurate reproductive and surgical history is an important component of risk assessment among women presenting for gynaecological care.

Pelvic inflammatory disease (PID) is another important risk factor because inflammation and infection of the upper reproductive tract may damage the fallopian tubes and interfere with normal reproductive function. Sexually transmitted infections, particularly Chlamydia trachomatis infection, have been associated with PID and subsequent tubal complications. Tubal scarring and impaired ciliary function may affect the movement of the fertilised ovum, increasing the likelihood of extrauterine implantation. The relationship between reproductive tract infections and ectopic pregnancy makes sexual and reproductive health services important in preventing long-term reproductive complications. However, a history of PID or sexually transmitted infection does not mean that ectopic pregnancy will inevitably occur; rather, these conditions may increase risk, depending on the severity and extent of tubal damage. Bouyer et al. (2003) identified a history of pelvic infection among factors relevant to ectopic pregnancy risk, while Shaw et al. (2010) discussed the relationship between Chlamydia trachomatis, reproductive tract damage, and adverse reproductive outcomes. Assessment of infection history, previous treatment, and related reproductive complications may therefore help clinicians identify women who require careful evaluation when pregnancy is suspected.

Other factors may also influence the risk of ectopic pregnancy, although their effects differ according to the circumstances in which conception occurs. Smoking has been associated with ectopic pregnancy and may affect tubal function through mechanisms involving reproductive tract physiology. Infertility, assisted reproductive technology, and certain reproductive interventions may also be relevant, particularly where underlying tubal disease is present. Contraception requires careful interpretation: most contraceptive methods reduce the overall likelihood of pregnancy and therefore reduce the absolute risk of ectopic pregnancy. Nevertheless, when pregnancy occurs despite the use of an intrauterine device, the possibility of an ectopic location requires clinical assessment because the proportion of pregnancies that are ectopic may be higher in this circumstance. Mol et al. (1995) examined the relationship between risk factors and ectopic pregnancy, contributing evidence on the relevance of reproductive history and lifestyle factors. ACOG (2018) similarly notes the importance of considering previous ectopic pregnancy, tubal disease, smoking, and conception following fertility treatment when evaluating a patient’s clinical history. These factors should be assessed together rather than treated as independent predictors in every woman, since individual risk depends on the combination of reproductive, medical, and behavioural circumstances.

In Nigeria, ectopic pregnancy remains an important concern for maternal health services because delayed presentation, limited awareness of early pregnancy complications, financial barriers, and difficulties accessing timely diagnostic and emergency obstetric care may contribute to poor outcomes in some settings. Women experiencing abdominal pain or vaginal bleeding during early pregnancy may initially seek care from different providers or may not recognise the symptoms as signs of a potentially serious condition. Where diagnosis is delayed, the risk of tubal rupture, severe haemorrhage, emergency surgery, and loss of reproductive capacity may increase. Lagos University Teaching Hospital (LUTH), Idi-Araba, Lagos State, is an appropriate setting for examining this issue because a tertiary hospital can provide a clinical context for reviewing diagnosed cases, documenting relevant reproductive histories, and investigating the distribution of recognised risk factors among women receiving care. Nevertheless, findings from LUTH should not automatically be generalised to every woman in Lagos State or Nigeria, as patients attending a tertiary referral hospital may differ from those treated in other facilities. A hospital-based assessment can still provide useful evidence on the characteristics and risk factors of affected women and help identify opportunities for improved clinical assessment, health education, and early referral. The World Health Organization (WHO, 2023) emphasises the importance of quality maternal healthcare and timely access to essential services in reducing preventable maternal deaths. Against this background, the present study seeks to assess risk factors associated with ectopic pregnancy among women of reproductive age at LUTH, Idi-Araba, Lagos State.

1.2 Statement of the Problem

Ectopic pregnancy remains a major reproductive health concern because it can cause severe maternal complications when diagnosis and treatment are delayed. Although advances in pregnancy testing, ultrasonography, and emergency gynaecological care have improved the recognition and management of the condition, women may still present with ruptured ectopic pregnancies and significant internal bleeding. The clinical challenge is that the early symptoms can resemble those of other pregnancy-related conditions, making timely assessment essential. The American College of Obstetricians and Gynecologists (ACOG, 2018) emphasises that ectopic pregnancy in a clinically unstable patient requires urgent intervention. Consequently, identifying the factors associated with ectopic pregnancy remains important for improving early clinical suspicion and reducing preventable complications among women of reproductive age.

A second problem concerns the contribution of reproductive tract infections and previous reproductive experiences to the occurrence of ectopic pregnancy. Pelvic inflammatory disease, sexually transmitted infections, previous ectopic pregnancy, tubal surgery, and other conditions that affect the fallopian tubes may increase the likelihood of abnormal implantation. In a Nigerian study involving patients from three Lagos hospitals, Anorlu et al. (2005) reported significant associations between ectopic pregnancy and a history of pelvic inflammatory disease, sexually transmitted infections, induced abortion, miscarriage, and pelvic surgery. These findings demonstrate the importance of examining reproductive and medical histories when investigating ectopic pregnancy. However, the presence of an association does not establish that every affected woman has experienced these conditions, since ectopic pregnancy can also occur without a recognised risk factor.

Another problem relates to the need for hospital-specific evidence to support appropriate clinical assessment and preventive interventions. A study conducted at Lagos University Teaching Hospital examined temporal trends, clinical presentation, and management outcomes of ectopic pregnancy between 2005 and 2014. The study reported that previous pelvic infection was the most common identifiable risk factor among the reviewed cases and documented maternal deaths associated with the condition (Anorlu et al., 2020). Although these findings provide important evidence about the burden of ectopic pregnancy at LUTH, they relate to an earlier study period and do not necessarily describe the current distribution of risk factors among women receiving care at the hospital. A further assessment is therefore justified to examine the relevant risk factors within a clearly defined study period and determine how they are distributed among women of reproductive age.

Furthermore, there is a need to examine how sociodemographic characteristics, reproductive history, previous infections, surgical history, and other relevant factors relate to ectopic pregnancy among women attending LUTH, Idi-Araba. Without clearly documented, setting-specific evidence, it may be difficult to determine which factors are most frequently reported among affected women and which areas deserve greater attention in reproductive health education, clinical history-taking, and early referral. This study therefore seeks to assess the risk factors associated with ectopic pregnancy among women of reproductive age at LUTH. By examining available clinical records and, where appropriate, other ethically approved sources of data, the study aims to provide evidence that may support improved risk assessment, early recognition, and reproductive health services.

1.3 Aim and Objectives of the Study

1.3.1 Aim of the Study

The aim of this study is to assess the risk factors associated with ectopic pregnancy among women of reproductive age at Lagos University Teaching Hospital (LUTH), Idi-Araba, Lagos State.

1.3.2 Specific Objectives

The specific objectives are to:

1. Examine the sociodemographic characteristics of women diagnosed with ectopic pregnancy at LUTH, Idi-Araba, Lagos State.

2. Identify the reproductive and obstetric risk factors associated with ectopic pregnancy among women of reproductive age at LUTH.

3. Assess the relationship between previous reproductive tract infections, previous pelvic or abdominal surgery, and ectopic pregnancy among the study participants.

4. Determine the association between selected reproductive and lifestyle factors, including previous ectopic pregnancy, infertility history, contraceptive history, and smoking where documented, and ectopic pregnancy among women of reproductive age at LUTH.

1.4 Research Questions

The following research questions will guide the study:

1. What are the sociodemographic characteristics of women diagnosed with ectopic pregnancy at LUTH, Idi-Araba, Lagos State?

2. What reproductive and obstetric risk factors are associated with ectopic pregnancy among women of reproductive age at LUTH?

3. What relationship exists between previous reproductive tract infections, previous pelvic or abdominal surgery, and ectopic pregnancy among the study participants?

4. What association exists between selected reproductive and lifestyle factors and ectopic pregnancy among women of reproductive age at LUTH?

1.5 Research Hypothesis

The following null hypothesis will be tested at the 0.05 level of significance:

H₀: There is no statistically significant association between selected reproductive and clinical risk factors and ectopic pregnancy among women of reproductive age at Lagos University Teaching Hospital, Idi-Araba, Lagos State.

1.6 Significance of the Study

The findings of this study are expected to be beneficial to healthcare professionals, women of reproductive age, hospital administrators, public health practitioners, policymakers, and future researchers.

1.6.1 Healthcare Professionals

The study may assist nurses, midwives, medical doctors, and other healthcare professionals in identifying reproductive and clinical factors that frequently occur among women diagnosed with ectopic pregnancy. Evidence from LUTH may help strengthen clinical history-taking, assessment of women presenting with early pregnancy symptoms, patient education, and referral practices. Olamijulo et al. (2020) demonstrated the importance of prompt diagnosis and intervention in the management of ectopic pregnancy at LUTH. The present study may complement such evidence by examining the distribution of selected risk factors within its defined study period.

1.6.2 Women of Reproductive Age

The study may improve awareness of reproductive health conditions associated with ectopic pregnancy, including pelvic inflammatory disease, sexually transmitted infections, previous ectopic pregnancy, and tubal damage. Such awareness may encourage women to seek timely medical evaluation when they experience unusual vaginal bleeding, pelvic pain, or other symptoms of early pregnancy complications. Anorlu et al. (2005) identified several reproductive health factors associated with ectopic pregnancy in Lagos, highlighting the relevance of infection prevention, reproductive health education, and appropriate treatment of sexually transmitted infections.

1.6.3 Hospital Management and Healthcare Administrators

The findings may provide useful information for planning reproductive health services, strengthening clinical documentation, and identifying opportunities for improving the assessment of women at risk of ectopic pregnancy. Hospital administrators may use the findings to support staff training, review patient education strategies, and improve the recording of relevant reproductive histories. Such measures may contribute to better clinical decision-making and more effective service delivery, although the study alone cannot establish that a particular intervention will reduce ectopic pregnancy.

1.6.4 Public Health Practitioners and Policymakers

The study may provide evidence to support public health programmes focusing on reproductive tract infection prevention, early pregnancy assessment, sexual health education, and timely access to gynaecological care. The findings may also help identify areas where additional research or health education is required. Bouyer et al. (2003) identified infectious history and smoking among the factors associated with ectopic pregnancy in a population-based case-control study, supporting the need to consider preventable and modifiable risk factors in reproductive health programmes.

1.6.5 Future Researchers and Academic Institutions

The study may contribute to the body of literature on ectopic pregnancy in Nigeria, particularly research conducted in tertiary healthcare settings. Its findings may provide a basis for further investigations into the relationship between reproductive history, pelvic infections, clinical characteristics, and ectopic pregnancy. Future researchers may also use the findings to develop comparative studies involving other hospitals, different geographical areas, or different periods.

1.7 Scope of the Study

The study will focus on the assessment of risk factors associated with ectopic pregnancy among women of reproductive age at Lagos University Teaching Hospital, Idi-Araba, Lagos State.

Geographically, the research will be restricted to LUTH. The population of interest will comprise women of reproductive age whose clinical characteristics and pregnancy outcomes meet the study’s eligibility criteria. The study will examine sociodemographic characteristics, previous ectopic pregnancy, reproductive and obstetric history, previous pelvic inflammatory disease or sexually transmitted infections, previous pelvic or abdominal surgery, infertility history, contraceptive history, and smoking where reliable information is available.

The study period will be specified according to the approved research protocol and availability of hospital records. If the research is designed to establish statistical associations between risk factors and ectopic pregnancy, women diagnosed with ectopic pregnancy should be compared with an appropriate control group of women with intrauterine pregnancies or another clearly defined pregnancy comparison population. This approach will allow the researcher to distinguish factors associated with ectopic pregnancy from characteristics that are simply common among women diagnosed with the condition.

1.8 Limitations of the Study

The study may encounter certain limitations that should be considered when interpreting the findings.

First, incomplete clinical records may limit the availability of information on previous infections, contraceptive use, surgical history, smoking, or other relevant risk factors. Second, some reproductive histories may be affected by recall bias where participants are required to provide information about past events. Third, the study will be conducted at a single tertiary hospital, meaning that its findings may not represent all women of reproductive age in Lagos State or Nigeria. Finally, a cross-sectional or retrospective design may identify statistical associations but cannot, by itself, establish that a particular factor caused ectopic pregnancy.

These limitations may be reduced through the use of clearly defined eligibility criteria, a standardised data collection instrument, appropriate statistical analysis, and careful interpretation of the results. Where a case-control design is adopted, appropriate selection of controls and adjustment for potential confounding variables will be important.

1.9 Operational Definition of Terms

Ectopic pregnancy: A pregnancy in which implantation occurs outside the normal endometrial cavity of the uterus, as defined in the clinical records or established through the hospital’s diagnostic procedures (ACOG, 2018).

Risk factors: Sociodemographic, reproductive, clinical, or lifestyle characteristics that may be associated with the occurrence of ectopic pregnancy.

Women of reproductive age: Women within the age range defined by the approved study protocol. For this study, the researcher may adopt 15–49 years, consistent with the commonly used reproductive-age range in population health research.

Pelvic inflammatory disease (PID): Infection and inflammation involving the upper female reproductive tract, which may result in damage to the fallopian tubes and other reproductive structures.

Previous ectopic pregnancy: A documented or reported history of an earlier pregnancy implanted outside the normal uterine cavity.

Tubal damage: Structural or functional impairment of the fallopian tubes that may interfere with the normal transport of a fertilised ovum.

Infertility history: A reported or documented history of difficulty achieving pregnancy, assessed according to the definition and criteria adopted by the study.

Contraceptive history: Information concerning previous or current contraceptive methods, including their type and duration where available.

Association: A statistical relationship between a selected risk factor and ectopic pregnancy, assessed using appropriate statistical methods.

LUTH: Lagos University Teaching Hospital, Idi-Araba, Lagos State, Nigeria, the institution selected as the study setting.

Project – Assessment of Risk Factors Associated with Ectopic Pregnancy among Women of Reproductive Age: A Case Study of Lagos University Teaching Hospital (LUTH), Idi-Araba, Lagos State.