Correlation between Ectopic Pregnancy and Reproductive History among Pregnant Women in Karbala City/ Iraq

: Background: Ectopic pregnancy (EP) is a major problem in obstetrics, with warnings of an uptick in cases all over the world. It contributes significantly to maternal morbidity and mortality. Ectopic pregnancy is a common and potentially life-threatening disorder that affects about (2%) of all pregnancies in the United States. It happens when a fertilized ovum implants outside of the uterus, usually in the ampulla of the fallopian tubes. The abdomen, cervix, caesarean-section scar, and ovary have all been identified as implantation sites. Aims of the study: To find out the correlation between ectopic pregnancy and reproductive history of pregnant women and to identify demographic characteristics of pregnant women with ectopic pregnancy. Methodology: This study was conducted at maternity hospital in Karbala city in Iraq to assess the physical health problems of women with ectopic pregnancy. This study was started in January 2020 to March 2021, The data regarding women's health problems was achieved from the patient’s charts that recorded in the Statistical Department in the hospital, the study consist of (40) women with ectopic pregnancy which were selected according to inclusion criteria (Women who had ectopic pregnancy, Women in reproductive age only). The data are analyzed through the use of cross-sectional study (descriptive) and inferential statistics analysis procedures were employed for the data analysis. Results: The findings of the study exhibits that that there is significant relationship between ectopic pregnancy and number of abortion among women at p-value =0.020, but there is no significant relationship has been reported among ectopic pregnancy and regular menstrual cycle


INTRODUCTION
Ectopic pregnancy (EP) This disorder has serious health implications and is a leading cause of morbidity and mortality among women of reproductive age (1) . Ectopic pregnancy is a common and potentially fatal condition that affects approximately 2% of all pregnancies in the United States. It occurs when a fertilized ovum implants outside of the uterus, most often in the fallopian tube ampulla. The implantation sites have been identified as the abdomen, cervix, caesarean-section wound, and ovary (2) . Ectopic pregnancy is becoming more common across the world as a result of higher rates of salpingitis, insufficient care for pelvic inflammatory disease, the usage of intrauterine contraceptives, a rise in surgical procedures for tubal disease, and improved diagnostic techniques. The risk of ectopic pregnancy has been linked to a number of factors. These risk factors work in the same way as the most common risk factor, affecting the ciliary functions of the fallopian tube with pelvic inflammatory disease (3) . Ectopic pregnancy (EP) is currently managed in three ways: surgical care with methotrexate injections, progressive surgery (fallopian tube removal, salpingectomy), and conservative surgery (preservation of the tube, salpingectomy). Improvements in diagnostic methods (such as ultrasonography and laboratory measurements) have enabled earlier and more reliable diagnosis of ectopic pregnancies, allowing for earlier management and a reduction in serious adverse events. As a result, EP treatment has been evaluated in terms of optimizing not only initial recovery but also subsequent fertility preservation (4) .
The sloughing of decidual endometrium causes vaginal bleeding in women with ectopic pregnancy, which may vary from spotting to menstruation-like amounts. Ectopic pregnancy pain can vary in nature, place, and severity. When the fallopian tube distends, it sometimes starts as a colicky abdominal or pelvic pain that is localized to one side. Once the tube ruptures and hem peritoneum forms, the pain can become more generalized. Presyncope, syncope, vomiting, diarrhea, shoulder pain, lower urinary tract symptoms, rectal discomfort, or pain with defecation are all possible symptoms (5) .

AIMS OF THE STUDY:
1. To find out the correlation between ectopic pregnancy and reproductive history of pregnant women.

2.
To identify demographic characteristics of pregnant women with ectopic pregnancy.

METHODOLOGY
This study was conducted at maternity hospitals in Karbala city in Iraq to assess the physical health of women with ectopic pregnancy. This study was started in from the January 2020 to March 2021, the data regarding rate women's with ectopic pregnancy was achieved from the data recorded in the Statistical Department in the hospital.
A descriptive study was non-probability (a purposive sample) the study consist of (40) women with ectopic pregnancy which were selected according to inclusion criteria that are (Women who had ectopic pregnancy, consists of sections that are related socio-demographic characteristics included part one (age, educational level, women occupation, Residency, and smoking). While part two include: reproductive status history, previous medical history, The Previous history of gynecological diseases, previous surgical history).
Later part three include: physical domain, Reliability of questionnaire is determined through a pilot study and validity through panel (13) expert's Descriptive statistical analysis and inferential statistical analysis procedures were employed for the data analysis. This table shows that women are with age 29±7 years in which the highest percentage is refer to 23-27 years (32.5%). It have been found (32.5%) of women are with age group 23 -27 years, they are read and write as reported with high percentage of 35% and 32.5% of them are graduated from primary school; (75%%) of women are housewives and only 22.5% of them are governmental employee, ( 72.5%) are resident in urban. The smoking status indicates that only 10% of women are smoking while most of them are not smoking (90%). This table reveals that 57.5% of women ceased menstrual cycle since 1-6 weeks ago. 72.5% are showing irregular menstrual cycle. Regarding gravidity, 60% of women are reporting that they have 1-3 gravida and 32.5% have 4-6 gravida. The number of ectopic pregnancy is reported once among 80% and twice among 20% of women. 60% of them are reporting their age of ectopic pregnancy is 3 -6 weeks. Regarding fallopian tube rupture, 70% of women are reporting that they have rupture of fallopian tube while 30% are not. More of women refer that have 1-3 Para which they are lived children (75%). The stillbirth is referring to one among only 7.5% of women. 30% of them are reporting 1-2 abortion. The mode of previous delivery is referring to normal vaginal delivery among 50% of women, 75% of women are reporting that they have 1-3 previous delivery. The contraceptive methods are used by 40% of women in which 30% of them are using pills and injection while 10% are using intrauterine device. 37.5% of women are using contraceptive for 1-4 years and 2.5% are using for more than 5 years. Only 20% of women are showing a history of infertility, 17.5% reporting that they use hormonal therapy and only 5% using IVF as treatment of infertility. there is significant relationship between ectopic pregnancy and number of abortion among women at p-value =0.020, but there is no significant relationship has been reported among ectopic pregnancy and regular menstrual cycle, gravidity, parity, lived children, stillbirth, mode of delivery, and use of contraceptive. Table 1 shows that the socio-demographic characteristics of women with ectopic pregnancy high percentage (32.5%) of women are with age group 23-27 years old Such finding was supported by the study of Li and others (2014). who found in their study that the highest percentage of women with ectopic pregnancy among (15-24) years old (50.6%) (6) . they are resident in urban are (72.5%), (25%) are resident in rural and only (2.5%) are resident in sub-urban. Non-compliance of pregnant women with prenatal visits to primary care centers to identify the causes and risk factors for ectopic pregnancy due to poor education .This finding are not agree with study for Negewo and others (2019), who found that most of the sample was resident in Rural 58.2 % (7) . With respect to their education, the study findings indicate that most of these women with ectopic pregnancy are Read & write (35%) (Table1). Such result does agree with a report has indicated that more than half (57.14%) of women with ectopic pregnancy reported Majority of patients had lower educational level (8) . With regard to the women's employment, the study has revealed that (75%) of the study sample are Housewife. These finding are supported by the study of (9) who found that most of sample was housewives 55.9 %. High percentage (90%) of women are none smoker such finding was supported by the Li and others (2015), who found in their study that the highest percentage of women with ectopic pregnancy were not smoking (95.31%) (10) .

DISCUSSION
Regarding to their past obstetric history, the study depicts that most of the women with ectopic pregnancy have been to have (1 -3) gravida, (1 -3) Para and no abortion (65%). This table reveals that (57.5%) of women ceased menstrual cycle since 1-6 weeks ago. (72.5%) are showing irregular menstrual cycle. Such findings have presented issues relevant to the latitude of the women past obstetric history. This finding are agree with study for Moini and others (2014).Who found that prior abortions associated with increased risk of ectopic pregnancy (11( . The number of ectopic pregnancy is reported once among 80% and twice among 20% of women, 60% of them are reporting their age of ectopic pregnancy is 3 -6 weeks. The results of the study showed that the occurrence of most of the ectopic pregnancy was the woman's first pregnancy. This finding is not agreed with study for Taran et al., 2015. Who found that most commonly diagnosed of ectopic pregnancy in the 6th through 9th week of gestation (12) .
In terms of women's delivery histories, According to the results, the majority of pregnant women have a normal vaginal delivery (50%), and Cesarean section (30%). Most Number of previous deliveries is (1 -3; 75%). This study agrees with study (13) . Who found that previous cesarean section may can risk factors to ectopic pregnancy.
The contraceptive methods are used by (40%) of women in which (30%) of them are using pills while 10% are using intrauterine device. (37.5%) of women are using contraceptive for 1-4 years and (2.5%) are using for more than 5 years. According to the results of the study, the use of contraceptives was not a major cause of ectopic pregnancy. Such result does agree with a report has indicated that Previous use of oral contraception was associated with a decreased risk of ectopic pregnancy. In contrast, previous use of an intrauterine device was associated with an increased risk of ectopic pregnancy (14) .
The results of the study show that there were a small percentage of women who had an ectopic pregnancy who had been infertile in the past. This finding are not agree with study for Sivalingam, and others (2011), who found that assisted reproductive technology (ART) risk factors ectopic pregnancy) (15) .

CONCLUSION
There is a correlation between incidence of ectopic pregnancy and previous history of pregnant.

RECOMMENDATIONS:
1. Encourage women to commitments in regular visits to primary health care centers to detecting and screening ectopic pregnancy early.

2.
Providing health education to pregnant women during their visits about the causes and risk factors of ectopic pregnancy.