บทความต้นฉบับปัจจัยเสี่ยงหลักสำหรับการตั้งครรภ์นอกมดลูก: ศึกษากรณีควบคุมในตัวอย่างของผู้หญิงอิหร่านShayesteh Parashi, M.D.1, Somayeh Moukhah, M.Sc.2*, Mahnaz Ashrafi, M.D.11. Akbarabadi โรงพยาบาล ภาควิชาสูติศาสตร์และ Gynocology ภาพตัดปะของวิทยาศาสตร์การแพทย์ อิหร่านมหาวิทยาลัยวิทยาศาสตร์การแพทย์ เตหะราน อิหร่าน2. แผนก ๒๔๖๓ ภาพตัดปะของวิทยาศาสตร์การแพทย์ Tarbiat Modares มหาวิทยาลัย เตหะราน อิหร่านบทคัดย่อพื้นหลัง: แม้ว่าปัจจัยเสี่ยงต่อการตั้งครรภ์นอกมดลูกมี การกำหนดในการศึกษาก่อนหน้านี้ ปัจจัยเสี่ยงหลักของการตั้งครรภ์นอกมดลูกแตกต่างกันในประเทศและพยายามต่าง ๆ เนื่องจากลักษณะสังคม และวัฒนธรรมที่แตกต่างกัน กำหนด tors fac ความเสี่ยงหลักของการตั้งครรภ์นอกมดลูกนำไปสู่การวินิจฉัยอย่างรวดเร็วและการปรับปรุงในกลยุทธ์การป้องกัน วัตถุประสงค์ของการศึกษานี้คือการ กำหนดปัจจัยเสี่ยงหลักของการตั้งครรภ์นอกมดลูกในตัวอย่างของผู้หญิงอิหร่านวัสดุและวิธีการ: เราออกแบบการควบคุมกรณีศึกษากรณี 150 และ 300 ควบคุม และเปรียบเทียบจากปัจจัยต่อไปนี้: ลักษณะทางประชากรสังคม วิธีคุมกำเนิด tubal ศัลยกรรมก่อน พยาธิ tubal ตั้งครรภ์นอกมดลูกก่อน ก่อนคลอด ทำแท้งก่อน ภาวะมีบุตรยากก่อน และก่อนผ่าตัดที่หน้าท้อง/อุ้งเชิงกรานResults: 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: so.moukhah@gmail.com 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 Methods
This 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
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