This was a retrospective study of ectopic pregnancies at St. Luke's Specialist Hospital, Anua, Uyo in South-South geopolitical zone of Nigeria between January 2000 and December 2004. The case notes/medical records of the patients from were examined for reported cases of ectopic pregnancies. The search spanned the casualty department, the theatre, and maternity sections of the hospital. Theatre registers were screened for those that underwent surgeries, the operation notes were scanned and data collated. Records of all registered pregnancies for the same period were obtained from the maternity section of the hospital. Information on the biosocial data, clinical symptoms and signs, sites and treatment options, risk factors for the disease as well as associated morbidity were extracted. The data was analyzed with simple descriptive statistics and presented in the tables under results section.

In the five-year review, there were a total of 23,981 deliveries and 72 ectopic gestations recorded. This gives an incidence of 0.30% of total deliveries with highest incidence recorded in 2004 (0.46%) and lowest in 2003 (0.20%). The majority of ectopic gestations, 59 (81.9%) were in the 21-30 age group (Table 1). Single women accounted for 51.4% of all cases with majority of them students (52.8%) (Table 2). Table 3 also shows that the highest yearly incidence of ectopic gestation was recorded in 2004 (0.46%) as against 0.20% in 2003. Thirty seven (51.4%) of the ectopic pregnancy occurred in the right fallopian tube, 23 (31.9%) in the left fallopian tube, 6 (8.3%) in the cornua, 4 (5.6%) in the isthmus while 2 (2.8%) in the ampullary region (Table 4).The three most common risk factors in the study are: pelvic inflammatory disease 37 (51.4%), previous abortions 18 (25.0%), and infertility 2 (2.8%) (Table 5).

Mortality: 1 patient was reported dead in the sampled period which gives a 1.4% mortality rate in this survey.

Ectopic pregnancy is prevalent in our environment affecting mainly young women of low parity who desire future pregnancies. The subsequent impact on future fertility of these women could be improved if efforts are focused on early diagnosis to prevent tubal rupture. Early diagnosis prior to rupture offers opportunity for medical management and conservative surgical procedures that are proven to improve future fertility [9]. The incidence of ectopic pregnancy has followed an increasing trend during the last three decades throughout the world [4,16]. The incidence of 0.3% or 3 per 1,000 in our present study is lower than most reported cases in the country. Musa et al. [9] reported an incidence of 1.74% in Jos, Anorlu et al. [8] reported an incidence of 23.1/1,000 in Lagos, Udigwe et al. [11] reported an incidence of 1.3% in Nnewi, Aboyeji et al. [10] reported 1.4% incidence in Ilorin. We believe that gross underreporting of cases and patronage of traditional birth attendants and prayer houses instead of hospitals on health issues and pregnancy related complications by patients might have be contributory. The incidence of 0.3% is comparable to similar studies in India which recorded 0.4% [21].

Mortality rate of 1.4% we reported was also lower compared to the 8.6% reported in Lagos by Anorlu et al. [8] and Amoko and Buga [17] which recorded 2.0% in a South African population. But this was similar to that reported by Igbarese et al. [6] which was around 1.5%. Mortality depends on population size as well as the clinical state of the patient on presentation [11]. In our case, we adduce that this was as a result of prompt surgical intervention in the hospital managed by a European medical missionaries during the period under study.

The peak age incidence was amongst women in the age group of 21-30 years which corroborates with findings of Majhi et al. [3] and Igbarese et al. [6]. This corresponds to the age of reproduction and peak sexual activity. Also, the incidence in present study was higher amongst single women and students than married women. This can be attributed to the fact that they are more prone to STDs as a result of having multiple sexual partners and they usually resort to induced abortion (which is usually performed by non-physicians resulting in complications and late presentation) from unwanted pregnancies. Patients are also unlikely to seek proper medical attention and resort to buying of drugs from patent medicine stores with the resultant effect of poor treatment leading to tubal blockage/damage [10] thus PID. Patients with ectopic pregnancy were found of a lower parity in some descriptive studies from Nigeria [12,22]. However, recent studies have shown a significantly increased risk of EP in women aged 40 and over 40 years [23,24]. Cumulative risk factors associated with getting pregnant at an older age were cited as being responsible for this increased risk of EP with age.

From the results, it has become clear that a sizeable percentage of our young women in their prime of reproductive years have become subjected to emotional and psychological problems of failure of reproduction associated with ectopic pregnancy in our environment where a lot of attention is placed on child bearing.

Due to advances in diagnostic techniques, it has become possible to identify and manage ectopic pregnancies before they cause clinical symptoms in many developed countries. However, the situation appears not to be the same in developing countries [17]. Early detection and conservative management using transvaginal sonography, laparoscopy and laparoscopic surgeries are the hallmark of treatment in developed countries [25,26]. But in developing countries 95% to 100% of the patients present late, with ruptured ectopics that are either immediately clinically obvious or where culdocentesis is virtually diagnostic because of haemoperitoreum. In these cases, the only option available was open laparotomy and salpingectomy [27]. The emphasis in the management of EP is on early diagnosis before rupture and conservative surgery.

However, in most developing countries especially Nigeria where patients still present late after rupture, salpingectomy remains the operative procedure [28]. Salpingectomy is the commonest surgical management for tubal pregnancy in Nigeria because most of the women present late [7,29]. Incidentally, this procedure which leads to tubal loss and reduced reproductive potentials is the commonest management option in low resource settings [30]. Intrauterine pregnancy rate after salpingectomy is about 45% with a 9% repeat EP [30]. In salpingostomy, tissue handling is minimized to reduce tissue trauma and prevent tubal occlusion or peritubal adhesions. The success of reconstructive tubal surgery for EP can be only measured in terms of subsequent live births the individual achieves. During the surgical treatment of EP by both laparatomy and laparoscopy, the state of the contra-lateral tube is noted. The condition of the contra-lateral tube has been reported to play a crucial role in subsequent fertility of patients with EP [31,32].

Most of the patients in our report had ampullary ectopic pregnancy (83.3%) which is consistent with studies from other centers [33-35]. The preponderance of ectopic pregnancies on the right Fallopian tube (51.4%) is similar to trends all over the world, with incidence of up to 66.2% and the left 33.8% of the cases [7,9,36]. Nordenskjöld and Ahlgren [36] attributed this right-sided preponderance to appendicitis.

As in industrialized countries, PID associated with STDs must be considered as the most important risk factor for ectopic pregnancy in developing countries [5]. About 86% of the cases reported by Amoko and Buga [17] had evidence of previous pelvic infection, thus making PID the most important risk factor for ectopic pregnancy. Our research findings are also in agreement with these findings and other [8,11] thus implicating PID as a major risk factor for ectopic pregnancy. Other factors like previous history of abortion and history of previous ectopic gestation were also predisposing factors for ectopic pregnancy [10,37,38].

While this study is a hospital-based one with its inherent biases, we would expect that population-based (cohort studies) of this magnitude be conducted to evaluate the actual incidence of ectopic pregnancy in the population as this would give better trends. In the light of the results obtained in this study and the body of existing literatures about ectopic pregnancy in developing countries like ours, emphasis should be placed on primary prevention and early detection of ectopic pregnancy. The burden of infections as a leading risk factor for ectopic pregnancy can be addressed by a more proactive approach on the professional and health care officials' approach to issues of maternal health.

Ectopic pregnancy, a gynecological emergency, is prevalent in our environment affecting mainly young women of low parity who desire future pregnancies. The subsequent impact on future fertility of these women could be very much improved if efforts were focused on primary prevention and early diagnosis to prevent tubal rupture. Advocacy to improve the knowledge of young women on risk factors and the symptoms of ectopic pregnancy should be encouraged. This would facilitate the early reporting to hospital for diagnoses and conservative management. We suggest also that our hospitals should be adequately equipped to handle early diagnoses and prompt treatment to reduce the incidence, morbidity, mortality and infertility associated with ectopic gestation.