Ectopic pregnancy (EP) refers to the implantation of a fertilized ovum outside the endometrial lining of the uterus. Globally, it accounts for 1% - 2% [1], while Africa has a prevalence of 1% - 4% of all pregnancies [2]. EP remains a life-threatening gynaecological emergency and a significant contributor to early pregnancy-related maternal morbidity and mortality, particularly in low-resource settings [3]. Ruptured EP is especially dangerous, accounting for approximately 2.7% of pregnancy-related deaths in the general population [4], with even higher mortality rates reported in sub-Saharan Africa. In Cameroon, for example, EP was responsible for 12.5% of maternal deaths [5]. The incidence of EP varies widely across regions, influenced by multiple risk factors including advanced maternal age, previous pelvic inflammatory disease (PID), tubal surgery, and a history of ectopic pregnancy [6].

Early clinical suspicion is crucial, as symptoms such as missed menstruation, abnormal uterine bleeding, and recent sexual activity should prompt immediate pregnancy testing [1]. EP typically presents with lower abdominal pain, vaginal bleeding, and amenorrhea. In more severe cases, symptoms like shoulder tip pain or syncope may indicate rupture and necessitate urgent intervention [7]. Suliman et al. [8] reported vaginal bleeding in 74.3% of EP cases, identifying it as the second most common presenting symptom, while 40.47% of patients exhibited the classical triad of amenorrhea, abdominal pain, and vaginal bleeding. Adnexal ectopic pregnancies often manifest as unilateral, colicky pelvic or abdominal pain [1], a symptom pattern supported by studies from Chisha [9] at 97.8%. Nevertheless, it is emphasized that these symptoms may not be present in all cases, underscoring the need for vigilant and thorough clinical evaluation [1].

The risk of EP increases with age, particularly in women over 35 years [10], [11]. Moini et al. similarly found that the likelihood of EP was significantly higher among women aged 33 - 39 and those over 40, compared to those aged 20 - 24. Certain contraceptive methods, including progestogen-only methods such as Levonorgestrel emergency contraception (LNG-EC) and intrauterine contraceptive devices (IUCDs), are associated with an elevated risk of EP in cases of contraceptive failure, though they do not increase the overall incidence of EP [1]. Supporting this, Shurie [12] demonstrated a statistically significant association (p < 0.001) between EP and the use of both IUCDs and LNG-EC [12]. Chisha [9] also reported notable behavioural risk factors, including having had more than one sexual partner (55.6%) or concurrent sexual partners (14.4%), which increased susceptibility to sexually transmitted infections (STIs), a known precursor to PID and EP.

In Zambia, prospective data on EP remain scarce. The only published study to date, conducted at the University Teaching Hospital (UTH) in Lusaka, reported a prevalence of 0.05% [9], but lacked detailed analysis of associated risk factors, clinical profiles, and treatment outcomes. At Ndola Teaching Hospital (NTH), a 2022 internal audit documented 114 EP cases among 8736 pregnancies, corresponding to a prevalence of 1.3%, and included two maternal deaths (NTH, Obstetrics and Gynaecology maternal audit report, 2022). However, due to inadequate documentation, the findings were limited in scope and utility, reinforcing the need for a well-structured, prospective study.

This study was conducted to determine the prevalence and clinical characteristics of ectopic pregnancy at NTH. Specifically, it explores socio-demographic variables, obstetric and gynaecological histories, presenting symptoms and clinical outcomes. The findings aim to inform the development of context-appropriate clinical protocols and enhance early diagnosis and management of EP in resource-constrained settings.

The prevalence of ectopic pregnancy (EP) observed at Ndola Teaching Hospital (NTH) was marginally higher than the one documented in different studies. For instance, Chisha [9] reported a prevalence of 0.05% at the University Teaching Hospital (UTH) in Lusaka, while Sefogah et al. [15] found a rate of 0.08% at Lekma Hospital in Ghana. Berhe et al. [16] reported a higher prevalence of 0.5%. However, it remains below the global range of 1% - 2% [15]. Notably, higher prevalence rates have been recorded in other settings, such as 2.1% in Ghana’s Volta Region [17], 2% at Bashair Teaching Hospital in Sudan [8], and 1.43% in Cameroon [18]. Such variability in prevalence rates may stem from disparities in diagnostic capabilities, differences in clinical reporting practices, variations in health-seeking behaviour, patient’s load in these hospitals and unequal access to healthcare services. These findings underscore the importance of enhanced surveillance mechanisms, like involving referring centres in Ndola district to be vigilant in the recognition of ectopic pregnancy through signs and symptoms and refer them to NTH for further management, and systematic case documentation to more accurately capture the epidemiological landscape of ectopic pregnancy, particularly in referral institutions like NTH. Accurate capturing of epidemiological data for ectopic pregnancy can be achieved by creating an early pregnancy unit (EPU) at NTH.

Sociodemographic analysis revealed that 79.8% of the women diagnosed with EP resided in low-income areas, 84% were married, 51.1% had attained secondary education, and 47.9% were unemployed. These characteristics are consistent with those reported by Chisha [9], who found 62.2% of affected women from low-income areas, 81.1% married, and 51.1% with secondary-level education. One study [19] also reported a significant proportion (74%) of EP cases among women from low-income backgrounds, with only 26% from higher-income brackets compared to 7.4% in the current study. The consistent association across studies suggests a relationship between socioeconomic disadvantage and increased EP risk.

The mean age in this cohort was 28 ± 5.82 years, ranging from 17 to 43 years, consistent with findings by multiple other studies [9][16][18], who all reported peak incidence among women aged 26 - 30 years. Njingu et al. [18] similarly observed that the majority of EPs in Cameroon occurred in women aged 20 - 34 years. This reproductive age group is generally more sexually active, which increases their vulnerability to sexually transmitted infections (STIs) and pelvic inflammatory disease (PID), both of which are established risk factors for EP [16][20].

Obstetric history showed that 31.9% of patients were para one, 22.3% para 2, and 20.2% were primigravida. These findings contrast slightly with Santoso [21], who found the highest EP incidence between second pregnancies (34.3%), followed by primigravida (32.2%), suggesting that EP is not confined to higher-parity women.

The mean gestational age at presentation (5.98 ± 1.15 weeks) was similar to that reported by Khan etal. [20]. However, Njingu et al. [18] reported a later presentation at 8.42 ± 3.25 weeks, while Suliman et al. [8] observed most presentations between 6 and 9 weeks. These differences may reflect variations in diagnostic awareness and healthcare access across settings.

Analysis of gynaecological history revealed that 57.4% of participants had a prior history of PID, confirming its established role in EP pathogenesis [18][22]-[25]. A statistically significant association was found between PID and pelvic adhesion (p = 0.015) whose OR was 2.833 (1.217 - 6.599), suggesting environmental or socioeconomic contributors to infection risk for majority of these patient came from low social income areas (79.8%). These findings support the need for preventative public health interventions.

About 3.2% of participants had history of previous EP, consistent with recurrence trends noted in previous studies. Prasanna et al. [26] reported a 6% recurrence, while Wang et al. [27] highlighted an increased risk due to pelvic and peritubular adhesions. American College of Obstetricians and Gynaecologists estimates that the recurrence risk may range from 10% to 27%, underscoring the critical need for close surveillance and early diagnostic evaluation in women with such a history [28]. In the present study, 11.7% of the women had a documented history of pelvic surgery. This observation reinforces the widely acknowledged understanding that previous pelvic or abdominal surgical interventions can predispose women to ectopic pregnancy by disrupting normal tubal anatomy and function [29].

Regarding contraceptive use, 33% of women had used Levonorgestrel emergency contraceptive pills and 2.1% had IUCD. Tarafdari et al. [30] identified a significant association between EP and use of intrauterine devices (IUCDs) or emergency contraception (p < 0.001), underscoring the need for tailored contraceptive counselling, particularly in high-risk populations. Additionally, Mahajan et al. [6] has acknowledged the increased risk of ectopic gestation following contraceptive failure, particularly among women with existing predisposing factors such as a history of pelvic inflammatory disease, tubal surgery, or prior ectopic pregnancy [6].

The predominance of abdominal pain (96.8%), amenorrhea (74.5%), and vaginal bleeding (62.8%) aligns with the classic symptom triad described in the literature [1][8][12][31]. These features remain the cornerstone of early clinical suspicion, particularly in settings where laboratory and imaging support may be limited. Noticed similar trends in studies from Tanzania, reinforcing the universality of these symptoms even in varied clinical environments [32]. Given diagnostic limitations in many low-resource settings, awareness of these symptom patterns is critical for early detection and management as this study reviewed the association between abdominal pain and abdominal tenderness with ruptured ectopic pregnancy p-values of 0.001 and 0.019 (4.33 [1.185 - 15.856]) respectively.

In the current study, among women who underwent additional clinical diagnosis, 27.7% demonstrated a positive Culdocentesis while 14.9% had a positive paracentesis. The identification of blood during Culdocentesis was a significant indicator of ruptured ectopic pregnancy, underscoring the strong correlation between hemoperitoneum and tubal compromise [33][34].

Outcomes at NTH indicated that 57.4% of patients had favourable clinical courses. This aligns with Berhe et al. [16] who reported a 62% favourable outcome rate [17]. However, 41.5% developed haemorrhagic shock and 1.1% of cases resulted in mortality similar to the rate reported in Zambia [9]. By contrast, several other studies reported no EP-related deaths [8][15][31]. At NTH, 77.7% of patients were managed in general gynaecological bays, reflecting constraints in access to high-dependency or ICU care. As Suresh et al. [35] also notes, delayed diagnosis often results in severe outcomes such as salpingectomy, blood transfusions, or hypovolemic shock procedures associated with increased morbidity and health system burden [35].

Ruptured ectopic pregnancy is a serious gynaecological emergency associated with significant maternal morbidity, primarily due to intra-abdominal bleeding which was a key finding of this study was the notably high incidence of ruptured ectopic pregnancies, observed in 88.3% of the cases. Delayed presentation remains a critical contributing factor. In the current study, a large proportion of women were either referred from peripheral facilities or self-presented only after severe symptoms had developed. This mirrors the findings of Andola and Desai [25], who reported that approximately 80% of patients presented after the EP ruptured. Contributing factors to delayed presentation in this current study include poor awareness of being pregnant (gestational age) where 23.4% of participants were unsure of their last menstrual period and ongoing vaginal bleeding reported in 62.8% of cases, which likely masked the early signs of pregnancy. Moreover, abdominal pain, which was reported by 96.8% of participants, typically only prompted hospital visits once the condition had progressed.

The observed strong association between ectopic pregnancy (EP) and low-income residential areas highlights the urgent need for targeted public health interventions in underserved communities. These should include comprehensive reproductive health education and robust strategies for the prevention and management of sexually transmitted infections (STIs). With more than half of EP cases linked to a prior history of pelvic inflammatory disease (PID), there is a critical need to expand access to STI screening, treatment, and health education—particularly in low-income and high-burden settings. Additionally, the considerable use of emergency contraception among affected individuals underscores the importance of informed contraceptive counselling. Healthcare providers should ensure that women, especially those at elevated risk, are adequately informed about the potential risks associated with methods such as Levonorgestrel emergency contraception (LNG-EC) and intrauterine contraceptive devices (IUCDs), including the possibility of ectopic implantation. The high incidence of haemorrhagic shock further indicates the necessity of improving emergency triage systems and increasing the availability of high-dependency or intensive care units for gynaecological emergencies. Finally, ongoing surveillance and the collection of region-specific epidemiological data are vital to inform effective policy development and the design of targeted programs aimed at reducing the burden of ectopic pregnancy.

A key strength of this study lies in its prospective design, which allowed for systematic data collection across multiple domains—sociodemographic, clinical, imaging, and surgical—minimizing recall bias and improving data completeness. The relatively large sample size (n = 94) for a single-centre study also contributed.

Being a cross-sectional study led to study limitations:

•It did not determine the cause-effect of independent and dependent variables.

•Generalization of results is not statistically right to the entire population in Ndola district for the research was hospital based (NTH).

•It only focused on the immediate outcomes of ectopic pregnancy leaving out the long-term outcomes like fertility issues.

This study provides critical insight into the epidemiology, clinical presentation, and outcomes of ectopic pregnancy (EP) at Ndola Teaching Hospital, highlighting both consistencies and disparities when compared to national, regional, and international data. The slightly elevated prevalence, combined with sociodemographic findings such as a predominance of cases among low-income, unemployed, and relatively young women, underscores the intersection between socioeconomic vulnerability and reproductive health outcomes. The high proportion of cases associated with pelvic inflammatory disease, early gestational presentation, and use of emergency contraception points to identifiable and, in many cases, preventable risk factors.

The significant incidence of haemorrhagic shock and the constraints in accessing high-dependency care further illustrate the challenges faced in resource-limited settings, where delayed diagnosis and limited emergency capacity contribute to maternal morbidity and mortality. These findings reinforce the urgent need for public health strategies that prioritize early diagnosis, improve access to care, enhance sexual and reproductive health education, and strengthen emergency response systems.

Overall, the results of this study emphasize the importance of routine surveillance, context-specific health education, and health system strengthening to reduce the burden of ectopic pregnancy and improve maternal health outcomes in Zambia and similar settings.