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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 4  |  Issue : 2  |  Page : 201-204

Histomorphology of fallopian tubes in ectopic pregnancy


Department of Pathology, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India

Date of Web Publication20-Dec-2016

Correspondence Address:
Savithri Ravindra
Department of Pathology, Kempegowda Institute of Medical Sciences, Bnashankari 2nd Stage, Bengaluru - 560 070, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-4848.196190

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  Abstract 

Background: Ectopic pregnancy can present as an acute life-threatening emergency when it ruptures and accounts for about 10% of all maternal mortalities. The fallopian tube is the most common site for ectopic pregnancy (90–95%). With an increasing incidence of ectopic pregnancy worldwide, a histopathological study of the resected fallopian tubes becomes important to look for predisposing/associated findings such as chronic salpingitis, salpingitis isthmica nodosa (SIN), and tuberculosis. Aim: The aim was to study the histomorphology of the fallopian tubes with ectopic gestation and note the presence of predisposing factors such as chronic salpingitis, SIN, and granulomas in association with ectopic. Materials and Methods: This was a retrospective study. The study was conducted on fallopian tube specimens with a clinical diagnosis of ectopic pregnancy. Sections from the fallopian tubes were studied for the presence of chorionic villi confirming the tubal gestation. The fallopian tubal wall was screened for features of chronic salpingitis, SIN, granulomas, Walthard cell rests, and any other related pathological findings. Results: Ninety cases were included in the study. The age of the patients ranged from 18 to 40 years with a peak in the third decade (71.11%). Chronic salpingitis was seen in 20 cases (22.22%), SIN in 11 cases (12.22%), and tuberculous salpingitis in one case. Conclusion: Histopathological examination of the resected fallopian tubal ectopics can provide an insight into the etiopathogenesis of ectopic pregnancy. In some cases, it can also aid in the treatment modality to prevent a recurrent ectopic.

Keywords: Ectopic pregnancy, fallopian tube, salpingitis, salpingitis isthmica nodosa, tuberculosis


How to cite this article:
Ravindra S, Prasad S, Suguna BV. Histomorphology of fallopian tubes in ectopic pregnancy. Arch Med Health Sci 2016;4:201-4

How to cite this URL:
Ravindra S, Prasad S, Suguna BV. Histomorphology of fallopian tubes in ectopic pregnancy. Arch Med Health Sci [serial online] 2016 [cited 2017 Oct 20];4:201-4. Available from: http://www.amhsjournal.org/text.asp?2016/4/2/201/196190


  Introduction Top


Ectopic pregnancy is an implantation of a fertilized egg outside the uterine corpus. It presents as an acute emergency and is a life-threatening event accounting for about 10% of all maternal mortalities.[1] The incidence of ectopic pregnancy has been increasing worldwide. The incidence of ectopic pregnancy in developed countries is about 19.7/1000 pregnancies [2] and that in India is 3.12/1000 pregnancies.[3]

The most common site for ectopic pregnancy is  Fallopian tube More Detailss (90–95%).[4],[5] Fallopian ectopic has multifactorial pathogenesis with the most important predisposing condition being pelvic inflammatory disease (PID). Other causes include tubal deformities and defects, endometriosis, previous surgery, and even treatment for infertility.[6] Histopathological examination of the resected fallopian tube can give an insight into the etiopathogenesis of ectopic pregnancy.

Aim

The aim of this study was to note the presence of predisposing factors such as chronic salpingitis, salpingitis isthmica nodosa (SIN), granulomas, and other related findings in association with ectopic tubal pregnancy.


  Materials and Methods Top


The present study includes all the resected specimens of fallopian tubes/tubal mass with a clinical diagnosis of ectopic tubal gestation received in the Department of Pathology, Kempegowda Institute of Medical Sciences, Bengaluru. This was a 5-year retrospective study from January 2010 to December 2014. Clinical and demographic data were noted from the case files. The Institutional Ethical Committee clearance was obtained.

Specimens were fixed in 10% formalin and processed routinely. Paraffin blocks were made and 4–6 micron sections were taken. These slides were stained with hematoxylin and eosin stain. Sections from the fallopian tubes were studied for the presence of chorionic villi confirming the tubal gestation. The fallopian tubal wall was screened for features of chronic salpingitis, SIN, granulomas, Walthard cell rests, and any other related pathological findings.


  Results Top


It was a retrospective analysis of the histomorphology of ninety cases of tubal gestation. The age of the patients ranged from 18 to 40 years. Most of the patients were in the third decade (64/90, 71.11%). The patients presented with acute abdominal pain. Most of the cases were ruptured (78/90, 86.66%) and the rest were unruptured (12/90, 13.33%) [Figure 1].
Figure 1: Gross photograph of resected fallopian tube with tubal ectopic.

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Right side fallopian tube was involved in 48 cases (53.33%) and left side in 42 cases (46.66%). Microscopic examination revealed chorionic villi in the wall of the tube [Figure 2] confirming the ectopic gestation. Chronic salpingitis was seen in twenty cases (22.2%) and it was characterized by chronic inflammatory cells in the wall along with distortion of plicae in some cases.
Figure 2: Photomicrograph showing chorionic villi with trophoblastic cells in the wall of the fallopian tube (H and E, ×100).

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SIN was seen in 11 cases (12.22%). SIN presents with nodular thickening of the fallopian tube and is microscopically characterized by the presence of tubal epithelial-lined glands surrounded by hypertrophied smooth muscle cells [Figure 3].
Figure 3: Photomicrograph showing salpingitis isthmica nodosa - epithelial-lined tubular structures surrounded by hyperplastic smooth muscle (H and E, ×400).

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A single case showed granulomatous inflammation. Epithelioid cell granulomas with Langhans type of giant cells suggestive of tuberculosis (TB) were seen in the mucosa and muscular layer [Figure 4]. Special stain for acid-fast Bacillus (AFB) showed an occasional AFB. Features of SIN were also noted in the same case. The patient did not have any evidence of TB elsewhere.
Figure 4: Photomicrograph showing epithelioid cell granuloma with Langhans giant cell within the mucosa (H and E, ×100).

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Walthard cell nests were noted in 5 cases (5.55%). They appear as 1–2 mm yellowish-white nodules on the serosa and are seen microscopically as nests of round to polygonal cells with ovoid nuclei, which sometimes show a longitudinal groove.


  Discussion Top


Ectopic pregnancy can occur at different sites such as fallopian tubes, ovary, and abdominal cavity. The most common site is the fallopian tube (90–95%).[5] A study from North India showed a higher prevalence in adults than in adolescents.[7] Other studies from India have also noted that ectopics occur more often in the third decade.[3] The age range in the present study was 18–40 years; most of them were in the third decade (71.11%).

Fallopian tubal pregnancy often presents as an acute medical emergency due to rupture of the fallopian tube. The wall of the fallopian tube becomes thinned out due to the invasion of trophoblastic cells and chorionic villi, which in turn is due to the limited ability of the endosalpingeal stroma to undergo decidualization. Unruptured ectopics are seen as irregular sausage-like dilatations of the tube, with a bluish discoloration caused by hematosalpinx. Ectopic tubal pregnancy is the most common cause of hematosalpinx. In the present study, 78/90 (86.66%) cases had presented with features of ruptured ectopic and 12/90 (13.33%) were unruptured.

Ectopic pregnancy has a slightly higher occurrence in the right fallopian tube (52–57%).[5],[8],[9] Findings in the present study were in concordance with the same (53.33%).

Chronic salpingitis due to chronic PID has been documented as one of the most important risk factors in the development of ectopic pregnancy. It is said that major proportion of salpingitis is the result of PID caused commonly by Chlamydia trachomatis and  Neisseria More Details gonorrhoeae. A history of the previous PID is the most important etiologic factor in 35–45% patients.[9] The risk of ectopic is known to increase 7-fold after an episode of acute salpingitis. The incidence of chronic salpingitis in fallopian tubal pregnancy has been variable (29–88%).[10],[11],[12] Studies in Sweden have shown that a reduction in PID is associated with a decline in the incidence of ectopic pregnancy.[2],[13] They noted that a low incidence of PID was associated with a low incidence of ectopic pregnancy and a high incidence of PID was associated with a high incidence of ectopic pregnancy, a decade or so later. Microscopically, chronic salpingitis shows lymphocytes and plasma cells in the mucosa with or without plical distortion/adhesions. Tubal scarring and fibrous adhesions may also be noted. Sometimes, when it involves the fimbriae, due to the proximity of the ovary to it, tubo-ovarian adhesions can form. In chlamydial salpingitis, repeated episodes of inflammation are associated with accumulation of CD8 T-cells and tubal scarring.[14] The current study showed the features of chronic salpingitis in 20/90 cases (22.22%).

One of the other causes for chronic salpingitis, especially in India, is genital TB. In India, the incidence of genital TB in patients undergoing surgery for acute ectopic pregnancy was as high as 35.29–40%.[7],[15] India has a high burden of TB accounting for 2 million cases annually as compared to 9.4 million cases globally, in the year 2009.[7] It is said that approximately 40% of the Indian population is infected with tubercle bacillus. In India, one in eight women suffering from pulmonary TB develops genital TB [7] and 10–20% women who die of TB have tubal involvement.[16] TB is characterized by granulomatous inflammation. The earliest microscopic lesions are mucosal with the extension of granulomas into the muscularis and serosa. As the tubercles enlarge, they erode through the mucosa and discharge contents into the lumen. The mucosal inflammation leads to progressive scarring with plical distortion. Even if tubercles are not present in the given sections, the presence of caseation, fibrosis, or calcification in a fallopian tube necessitates a more thorough study to rule out TB. The complications of tuberculous salpingitis are several. Alteration of tubal function and bilaterality of the disease lead to sterility. The present study had one case of tuberculous salpingitis.

Since ectopic pregnancy is one of the most serious complications of PID, the identification of features of chronic salpingitis with subsequent treatment reduces the risk of a recurrent ectopic. Hence, it is important to thoroughly examine the fallopian tube to identify the features of chronic salpingitis in all resected tubal ectopic specimens.

SIN is often bilateral, usually seen as a result of postinflammatory distortion of the fallopian tube with diverticula of tubal epithelium into the muscular layer.[12],[17] Inflammatory tubal disease may be associated with SIN ipsilaterally or contralaterally. Grossly, it is characterized by one or more nodular swellings in the isthmus of the fallopian tube. SIN is seen to occur in about 10–43% of tubal ectopics.[10],[12],[18] SIN was seen to be concomitant with chronic salpingitis in some studies.[12] In another study, SIN was noted in 7.4% of infertile women with tubal obstruction and 10% of women with ectopic tubal pregnancy. In the same study, SIN was present in both the tubes in 60% cases.[18] Skibsted et al., in their study of SIN in Danish women, concluded that women with SIN had a greater risk of tubal pregnancies as compared to women without SIN.[19] The most serious clinical and pathological complications of SIN are infertility and a strong association with ectopic pregnancy.[10],[20] We came across 11 cases (12.22%) of SIN in this study.

There is no noted association of Walthard cell nests with ectopic pregnancy. These were observed as incidental findings (5.55%) in the present study.


  Conclusion Top


Histopathological examination of the resected fallopian tubal ectopics can provide an insight into the etiopathogenesis of ectopic pregnancy. In some cases, it can also aid in the treatment modality to prevent a recurrent ectopic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Dimitry ES, Rizk B. Ectopic pregnancy: Epidemiology, advances in diagnosis and management. Br J Clin Pract 1992;46:52-4.  Back to cited text no. 1
    
2.
Kamwendo F, Forslin L, Bodin L, Danielsson D. Epidemiology of ectopic pregnancy during a 28 year period and the role of pelvic inflammatory disease. Sex Transm Infect 2000;76:28-32.  Back to cited text no. 2
    
3.
Mufti S, Rather S, Mufti S, Rangrez RA, Wasiqa, Khalida. Ectopic pregnancy: An analysis of 114 cases. JK Pract 2012;17:20-3.  Back to cited text no. 3
    
4.
Ellenson LH, Pirog EC. The female genital tract. In: Kumar V, Abbas AK, Fausto N, Aster JC, editors. Robbins and Cotran Pathologic Basis of Disease. 8th ed. New Delhi: Elsevier; 2010. p. 1053-4.  Back to cited text no. 4
    
5.
Wheeler JE. Diseases of the fallopian tube. In: Kurman RJ, editor. Blaustein's Pathology of the Female Genital Tract. 5th ed. New York: Springer; 2002. p. 617-48.  Back to cited text no. 5
    
6.
Patil M. Ectopic pregnancy after infertility treatment. J Hum Reprod Sci 2012;5:154-65.  Back to cited text no. 6
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7.
Banerjee A, Prateek S, Malik S, Dhingra D. Genital tuberculosis in adolescent girls from low socioeconomic status with acute ectopic pregnancy presenting at a tertiary care hospital in urban Northern India: Are we missing an opportunity to treat? Arch Gynecol Obstet 2012;286:1477-82.  Back to cited text no. 7
    
8.
Breen JL. A 21 year survey of 654 ectopic pregnancies. Am J Obstet Gynecol 1970;106:1004-19.  Back to cited text no. 8
    
9.
Brenner PF, Roy S, Mishell DR Jr. Ectopic pregnancy. A study of 300 consecutive surgically treated cases. JAMA 1980;243:673-6.  Back to cited text no. 9
    
10.
Green LK, Kott ML. Histopathologic findings in ectopic tubal pregnancy. Int J Gynecol Pathol 1989;8:255-62.  Back to cited text no. 10
    
11.
Ramirez NC, Lawrence WD, Ginsburg KA. Ectopic pregnancy. A recent five-year study and review of the last 50 years' literature. J Reprod Med 1996;41:733-40.  Back to cited text no. 11
    
12.
Kutluay L, Vicdan K, Turan C, Batioglu S, Oguz S, Gökmen O. Tubal histopathology in ectopic pregnancies. Eur J Obstet Gynecol Reprod Biol 1994;57:91-4.  Back to cited text no. 12
    
13.
Egger M, Low N, Smith GD, Lindblom B, Herrmann B. Screening for chlamydial infections and the risk of ectopic pregnancy in a county in Sweden: Ecological analysis. BMJ 1998;316:1776-80.  Back to cited text no. 13
    
14.
Van Voorhis WC, Barrett LK, Sweeney YT, Kuo CC, Patton DL. Repeated Chlamydia trachomatis infection of Macaca nemestrina fallopian tubes produces a Th1-like cytokine response associated with fibrosis and scarring. Infect Immun 1997;65:2175-82.  Back to cited text no. 14
    
15.
Parikh FR, Nadkarni SG, Kamat SA, Naik N, Soonawala SB, Parikh RM. Genital tuberculosis – A major pelvic factor causing infertility in Indian women. Fertil Steril 1997;67:497-500.  Back to cited text no. 15
    
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Schaefer G. Tuberculosis of the female genital tract. Clin Obstet Gynecol 1970;13:965-98.  Back to cited text no. 16
    
17.
McComb PF, Rowe TC. Salpingitis isthmica nodosa: Evidence it is a progressive disease. Fertil Steril 1989;51:542-5.  Back to cited text no. 17
    
18.
Saraçoglu FO, Mungan T, Tanzer F. Salpingitis isthmica nodosa in infertility and ectopic pregnancy. Gynecol Obstet Invest 1992;34:202-5.  Back to cited text no. 18
    
19.
Skibsted L, Sperling L, Hansen U, Hertz J. Salpingitis isthmica nodosa in female infertility and tubal diseases. Hum Reprod 1991;6:828-31.  Back to cited text no. 19
    
20.
Persaud V. Etiology of tubal ectopic pregnancy. Radiologic and pathologic studies. Obstet Gynecol 1970;36:257-63.  Back to cited text no. 20
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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