|Year : 2020 | Volume
| Issue : 3 | Page : 149-153
Study of resected specimens of ectopic pregnancy: A-5 year experience in Regional Institute of Medical Sciences Hospital, Imphal
Rachel Shimray, Paramita Rudra Pal, Sharmila Laishram, Gayatri Pukhrambam
Department of Pathology, RIMS, Imphal, Manipur, India
|Date of Submission||04-Jan-2021|
|Date of Acceptance||15-Jan-2021|
|Date of Web Publication||29-Apr-2021|
Department of Pathology, RIMS, Imphal, Manipur
Source of Support: None, Conflict of Interest: None
Background: Ectopic pregnancy remains the leading cause of maternal death in early pregnancy. It is assuming greater importance because of its increasing incidence and its impact on woman's fertility.
Objectives: To study the histomorphological changes of ectopic pregnancy and its correlation with relevant parameters such as age, site, parity, and gestational age.
Materials and Methods: This study was conducted in the Department of Pathology, Regional Institute of Medical Sciences, Imphal, for a period of 5 years (January 2015–December 2019). All the specimens with a clinical diagnosis of ectopic pregnancy were included in the study. Histomorphological changes and other relevant parameters such as age, site, parity, and gestational age were analyzed.
Results: A total of 160 ectopic pregnancies were diagnosed during the study period. A total number of pregnant women attending antenatal outpatient department during the study period was found to be 121,1941 giving an overall rate of occurrence of 0.13% or 1.31/1000 pregnancies. The most common site of involvement was fallopian tube (95%), mostly on the right side (64.37%). The most common age group was 30–39 years (mean age 30.8 years). Nearly 91.25% of cases were multiparous presenting mostly in their first trimester. Predominant-associated histopathological findings were chronic salpingitis (43.12%), acute salpingitis (20.62%), and salpingitis isthmica nodosa (7.5%). One case was found to be associated with paratubal cyst.
Conclusion: Histopathological examination of resected ectopic pregnancy specimens can give an insight into the etiopathogenesis of ectopic pregnancy, thereby helping in early treatment and preventing recurrence.
Keywords: Ectopic pregnancy, salpingitis, salpingitis isthmica nodosa
|How to cite this article:|
Shimray R, Pal PR, Laishram S, Pukhrambam G. Study of resected specimens of ectopic pregnancy: A-5 year experience in Regional Institute of Medical Sciences Hospital, Imphal. J Med Soc 2020;34:149-53
|How to cite this URL:|
Shimray R, Pal PR, Laishram S, Pukhrambam G. Study of resected specimens of ectopic pregnancy: A-5 year experience in Regional Institute of Medical Sciences Hospital, Imphal. J Med Soc [serial online] 2020 [cited 2021 Jun 21];34:149-53. Available from: https://www.jmedsoc.org/text.asp?2020/34/3/149/315104
| Introduction|| |
Ectopic pregnancy is defined as any pregnancy where the fertilized ovum gets implanted and develops in a site other than normal uterine cavity. It presents as a life-threatening obstetric event accounting for around 10% maternal mortality. Incidence of ectopic pregnancy is quite variable throughout the world. In India, incidence is 3.12/1000 pregnancies. There is a rising trend of ectopic pregnancy over the couple of decades due to various reasons which include increased prevalence of chronic pelvic inflammatory disease (PID), ovulation induction, tubal reconstructive surgery, increase use of intrauterine devices, assisted reproductive techniques, and better diagnostic facilities. However, mortality has been reduced by 80% due to early diagnosis and treatment.
The most common implantation site for ectopic pregnancy is fallopian tube (90%–95%)., Ovarian and cervical ectopic pregnancy is rare accounting for 0.5%–3% and <1%, respectively, of all pregnancies., Around 1% of ectopic pregnancy is abdominal pregnancy, but its mortality rate is around seven times higher than in tubal pregnancy.
There are many predisposing factors of ectopic pregnancy, chronic salpingitis being the most common one. Others include acute salpingitis, salpingitis isthmica nodosa (SIN), tuberculosis, endometriosis, previous ectopic pregnancy, treatment for infertility, and previous abortion.
Aim and object
This study was conducted to note the histomorphology of ectopic pregnancy, other associated lesions, and also to corroborate ectopic pregnancy with relevant parameters such as age, implantation site, parity, and gestational age.
| Materials and Methods|| |
This study was conducted for a period of 5 years (January 2015–December 2019) in the Department of Pathology, Regional Institute of Medical Sciences (RIMS), Imphal, Manipur. One hundred and sixty cases of clinically diagnosed specimens of ectopic pregnancy were included in our study. The demographic profiles such as age, parity, gestational age, side and site of ectopic pregnancy, ultrasonographic findings, and other relevant information were recorded from the data received in the Department of Pathology, RIMS. Information regarding a total number of pregnancies during our study period was noted from antenatal outpatient department (OPD) record from the Department of Obstetrics and Gynaecology, RIMS. A complete analysis regarding age of patient, parity, gestational age, and site and side of ectopic gestation was made.
All the specimens were fixed in 10% neutral buffered formalin and processed routinely. Histological sections were stained with hematoxylin and eosin stain. Sections from all the tissues were studied for the presence of chorionic villi and trophoblastic cells to confirm ectopic gestation. All the sections were thoroughly studied for any associated findings sucj as chronic and acute salpingitis, SIN, and tuberculosis.
| Results|| |
A total of 160 confirmed ectopic pregnancy specimens were studied and analyzed out of 121,1941 pregnant women attending antenatal OPD during the study period giving an overall rate of occurrence of 0.13% or 1.31/1000 pregnancies. The age of the patients ranged from 18 to 59 years (mean age 30.8 years). Most of the patients were in the age group of 30–39 years (46.25%) [Table 1].One hundred and forty-six cases (91.25%) were multiparous women [Figure 1]; most of them presenting during the first trimester (148/160, 92.5%). Sixty-nine cases (43.12%) were ruptured ectopic pregnancy and the rest were unruptured.
Fallopian tube was found to be the most common site (95%), followed by cervix (3%) and ovary (3%) [Table 2]. Right-sided tubal ectopic was found in 103 cases (64%), and in 52 cases (33%), left side was affected [Figure 2]. Microscopic examination of the fallopian tube revealed chorionic villi in the wall, extravillous trophoblast, variable fetal parts, decidual change in the lamina propria, and mesothelial reaction, confirming the ectopic gestation [Figure 3].
|Figure 3: Photomicrograph showing chorionic villi with trophoblastic cells (arrow) in the wall of fallopian tube (H and E, ×100)|
Click here to view
According to Rubin histopathological criteria of cervical pregnancy include the presence of cervical glands opposite the attachment of trophoblast or placenta, attachment of trophoblast must be below the level of entrance of uterine vessels to the uterus or anterior peritoneal reflection, and fetal elements (products of conception) must be absent from uterine corpus.
Ovarian pregnancy is diagnosed following Spiegelberg's criteria which includes – fallopian tube at the affected side must be intact, gestational sac must be located in the region of the ovary, ectopic pregnancy must be connected to the uterus by ovarian ligament, and ovarian tissue must be located within the wall of the gestational sac and proved histologically.
One case each of intra-abdominal and rudimentary horn pregnancy was found.
Microscopic examination revealed chorionic villi, trophoblastic cells, and decidual cells in the respective sites confirming ectopic gestation [Figure 4] and [Figure 5].
|Figure 4: Photomicrograph showing chorionic villi (arrow) in cervix (H and E, ×100)|
Click here to view
|Figure 5: Photomicrograph showing decidual reaction (arrow) and trophoblasts (arrow head) in ovary (H and E, ×100)|
Click here to view
Chronic salpingitis was seen in 69 cases (43.12%) which is characterized microscopically by lymphoplasmacytic infiltrate in the wall along with distortion of plicae [Figure 6] and [Figure 7]. Acute salpingitis was found in 20.62% of cases characterized by the presence of polymorphs in the wall of the tube. Twelve cases (7.5%) were associated with SIN, characterized by the presence of tubal epithelial lined glands surrounded by hypertrophied smooth muscle cells. [Figure 8].
|Figure 7: Photomicrograph showing chronic inflammatory cells (arrow) in the well of fallopian tube (H and E, ×100)|
Click here to view
|Figure 8: Photomicrograph showing salipingitis isthmica nodosa – epithelial lined tubular structure surrounded by hyperplastic smooth muscle (arrow) (H and E, ×100)|
Click here to view
We encountered a rising trend of ectopic pregnancy over 5 years of our study period from 0.81/1000 pregnancy in 2015 to 1.77/1000 pregnancy in 2019 [Figure 9].
| Discussion|| |
There has been a significant increase in the incidence of ectopic pregnancy worldwide. Our study also shows a rising trend in the occurrence of ectopic pregnancy during the study period, i.e., 0.81/1000 pregnancy (2015) to 1.77/1000 pregnancy (2019). The rate of occurrence of ectopic pregnancy in our study is 0.13% of all pregnancies which is very close to the worldwide rate of occurrence (0.25%–2.0%).
Studies from different parts of India showed a higher prevalence of ectopic pregnancy between the age group of 25 and 35 years., In our study, age of the patient ranged from 18 to 59 years; most of them were in the group range of 30–39 years (46.25%), mean age being 30.8 years which is comparable to a study conducted by Rajendra and Kshama.
The most common site of ectopic pregnancy is fallopian tube, followed by ovary and cervix which are also found in our study. Right-sided ectopic is more common than left (50%–70%) which is also a finding in our study (64%).,, There are certain tubal and nontubal risk factors for the development of ectopic gestation in fallopian tube. The tubal factors include congenital abnormalities in the tube such as diverticula, hypoplasia, accessory ostia, and exposure to diethylstilbestrol resulting in structural abnormality; postligation pregnancy, tuboplasty; chronic salpingitis, granulomatous and nongranulomatous salpingitis due to tuberculosis, chlamydia and mycoplasma resulting in scarring and ciliary dysfunction. Some of the extratubal factors such as smoking, resulting in ciliary damage causing an increase in amount of time it takes for the fertilized egg to reach the endometrial cavity.
In our study, majority of the patients were multiparous women (91.25%) diagnosed during the first trimester (92.5%) which is comparable to other studies.
Ectopic pregnancy can present as acute emergency due to rupture of the implantation site, most commonly isthmic and interstitial implantation. Tubal rupture results from thinning of the wall due to invasion of trophoblastic cells and chorionic villi, leading to limited ability of the endosalpingeal stroma to undergo decidualization. Sixty-nine cases (43.12%) in our study were ruptured tubal ectopic pregnancy which is less in comparison to other studies.,,
Unruptured tubal ectopics are seen as irregular sausage like dilatations of the tube with bluish discoloration caused by hematosalpinx.
PID mainly chronic salpingitis is one of the most common predisposing factors for ectopic pregnancy. Chronic salpingitis causes scaring of the tube following mucosal damage which prevents normal embryo transport. The incidence of chronic salpingitis in ectopic pregnancy is quite variable (29%–88%)., Our study showed the findings of chronic salpingitis in 69/160 of cases (43.12%) which is similar to other studies.,
In India, one of the most common causes of chronic salpingitis is genital tuberculosis, incidence of which was found to be 35.29%–40%. However, in our study, we did not find any case associated with tuberculosis.
Acute salpingitis is known to increase the risk of ectopic pregnancy by 7 fold. Thirty-three cases (20.62%) in our study were found to be associated with acute salpingitis which is comparable to other studies.,
SIN which occurs due to distortion of fallopian tube as a result of inflammation has a strong association with ectopic pregnancy. Different study findings showed the concomitant presence of SIN and ectopic gestation in about 8%–43% of cases.,,, Our study showed 12/160 cases of SIN (7.5%).
| Conclusion|| |
From the present study, it can be concluded that histopathological examination is the gold standard for confirming ectopic pregnancy. Histopathological examination (HPE) can highlight the associated findings such as chronic and acute salpingitis, SIN which may explain the etiopathology of some of the cases. Recurrence can be prevented by treating these associated pathology.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Dutta DC, Konar H. DC Dutta's Textbook of Obstettic's. 8th
ed. New Delhi: Joypee Brothers Medical Publishers; 2015.
Dimitry ES, Rizk B. Ectopic pregnancy: Epidemiology, advances in diagnosis and management. Br J Clin Pract 1992;46:52-4.
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.
Mufti S, Rather S, Mufti S, Ranrez RA, Wasiqa, Khalida. Ectopic pregnancy: An analysis of 114 cases. JK Pract 2012;17:20-3.
Niles JH, Clark JF. Pathogenesis of tubal pregnancy. Am J Obstet Gynecol 1969;105:1230-4.
Ravindra S, Prasad S, Suguna BV. Histomorphology of fallopian tubes in ectopic pregnancy. Arch Med Health Sci 2016;4:201-4. [Full text]
Celik C, Bala A, Acar A, Gezginc K, Akyurek C. Methotraxate for cervical pregnancy. A case report. J Reprod Med 2003;48:130-2.
Raziel A, Golan A, Pansky M, Ron-El R, Bukovsky I, Caspi E. Ovarian pregnancy: A report of twenty cases in one institution. Am J Obstet Gynecol 1990;163:1182-5.
Atrash HK, Friede A, Hogue CJ. Abdominal pregnancy in the United States: Frequency and maternal mortality. Obstet Gynecol 1987;69:333-7.
Dama S, Kamat A. A clinical study of ectopic pregnancy in a tertiary care centre in Hubli. Int J Reprod Contracept Obstet Gynecol 2017;6:1566-9.
Rubin IC. Cervical pregnancy. Surg Gynecol Obstet 1911;13:625-33.
Young RH, Clement PB. Female Reproductive System & Peritoneum. In: Mills SE, Carter D, Greenson JK, Reuter VE, Stoler MH, editors. Sternberg's Diagnostic Surgical Pathology. 5th
ed. Philadelphia: Lippincott Williams and Wilkins; 2010.
Gupta V, Goel G, Gupta R, Bansal S, Chaturvedi J. Conventional surgical management of ectopic pregnancy in remote areas. Obstet Gynecol 2007;57:142-4.
Bembde AS, Bindu SM, Bhale CP. Clinico-pathological study of tubal ectopic gestation and evaluation of associated risk factors in a tertiary center. Ann Pathol Lab Med 2019;6:348-51.
Rajendra W, Kshama K. Ectopic pregnancy – A rising trend. Int J Sci Study 2015;3:18-22.
Brenner PF, Roy S, Mishell DR Jr. Ectopic pregnancy. A study of 300 consecutive surgically treated cases. JAMA 1980;243:673-6.
Mahendran R, Kanchana MP. Histomorphological study on ectopoic pregnancies in a tertiary care obstetrics centre – A retrospective 5 year study. IJMSIR 2020;5:129-35.
Gaddagi RA, Chandrashekar AP. A clinical study of ectopic pregnancy. JCDR 2012;6:867-9.
Green LK, Kott ML. Histopathologic findings in ectopic tubal pregnancy. Int J Gynecol Pathol 1989;8:255-62.
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.
Dahiya N, Singh S, Kalra R, Sen R, Kumar S. Histopatholocal changes associated with ectopic tubal pregnancy. IJPSR 2011;2:929-33.
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.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
[Table 1], [Table 2]