The role of Chlamydia trachomatis and Neisseria gonorrhoeae in the aetiology of ectopic pregnancy in Gabon

OBJECTIVE

To study the association between ectopic pregnancy and Chlamydia trachomatis and Neisseria gonorrhoeae.

DESIGN

A prospective observational study with two comparison groups.

SETTING

A general hospital in Franceville, Gabon.

SUBJECTS

Forty-five women with ectopic pregnancies and two comparison groups each of 45 women, one at 5 to 12 and the other at 32 to 41 weeks gestation.

MAIN OUTCOME MEASURES

Serum levels of IgG and IgA antibodies to C. trachomatis (L1 and rMOMP) and N. gonorrhoeae (pili) in all the women. In the women with ectopic pregnancy peritoneal adhesions were scored and in 40 women samples of tube were cultured for organisms being studied.

RESULTS

IgG and IgA antibodies to C. trachomatis (L1) were detected in 84% of the ectopic group and 53 and 39% of the comparison groups (P less than 0.0001). IgG and IgA antibodies to N. gonorrhoeae occurred in 49, 28 and 18% and 49, 28 and 26% of the groups but the differences were not statistically significant. Adhesions were positively associated with the antibodies. C. trachomatis was cultured from the tubes of 71% of the women with ectopic pregnancy.

CONCLUSIONS

Infection with chlamydia, and probably with N. gonorrhoeae, is an important factor in the causation of ectopic pregnancy in Gabon.

Risk factors for ectopic pregnancy: a case-control study in France, with special focus on infectious factors

A case-control study was conducted in 1988 in seven Paris area maternity hospitals to evaluate the role of several risk factors, particularly infectious factors, in ectopic pregnancy. A total of 279 cases and 279 controls were compared for sociodemographic characteristics, cigarette smoking, sexual, reproductive and surgical histories, and conditions of conception. Pelvic inflammatory disease confirmed by celioscopy (odds ratio (OR) = 5.5, 95% confidence interval (CI) 2.1-13.9) and Chlamydia trachomatis seropositivity (OR = 3.9, 95% CI 2.3-6.7) appeared to be important risk factors for ectopic pregnancy. Other risk factors found to be associated with an increased risk of ectopic pregnancy were dose-related cigarette smoking at the time of conception (ORs 1.3 to 2.5), appendectomy (OR = 1.6, 95% CI 1.1-2.5), prior tubal surgery (OR = 5.1, 95% CI 1.7-15.4), induced conception cycle (OR = 3.2, 95% CI 1.1-9.3), and prior ectopic pregnancy (OR = 13.3, 95% CI 4.5-39.2). However, some of the latter risk factors, i.e., prior tubal surgery, prior ectopic pregnancy, and perhaps appendectomy, may be considered to be the results of pelvic inflammatory disease and sexually transmitted diseases. Maternal age, parity, prior induced abortion, and prior spontaneous abortion were not associated with ectopic pregnancy. Use of intrauterine device, progestagen micropill, and also combined estroprogestative pill at the time of conception were associated with a better prevention of intrauterine pregnancy than of ectopic pregnancy. These findings confirm the importance of several previously reported risk factors of ectopic pregnancy: sexually transmitted diseases, cigarette smoking, and prior ectopic pregnancy. They also identified new risk factors, appendectomy and induced conception cycle, and revealed that the combined estroprogestative pill does not prevent ectopic pregnancy as effectively as it does intrauterine pregnancy.

Ectopic pregnancy in women with previous tubal sterilizations at a Canadian community hospital

A Canadian community hospital review of women with ectopic pregnancies revealed that 7.6% had had a previous tubal sterilization. This rate was higher than reported previously.

Ectopic pregnancies due to contralateral fistulas after sterilization by electrocoagulation; case reports

Three cases of post-sterilization tubal pregnancy are discussed. The sterilizations were performed by bipolar electrocoagulation. The location of the pregnancy was distal to the site of sterilization. There was no continuity between the segment containing the ectopic pregnancy and the uterus. Spermatozoa reached the site of fertilization via a tuboperitoneal fistula. The existence of the fistulas was confirmed by a methylene blue test. In two cases fistulas existed on the contralateral side to the ectopic pregnancy. In the third case, bilateral fistulas were found. So, on performing a salpingectomy for ectopic pregnancy after sterilization failure, we have to be aware of contralateral fistulas. Also good understanding of the mechanism of extra-uterine pregnancy secondary to transperitoneal migration of spermatozoa is important when doing conservative tubal surgery.

The contribution of previous induced abortion to tubal ectopic pregnancy

Data from a one year prospective study of thirty-one tubal ectopic pregnancies and ninety-three matched controls is presented. Compared with the controls, a history of induced abortion, was not only statistically significantly more frequent amongst the subjects (P less than 001) but was the Penultimate cyesis in 41.9% of ectopic cases as against 3.2% of the controls (P less than 001). Non-physicians provided 51.6% and 3.3% of induced abortions in the study and control groups respectively. Complications occurred in 51.6% of study population and 6.5% of controls. It is concluded that induced abortions created the predispotion to tubal implantation in the study population and therefore a reduction in the incidence of illegally induced abortion in the community can reduce the incidence of ectopic tubal gestation and tubal infertility.

Serum IgG and IgA antibodies to Chlamydia in ectopic pregnancies

The possible association of Chlamydia trachomatis with ectopic pregnancies was evaluated in a case-control study, comprising 35 women with ectopic pregnancy and 294 apparently healthy women who served as controls. Chlamydia-specific IgG and IgA antibodies were determined by single serovar (L2) inclusion immunoperoxidase assay (IPA). Socio-demographic characteristics, gynecological history and contraceptive methods were also evaluated. An inverse relationship was found between the educational levels and the prevalence of IgG and IgA antibodies to chlamydia. The prevalence rate of elevated IPA IgG (titer greater than or equal to 128) and IPA IgA (titer greater than or equal to 16) specific to chlamydia was significantly higher in women with ectopic pregnancy versus controls (32% vs 8%, respectively, for IgG: odds ratio = 4.9; and 26% vs 4% for IgA: odds ratio = 7.5). Chlamydia trachomatis was not isolated in cell cultures in 10 specimens available from fallopian tubes of women with ectopic pregnancy. Only 9% of the women recall having pelvic inflammatory disease (PID) indicating that most of the infections were asymptomatic. Women who did not use IUD had a higher proportion of chlamydia-specific IgG and IgA seropositives, though not statistically significant, as compared to IUD users. This study further supports the hypothesis that subclinical infection of the tube with C. trachomatis may underlie ectopic pregnancies.

Increasing incidence of ovarian pregnancy

This paper presents the results of a review of seven ovarian pregnancies occurring during an 11 year period (1976-1986). The prevalence of the disease is higher than that expected either for the number of deliveries or for all ectopic pregnancies. The presence of etiological factors such as pelvic inflammatory disease, previous abdominal surgery, endometriosis or use of IUD, is considered. Four of these cases presented in actual users of IUD and one in an infertile woman previously diagnosed of endometriosis. The clinical pattern was similar to that recorded for tubal ectopic pregnancies. The role of IUDs and other risk factors in the apparent increase in the number of ectopic pregnancies detected is discussed. Measures to increase accuracy in the detection of early ovarian pregnancies are proposed.

Ectopic tubal pregnancy in Zimbabwe

A study of 441 ectopic tubal pregnancies treated at Harare Central Hospital between 1981-84 was carried out. During that time, there were 162,964 deliveries in the unit. The incidence of tubal pregnancy in this study was only 0.27%. Patients ranged in age from 13-46 years with the majority (67%) between ages 20-29. 88% of the patients were parous, the mean parity being 2.6 96% of the patients complained of abdominal pain, 78% of amenorrhea, and 64% of abnormal uterine bleeding. Abdominal tenderness (96%) and cervical excitation (91%) were the most significant signs. Paracentesis was positive in 78% of the cases. It was a little value in the diagnosis of chronic or unruptured tubal pregnancy. There was 1 maternal death.

Ectopic pregnancy and prior induced abortion

As part of the Women's Health Study, a case-control study conducted in nine cities in the United States, women hospitalized with an ectopic pregnancy and women hospitalized with non-gynecologic, medical or surgical diagnoses were interviewed concerning past reproductive history. There were 462 women meeting eligibility criteria in the ectopic pregnancy case group and 2326 women meeting the criteria for the control group. After adjustment for a number of possible confounders, the relative risk of ectopic pregnancy for women with a history of one induced abortion was 1.0 (95% confidence limits: 0.5 to 1.8) and was 0.9 (95% confidence limits: 0.8 to 1.1) for women with a history of two or more prior induced abortions. These results suggest that prior induced abortion does not significantly increase the risk of subsequent ectopic pregnancy.

Ectopic pregnancy: a case-control study of aetiological risk factors

Aetiological risk factors for ectopic pregnancies were evaluated in a prospective study of 86 consecutive patients with ectopic pregnancy and two age- and parity-matched control groups of women in normal early pregnancy; those with planned pregnancy (65 pairs) and those having legal abortion (51 pairs). Compared with women with planned pregnancy, the patients with ectopic pregnancy more often had an IUD in situ, they had less frequently used hormonal contraception, and they had more legal abortions, curettages, previous ectopic pregnancies, gynaecological operations and salpingo-oophoritis. Compared with women having legal abortion, the patients with ectopic pregnancy had favoured IUD-usage, or they had been without any contraception, and they had an increased frequency of previous ectopic pregnancies. The frequency of fertility problems was also increased in patients with ectopic pregnancy. Our results show that gynaecological pelvic operations, endometrial curettage and evacuation, gynaecological infections, and usage of IUD are important risk factors for ectopic pregnancy, and that infertility seems to be a sign of this risk. In addition, the clinical characteristics of the patients with ectopic pregnancy were similar to those of the patients having legal abortion.

The intrauterine device and ectopic pregnancy

Based on data given by case-control and cohort studies the relationships between current and past IUD use, duration of IUD use and the type of IUD were evaluated to determine the risk of ectopic pregnancy among IUD users. The results of this review indicate that current and past IUD users do not have an increased risk of ectopic pregnancy. No relationship was found between the duration of IUD use, for either current or past IUD users, and the risk of ectopic pregnancy. Pooled data from clinical studies of different types of IUD showed that the lowest risk of ectopic pregnancy was for users of copper-bearing IUDs, and the highest risk was for users of progesterone-releasing IUDs. Further research is needed to evaluate the ectopic pregnancy risks to past IUD users, especially in view of recent studies which have shown that these women may be at a higher risk of infertility.

Background factors of ectopic pregnancy. II. Risk estimation by means of a logistic model

Based on the frequency distribution in a previous case-control study of ectopic pregnancy in Sweden, the prognostic value of a number of risk factors was analysed. A logistic procedure was applied in a stepwise manner, resulting in a risk-scoring model in which the probability of ectopic pregnancy can be determined on the basis of four background factors.

Background factors of ectopic pregnancy. I. Frequency distribution in a case-control study

Two hundred and five patients with ectopic pregnancy in a well-defined Swedish population were interviewed with respect to prior disease and pregnancy histories as well as various constitutional and socioeconomic factors. The results were compared with those of two control groups, i.e. 110 early pregnant women intending to continue the gestation to term as well as 101 women seeking voluntary interruption of pregnancy. The results provide evidence that several may be involved in the etiology of ectopic pregnancy, including abdominal (or pelvic) surgery, previous ectopic pregnancy and pelvic inflammatory disease. Furthermore, a history of infertility is strongly correlated to ectopic pregnancy. On the other hand, there is no evidence that uncomplicated spontaneous or induced abortion, parity or marital status are important factors.

Ectopic pregnancy--an analysis of the etiology, diagnosis and treatment in 552 cases

An analysis of the clinical data of 552 patients treated for ectopic pregnancy during 1973-82 in our hospital showed that the prevalence of this complication rose twofold (P less than 0.01) from an annual rate of 10.9 per thousand in 1973 to 20.9 per thousand in 1982. As regards parity distribution, the proportion of the 2-paras increased significantly (P less than 0.05) and this increase was significantly greater (P less than 0.001) than in the total population of parturients during this period. The increasing incidence of ectopic pregnancies had a significant positive correlation (P less than 0.05) with the use of an intrauterine device (IUD), but not with previous or present pelvic inflammatory disease or gynaecological or abdominal surgery. Because the 158 patients with an IUD in situ (34%) had a significantly less frequent past history of salpingitis, pelvic operation, infertility, ectopic pregnancy or spontaneous abortion and had less actual pelvic inflammatory changes than the 259 patients without contraception (57%), the IUD seemed to be directly involved with the increased risk of ectopic pregnancy. In the present study lower abdominal pain occurred in 97% of the patients and menstrual disorders in 93%; pelvic examination revealed adnexal mass in 63% and adnexal tenderness in 90% of the patients. Laparoscopy, a sensitive urinary pregnancy test (detection limit 75 IU/1) and culdocentesis were the most important factors in the diagnosis of ectopic pregnancy as evidenced by positive results in 97, 90 and 83% of the cases, respectively. Due to improved diagnostic procedures the annual rate of an unruptured tube at operation increased from 49% to 73% during the study period.

Ectopic pregnancy

The diagnosis of ectopic pregnancy has become precise and reliable. Consequently, the management of ectopic pregnancy has progressed to the point where the physician is often able to preserve fertility. Therefore, conservative surgery is indicated if the patient desires future fertility and conditions are appropriate. The combination of ultrasound, beta-hCG pregnancy testing, and laparoscopy has led to a rising incidence of diagnosed ectopic pregnancy prior to rupture. This has greatly facilitated the use of the conservative approach to the management of tubal pregnancy. Although ectopic pregnancy can be diagnosed early and managed conservatively, it is, and will remain a potentially life-threatening disease and must be approached as such. Table 3 summarizes our proposed surgical management of tubal pregnancy. Table 4 summarizes the results of conservative surgery for tubal pregnancy.

Morphological changes in tubal mucosa associated with the use of intrauterine contraceptive devices

We examined the endosalpinx of 28 healthy non-pregnant women, 12 of whom had an intrauterine contraceptive device (IUCD) and 16 of whom had neither an IUCD nor used oral contraceptives. Measurements made on light- and scanning electron micrographs showed that the percentage area covered by ciliated cells was approximately 40% in non-IUCD users and only 20% in IUCD users.

Tubal conservation with ectopic gestations. A reappraisal

Ectopic pregnancies have shown an increasing trend during the past decade. Factors that appear to be responsible are the intrauterine device (IUD), fallopian tube surgery (ligation reversals, reconstructive tuboplasty), and more effective antibiotics against pelvic inflammatory disease (precluding radical pelvic surgery). Our ability to diagnose an ectopic pregnancy at an earlier gestation (prior to rupture) through the use of highly sensitive pregnancy tests (Beta-HCG), ultrasonography, and diagnostic laparoscopy, has significantly altered our approach in treatment. Because these ectopic gestations are seen in a younger population, older nulliparous patients, and patients who desire future fertility, earlier diagnosis precludes an emergency approach to a now-elective procedure. In this paper, we will explore the pros and cons of conservative management for ectopic pregnancies, emphasizing present day evaluation and microsurgical approaches for repair.

Ectopic pregnancy: a seven-year survey

Seventy-five patients with ectopic pregnancy were treated at Jordan University Hospital (JUH) during a 7-yr period from January 1976 to December 1982. The ratio of ectopic pregnancies to deliveries was 1 to 162. The most common symptoms were: abdominal pain, 96%; amenorrhea, 69.3%; vaginal bleeding, 60%. No patients with pelvic inflammatory disease were found. An intrauterine contraceptive device was present in 14.6% of the patients and 10.6% of the cases had previous pelvic surgery. Culdocentesis gave false negative results in 16.7% of the patients. The treatment of choice was salpingectomy. There were no maternal deaths in this series.

The rise in ectopic pregnancy--exploration of possible reasons

The rate of ectopic pregnancies has been rising in the past decade and it is responsible for an increasing proportion of maternal deaths. A history of pelvic inflammatory disease is strongly associated with ectopic pregnancy. There is a higher rate of ectopic pregnancy among intrauterine device users than non-users. A history of abdominal surgery has been associated with ectopic pregnancy and there is some evidence that women taking certain hormonal preparations experience excess ectopic pregnancies. Through a critical review of the literature, the author explores the evidence for these associations. The paper closes with recommendations for future research.

Endosalpingosis ("endosalpingoblastosis") following laparoscopic tubal coagulation as an etiologic factor of ectopic pregnancy

Recent literature has suggested that the majority of pregnancies following a laparoscopic tubal coagulation failure are ectopic. This is in direct contrast to the failure of other types of tubal ligation procedures which usually result in intrauterine pregnancies. The purpose of this paper is to explain this disparity in hopes of reducing the chance of ectopic pregnancies. A study of pathology is presented and how different portions of the oviduct respond to coagulation injury is reported. It was found that the endosalpinx of the proximal oviduct, which is so frequently injured during laparoscopic coagulation, becomes activated (endosalpingosis or "endosalpingoblastosis") with potential fistula formation. If the coagulation is more distal only fibrosis occurs. This is clinically significant in that if the laparoscopist avoids injury to the proximal isthmic portion of the oviduct, the chance of "endosalpingoblastosis," fistula, and ectopic pregnancy should be reduced, thus improving the outcome of this technique.

Basal body temperature recordings in ectopic pregnancy

Basal body temperature charts taken during the cycle of conception of tubal pregnancies suggested the presence of luteal phase defect in the background of ectopic implantation and the recurrence of an apparent menstruation at the expected time of the next period. The temperature changes were compatible with the occurrence of a "superovulation" shortly before the occurrence of tubal abortion.