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|Year : 2013 | Volume
| Issue : 4 | Page : 315-317
Ruptured ectopic pregnancy associated with tubal schistosomiasis
L Sahu1, A Tempe1, S Singh1, N Khurana2
1 Department of Obstetrics and Gynecology, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
2 Department of Pathology, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
|Date of Submission||14-Oct-2012|
|Date of Decision||12-Dec-2012|
|Date of Acceptance||08-Feb-2013|
|Date of Web Publication||17-Dec-2013|
Department of Obstetrics and Gynecology, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
Endemic in major parts of Africa and Middle East, Schistosoma haematobium is a common cause of recurrent urogenital infections and obstetric complications such as spontaneous abortions, ectopic pregnancies, and low birth weight babies. The involvement of fallopian tubes is not rare in endemic areas and may predispose to ectopic pregnancy and infertility. Indian subcontinent is a very lowrisk region for schistosoma infection. Tubal schistosomiasis is not exceptional in endemic zones, but is rarely found in India. The species most often isolated is S. haematobium. Contamination occurs via vascular anastomoses between the bladder and the genital organs. We report a case of tubal schistosomiasis presenting as ruptured ectopic pregnancy discovered on a surgical specimen after salpingectomy.
Keywords: Ectopic pregnancy, female genital schistosomiasis, tubal schistosomiasis
|How to cite this article:|
Sahu L, Tempe A, Singh S, Khurana N. Ruptured ectopic pregnancy associated with tubal schistosomiasis. J Postgrad Med 2013;59:315-7
| :: Introduction|| |
Schistosomiasis is a parasitic infection endemic in 74 resource-poor nations that affects approximately 200 million people. Schistosomes are water-borne flatworms or blood flukes that enter the human body through the skin. Schistosomiasis is a neglected tropical disease, and its global health impact is grossly underestimated. Women suffer considerably from female genital schistosomiasis that causes infertility, preterm labor, anemia, menstrual disorders, and dyspareunia. Today, 120 million people are symptomatic.  Over 80% of the disease is currently found in sub-Saharan Africa. According to the World Health Organization (WHO), approximately 652 million people are at risk with an estimated 200,000 deaths occurring annually. Forty million women of childbearing age are infected.  WHO has placed schistosomiasis as the third most devastating tropical disease, following malaria and intestinal helminthiasis. The frequency of distribution of schistosomal disease of the genital tract has not been estimated because only the cases with overt disease are usually considered.
An estimated 85% of the world's cases of schistosomiasis are in Africa, where prevalence rates can exceed 50% in local populations. Schistosoma mansoni and S. haematobium are distributed throughout Africa; only S. haematobium is found in areas of the Middle East, and S. japonicum is found in Indonesia and parts of China and Southeast Asia. India is a low-risk endemic zone for genitourinary schistosomiasis and low index of suspicion leads to majority of cases left un recognized. 
| :: Case Report|| |
A 25 years-old female, third gravida, para two and live two, presented to gynecologic emergency with one and a half month of amenorrhea, acute pain abdomen, bleeding per-vagina, dizziness, and fainting attack for the last 6 hours. On examination, her pulse rate was 120/min, blood pressure was 90/50 mm Hg, pallor ++, abdominal distension, and tenderness in right lower abdomen was present. Per vaginum examination revealed uterus to be of normal size, and a 3 × 3 cm cystic tender mobile mass palpable in right adnexa. Cervical motion tenderness was present. Urine pregnancy test was positive, Ultrasound evaluation showed uterus of normal size endometrial thickness = 8 mm, a 3.4 × 3.6 cm heterogenous lesion, with increased vascularity, and free fluid in the pouch of Douglas suggestive of ectopic gestation with hemoperitoneum. Culdocentesis revealed dark hemorrhagic fluid. Provisional diagnosis of ruptured ectopic pregnancy was made and she was taken up for emergency laparotomy.
Per operative findings were hemoperitoneum of around 700 mL, chronically inflamed uterus, bruised and adhered to gut. Right side tube was ruptured at the ampullary region. The tube was chronically inflamed and adhered to the gut. Left tube was also thickened and inflamed, both the ovaries buried in adhesions. Right sided total salpingectomy was done. Peritoneal washing done, hemostasis achieved, and abdomen was closed in layer. Postoperative period was uneventful. Histopathology confirmed a tubal gestation with large areas of necrosis. Also entrapped were multiple ova elongated with transparent shell [Figure 1]. Few ova carrying a terminal spine at one pole [Figure 2], black arrow]. Some of the ova contained fully developed internal structure resembling miracidium [Figure 2], white arrow], while some others were degenerated. Findings were suggestive of schistosomiasis and due to the presence of terminal spine hematobium species was suggested. A course of tab praziquantel single dose 4800 mg in four divided doses, 1200 mg QID for one day was given. She responded well to expert postoperative care and praziquantel and was discharged on 10 th postoperative day. After enquiry from us she revealed her prior travel to endemic areas of schistosomiasis, but her contacts and other relatives could not be traced as she lost follow-up afterwards.
|Figure 1: Fallopian tube section with large areas of necrosis and hemorrhage. Also, entrapped multiple ova (arrow)|
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| :: Discussion|| |
Schistosomiais is prevalent in tropical and sub-tropical areas, especially in poor communities without access to safe drinking water and adequate sanitation. It is estimated that at least 90% of those requiring treatment for schistosomiasis live in Africa. Schistosomiasis particularly affects agricultural and fishing populations. Women doing domestic chores in infested water, such as washing clothes, are also at risk. Hygiene and play habits make children vulnerable to infection. All ages are at risk for infection with travel to endemic areas and freshwater exposure. Swimming, bathing, and wading in contaminated freshwater can result in infection. The distribution of schistosomiasis is very focal and determined by the presence of competent snail vectors, inadequate sanitation, and infected humans. The geographic distribution of cases of schistosomiasis acquired by travelers reflects travel and immigration patterns. Most travel-associated cases of schistosomiasis are acquired in sub-Saharan Africa.
Tubal schistosomiasis leading to complications is not exceptional in endemic zones, but is only rarely found in India. Female genital schistosomiasis (FGS) is predominantly caused by S. haematobium. During their reproductive years, women suffer severe morbidity and mortality because of FGS. As the eggs penetrate the urinary system, they can find their way to the female genital region and form granulomas in the uterus, fallopian tube, and ovaries. Women develop uterine enlargement, menstrual disorders, cervicitis, and infertility. Externally, vulvar or perianal lesions develop in 30% of women. These lesions appear ulcerated, hypertrophic, or even fistulous. Urogenital schistosomiasis can cause devastating immune-mediated damage in fallopian tubes and increase the risk of ectopic gestation. ,
Schistosomiasis also affects the uterine environment during pregnancy. Approximately, 10 million women in Africa have schistosomiasis in pregnancy.  Studies have demonstrated that pregnant women infected with schistosomiasis develop severe anemia, have low birth weight infants, and an increased infant and maternal mortality rate. , Schistosomiasis has been detected in the placenta, and newborns have been diagnosed with the disease, thus confirming congenital infection. Data suggest that infected women have a higher rate of spontaneous abortions and a higher risk for ectopic pregnancies. ,
The increased pelvic blood flow during pregnancy is thought to assist in accelerating the disease and increasing the infection load.
Praziquantel is used to treat schistosomiasis; the dose is 20 mg/kg by mouth every 4-6 hours for one day. The dosage is for patients over 4 years old, and are to be taken with food or a few minutes before a meal. The drug kills the adult worm, but does not affect the ova. The ova induce a granulomatous reaction (the Splendore-Hoeppli phenomenon) that leads to fibrosis and the side effects of (among others) FGS. In order to prevent this, school children in endemic areas should receive prophylaxis before the reaction starts around the ova.
Recent studies have determined the safety and efficacy of praziquantel in pregnancy. , The present case shows evidence of schistosomiasis as a rare but important cause of ectopic pregnancy leading to life-threatening intraperitoneal hemorrhage. Clinicians should therefore consider schistosomiasis as a possible etiology for pelvic inflammatory disease and ectopic pregnancy, even in patients from nonendemic regions like India, especially with history of travel to endemic regions.
| :: References|| |
|1.||World Health Organization, authors. Schistosomiasis, Fact Sheet No 115, Feb, 2010. Available from: http://www.who.int/mediacentre/factsheets/fs115/en/index.html [Last accessed on 2010 Mar 16]. |
|2.||Friedman JF, Mital P, Kanzaria HK, Old GR Kurtis JD. Schistosomiasis and pregnancy. Trends Parasitol 2007;23:159-64. |
|3.||Bahrami S, Alatassi H, Slone SP, O'Connor DM. Tubal gestation and schistosomiasis: A case report. J Reprod Med 2006;51:595-8. |
|4.||Laxman VV, Adamson B, Mahmood T. Recurrent ectopic pregnancy due to Schistosoma haematobium. J Obstet Gynaecol 2008;28:461-2. |
|5.||Ajanga A, Lwambo N, Blair L, Nyandindi U, Fenwick A, Brooker S. Schistosoma mansoni in pregnancy and associations with anaemia in northwest Tanzania. Trans R Soc Trop Med Hyg 2006;100:59-63. |
|6.||Tweyongyere R, Mawa P, Emojong N, Mpairwe H, Jones FM, Duong T, et al. Effect of praziquantel treatment of Schistosoma mansoni during pregnancy on intensity of infection and antibody responses to schistosome antigens: Results of a randomized, placebo-controlled trial. BMC Inf Dis 2009;9:32. |
[Figure 1], [Figure 2]
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