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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 5  |  Issue : 4  |  Page : 228-230

Schistosomiasis and second trimester tubal pregnancy in a multiparous female: A report and review of its pathology


1 Department of Pathology and Morbid Anatomy, Ahmadu Bello University Teaching Hospital, Ahmadu Bello University, Zaria, Kaduna State, Northwest Nigeria
2 Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Ahmadu Bello University, Zaria, Kaduna State, Northwest Nigeria

Date of Web Publication21-Jan-2016

Correspondence Address:
Dr. Modupeola Omotara Samaila
Department of Pathology and Morbid Anatomy, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State
Northwest Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.174677

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  Abstract 

Schistosomiasis remains a burden in sub-Saharan countries and detection is often incidental in females. Also, there is an increase in the incidence of tubal ectopic pregnancy due to pelvic inflammatory diseases (PIDs). The coexistence of these two pathologies in the female reproductive organs may lead to impaired fertility. We present a 28-year-old gravida 7, para 4 + 2 female with 2-months amenorrhea, 6 days lower abdominal pain, and 2-h history of dizzy spells seen at the Accident and Emergency Unit of our hospital. Clinical examination and ultrasound findings confirmed a ruptured right tubal gestation. She had salpingectomy and specimen was sent to the histopathology laboratory for analysis. Grossly, a well-formed male fetus consistent with 4-lunar-month gestation was seen in the expanded fallopian tube. Histopathologic sections from the tube revealed a ruptured expanded wall containing chorionic villi, decidua, and numerous Schistosoma haematobium ova. There was extensive fibrosis of the tubal wall. The diagnosis of schistosomiasis in reproductive age females is often incidental due to either absent or nonspecific symptoms, while tubal ectopic gestation is common and there are many factors attributable to its rising global incidence. Both schistosomiasis and ectopic gestation are strongly associated with infertility. Thus, the occurrence of schistosomiasis and second trimester tubal pregnancy in the same location in a multiparous female is a novelty.

Keywords: Fetal loss, multiparity, second trimester pregnancy, tubal schistosomiasis


How to cite this article:
Samaila MO, Abdulquadir FY, Adoke K, Oguntayo A, Koledade AK, Abubakar N. Schistosomiasis and second trimester tubal pregnancy in a multiparous female: A report and review of its pathology. Arch Int Surg 2015;5:228-30

How to cite this URL:
Samaila MO, Abdulquadir FY, Adoke K, Oguntayo A, Koledade AK, Abubakar N. Schistosomiasis and second trimester tubal pregnancy in a multiparous female: A report and review of its pathology. Arch Int Surg [serial online] 2015 [cited 2019 Aug 24];5:228-30. Available from: http://www.archintsurg.org/text.asp?2015/5/4/228/174677


  Introduction Top


Schistosomiasis is a public health problem in endemic regions and the highest disease burden is in sub-Saharan Africa where almost 40 million reproductive age women are infected. [1],[2],[3] The diagnosis of genital schistosomiasis in this group of females is often missed or delayed due to absent or nonspecific symptoms especially in the absence of urinary bladder involvement. Endemicity in Nigeria is low due to the mass chemotherapeutic treatment of population at risk with oral intake of praziquantel in the recent past. [4] Its resurgence is greatly enhanced by irrigation methods used in agricultural practices in different parts of the country. Ectopic gestation is a gynecological emergency with rising incidence particularly in developing countries due to the prevalence of PIDs. Its reported frequency rate ranges from 1.2% to 2.7% of deliveries in Nigeria while global incidence rates are variable. [5] Reports of tubal pregnancy and lower genital schistosomiasis are common in high endemic regions and have been associated with infertility in affected females. This report emphasizes a second trimester tubal pregnancy and severe schistosomiasis in a multiparous female.


  Case Report Top


A 28-year-old gravida 7, para 4 + 2 female with complaints of 6 days lower abdominal pains and 2 h dizzy spells without loss of consciousness was admitted at the accident and emergency (A & E) department of our hospital. Her last menstruation was 4 months prior to presentation. She delivered a live baby 14 months prior to the present pregnancy. She also had two previous spontaneous abortions in the first trimester that were not evaluated in the hospital. She had not commenced antenatal care for the index pregnancy. She had no history of diabetes, hypertension, smoking, or urinary disorders.

Clinical examination revealed a severely pale young female in painful distress with abdominal tenderness and guarding. Her packed cell volume (PCV) was 18%, blood chemistry was within the normal range, and temperature was 37°C. Abdominal-pelvic ultrasound scanning revealed a leaking right ectopic gestation. There was no abnormality detected in other pelvic and intra-abdominal organs. She was counseled and consent was obtained for emergency exploratory laparotomy. Intra-operatively, hemoperitoneum of 1.2 L, a ruptured right salpinx, and intact gestational sac with fimbriae buried within adhesion bands were seen. The uterus, left salpinx, and both ovaries were normal. She had a right salpingectomy and was transfused two pints of whole blood. The specimen sent to the histopathology laboratory for analysis was a gray tan irregular mass that weighed 85 g and measured 9 cm × 5 cm × 5 cm in dimensions. Cut surfaces revealed a ruptured thickened tubal wall with expanded cavity occupied by a well-formed male fetus with crown rump length (CRL) of 80 mm, crown heel length (CHL) of 140 mm, and weight of 15 g, consistent with a 4-lunar-month gestation with growth retardation [Figure 1] and edematous fimbria. A diagnosis of schistosomiasis with tubal gestation was made based on the histopathological finding of Schistosoma haematobium ova within fibrosed tubal wall and numerous chorionic villi. [Figure 2] She was treated with a single dose oral praziquantel (40 mg/kg body weight) and was discharged 2 weeks after surgery following full recovery. The possibility of compromised fertility due to Schistosomiasis infection on future pregnancy was explained to the patient who was still desirous of more children.
Figure 1: Four-lunar-month well-formed fetus with growth retardation

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Figure 2: Schistosoma haematobium ova within fibrosed tubal wall and numerous chorionic villi


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  Discussion Top


Genital schistosomiasis of the upper female pelvic organs is uncommon though there have been reports from high endemic regions and the implicated specie is S. haematobium. [6],[7] Its prevalence is relatively high in regions with slow moving rivers and fresh water bodies, such as dams, where the intermediate snail host proliferates and releases the cercaria that penetrates the skin of the definite host from where it reaches the lungs and liver. Adult worms mature in the pelvic venous plexuses and migrate to different tissues and organs to deposit the eggs responsible for the pathologic manifestation of the infection. Symptomatic infection depends on the number of eggs laid within the affected tissues, though chronic cases are often asymptomatic. [7] Again parasite intensity and burden reduces with increasing age and the greatest burden is seen in ages 15-20 years. [8],[9] This may explain the absence of symptoms in the patient.

The host antigenic immune response to the presence of Schistosoma eggs results in granuloma formation and varying fibrosis of the involved organs seen in the  Fallopian tube More Details of this patient. Fibrosis invariably results in tubal blockage. [6],[10],[11] Also the presence of adhesion bands intraoperatively was highly suggestive of PID. The combination of PID and schistosomiasis induced tubal fibrosis was the trigger for the index ectopic pregnancy and thus supports reports of increased incidence of ectopic in association with schistosomiasis and PID.

Tubal gestation remains the commonest ectopic type and the ampulla is the favored location with attendant high morbidity in developing countries. Rupture usually occurs in the first trimester between 5 weeks and 11 weeks of gestation [12] contrary to the index case who presented in the second trimester. Ruptured ectopic with a 1.2 L hemoperitoneum is a gynecologic emergency and the surgical intervention of salpingectomy was appropriate and adequate since only the right salpinx was ruptured. Later stage tubal pregnancies have been documented in literature but none was associated with schistosomiasis. Also, risk factors such as increased maternal age, previous ectopic pregnancy, sub fertility and infertility, and smoking were not recorded in this patient whose two previous abortions were followed by a live birth. We however, have no information on the possibility of congenital schistosomiasis in the live birth child. Extrauterine pregnancy is often associated with increased fetal wastage and growth retardation because only the uterine cavity is equipped to carry the fetus to term and provide the necessary ambient environment for growth and development. Most reports on genital schistosomiasis were seen in a background of infertility or nulliparous females in contrast with this patient whose infection appeared limited to the right fallopian tube based on her last live birth and intraoperative findings of normal uterus and left fallopian tube. The diagnosis of schistosomiasis in asymptomatic patients can also be achieved with an enzyme-linked immunosorbent assay (ELISA) by detection of specific antibodies. [13]

This report emphasizes the consideration of tubal schistosomiasis in the differentials for ectopic gestation irrespective of the patient's parity or fertility status. Regular water treatment to eliminate the intermediate host and administration of oral praziquantel chemotherapy to population at risk should reduce the attendant morbidity of schistosomiasis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Chitsulo L, Engels D, Montresor A, Savioli L. The global status of schistosomiasis and its control. Acta Trop 2000;77:41-51.  Back to cited text no. 1
    
2.
Southgate VR, Rollinson D, Tchuem Tchuenté LA, Hagan P. Towards control of schistosomiasis in sub-Saharan Africa. J Helminthol 2005;79:181-5.  Back to cited text no. 2
    
3.
Friedman JF, Mital P, Kanzaria HK, Olds GR, Kurtis JD. Schistosomiasis and pregnancy. Trends Parasitol 2007;23: 159-64.  Back to cited text no. 3
    
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Ejezie GC, Gemade EI, Utsalo SJ. The schistosomiasis problem in Nigeria. J Hyg Epidemiol Microbiol Immunol 1989;33:169-79.  Back to cited text no. 4
    
5.
Panti A, Ikechukwu NE, Lukman OO, Yakubu A, Egondu SC, Tanko BA. Ectopic pregnancy at Usmanu Danfodiyo University Teaching Hospital Sokoto: A ten year review. Ann Nigerian Med 2012;6:87-91.  Back to cited text no. 5
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Sahu L, Tempe A, Singh S, Khurana N. Ruptured ectopic pregnancy associated with tubal schistosomiasis. J Postgrad Med 2013;59:315-7.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.
Poggensee G, Kiwelu I, Saria M, Richter J, Krantz I, Feldmeier H. Schistosomiasis of the lower reproductive tract without egg excretion in urine. Am J Trop Med Hyg 1998;59:782-3.   Back to cited text no. 7
    
8.
Leder K, Weller P. Epidemiology; pathogenesis; and clinical features of schistosomiasis. J Natl Med Assoc 2007;99:570-4.  Back to cited text no. 8
    
9.
King CH, Keating CE, Muruka JF. Ouma JH, Houser H, Siongok TK, et al. Urinary tract morbidity in schistosomiasis haematobia: Associated with age and intensity of infection in an endemic area of coast province, Kenya. Am J Trop Med Hyg 1988;39:361-8.  Back to cited text no. 9
    
10.
Mohammed AZ, Edino ST, Samaila AA. Surgical pathology of schistosomiasis. J Natl Med Assoc 2007;99:570-4.  Back to cited text no. 10
    
11.
Ville Y, Leruez M, Picaud A, Walter P, Fernandez H. Tubal schistosomiasis as a cause of ectopic pregnancy in endemic areas? A report of three cases. Eur J Obstet Gynecol Reprod Biol 1991;42:77-9.  Back to cited text no. 11
    
12.
Nkwabong E, Tincho EF. 2012. A case of a 26-week ampullary pregnancy mimicking intrauterine fetal death. Anatol J Obstet Gynecol 2012;1:1-3.  Back to cited text no. 12
    
13.
Hamilton JV, Klinkert M, Doenhoff MJ. Diagnosis of schistosomiasis: Antibody detection, with notes on parasitological and antigen detection methods. Parasitology 1988;117(Suppl):S41-57.  Back to cited text no. 13
    


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