The frequency of salpingitis and ectopic pregnancy as epidemiologic markers of Chlamydia trachomatis

BACKGROUND: To study the incidence of non-gonococcal salpingitis, gonococcal salpingitis and ectopic pregnancy in a defined population over a 28-year period on the assumption that the frequency of salpingitis and ectopic pregnancy may indirectly illustrate the epidemiological pattern of Chlamydia trachomatis. DESIGN: A retrospective epidemiological study. SETTING: University hospital with an urban catchment area. PATIENTS: Five thousand two hundred and thirty-three patients admitted to the hospital between 1969 and 1996 with a diagnosis of ectopic pregnancy, non-gonococcal salpingitis, or gonococcal salpingitis. RESULTS: The frequencies of both non-gonococcal and gonococcal salpingitis increased steeply early in the period under study, rising to a peak in the early 1970s, then decreasing throughout the period except for the last 3 years when a slight increase was seen again. The frequency of ectopic pregnancy showed a steady increase, peaking in the late 1980s and early 1990s and then declining at the end of the study period. While the introduction of more sensitive pregnancy tests and programs for assisted fertility would increase the rate of ectopic frequency the decline during the 'nineties cannot be accounted for in this way. The peak of salpingitis cases in the early 'seventies seems to be mirrored exactly by the peak of ectopic pregnancies fifteen years later in the late 'eighties. CONCLUSION: The frequencies of salpingitis and of ectopic pregnancy can probably be used to estimate the incidence of preceding Chlamydia trachomatis. Thus the incidence of C. trachomatis has probably declined since the early 'seventies like that of N. gonorrheae.     

Tubal Pregnancy: Relationship of Conservative and Radical Management and Follicular Salpingitis Upon Reproductive Outcome

Eight-four patients with tubal pregnancy presenting between January, 1981 and December, 1982 to National Women's Hospital, Auckland, New Zealand, were identified from medical records and pathology files; 64 had radical surgery, 20 had conservative surgery performed. The 2 groups were analysed for reproductive outcome over a 5-year follow-up period. Subsequent viable pregnancy rates of 53% for the group with radical surgery, and 50% for the group with conservative surgery, are similar to those quoted in the world literature, as is a recurrent tubal pregnancy rate of 14% for the radically treated group. However a recurrent tubal pregnancy rate of 45% for the conservatively treated group in our study is significantly higher than that reported elsewhere. The relationship between recurrent tubal pregnancy and histological evidence of follicular salpingitis was examined. An unexpected finding was that no correlation exists between salpingitis diagnosed at the time of the initial tubal pregnancy, and an increased risk of subsequent tubal pregnancy.     

Recurrence of ectopic pregnancy: the role of salpingitis

We evaluated the role of salpingitis on the recurrence of ectopic pregnancy from a historical cohort of 2501 women who had undergone laparoscopic examination for acute salpingitis. We used pregnancy (N = 2899) as the unit of analysis and a modified conditional logistic regression to estimate a pairwise odds ratio as a measure of the recurrence of ectopic pregnancy. Among the second or higher order of pregnancy, the recurrence was 21.7%. For pregnancies with a prior uterine pregnancy, the ectopic pregnancy rate increased with prior salpingitis scores constructed from a combination of prior salpingitis episodes and severity (0 score, 2.7%; 1 to 2 scores, 4.8%; and greater than or equal to 3 scores, 12.1%). For those with a prior ectopic pregnancy, the rate did not increase with prior salpingitis scores (score 0, 20.0%; score 1 or 2, 19.2%; and score greater than or equal to 3, 26.9%). The adjusted pairwise odds ratio was 2.2 and was practically unchanged (2.1) after additional adjustment with prior salpingitis scores. These findings confirm salpingitis as a risk factor for first ectopic pregnancy, but once a woman had an ectopic pregnancy, previous salpingitis might not add any incremental risk.     

输卵管组织LIF和LIFR的表达与慢性输卵管炎和输卵管异位妊娠的关系

目的:探讨白血病抑制因子(LIF)及其受体(LIFR)与慢性输卵管炎和输卵管异位妊娠的关系。方法:采用免疫组化技术检测15例正常非孕妇女、20例慢性输卵管炎患者和40例输卵管异位妊娠患者的输卵管组织中LIF和LIFR的表达水平,半定量分析其在各组间的表达差异。结果:LIF和LIFR在各组输卵管腺上皮和间质细胞均有表达,且主要定位于腺上皮细胞胞浆。无论是月经分泌期还是增生期,慢性输卵管炎组输卵管腺上皮和间质细胞中LIF的表达明显强于正常组和输卵管妊娠组(P<0.05)。慢性输卵管炎组输卵管腺上皮中LIFR的表达显著高于输卵管妊娠组和正常非孕组(P<0.05);而在输卵管间质中,LIFR在正常非孕组的表达明显高于输卵管妊娠组和慢性输卵管炎组(P<0.01)。结论:慢性输卵管炎的输卵管微环境改变可能是输卵管炎患者易发异位妊娠的原因。     

Ectopic pregnancy and antibodies to Chlamydia trachomatis

Ectopic pregnancy is one of the most serious sequelae to acute salpingitis. Chlamydia trachomatis seems to be the most common etiologic agent of acute salpingitis. In the present study, we tested whether women with ectopic pregnancy had serologic evidence of a current or past chlamydial infection. Sixty-five percent of the women with ectopic pregnancy had IgG serum antibodies to C. trachomatis, and 21% of women pregnant in utero had such antibodies. Eleven percent of women with infertile husbands, 42% of women with cervicitis, and 69% of women with salpingitis had IgG serum antibodies to C. trachomatis. In women with ectopic pregnancy, there was a correlation between the occurrence of IgG antibodies and a history of salpingitis or gross evidence of a previous tubal inflammation. We conclude that previous chlamydial salpingitis may be a major etiologic factor leading to ectopic pregnancy.     

Serologic evidence of prior chlamydial infection in patients with tubal ectopic pregnancy and contralateral tubal disease

Oviductal damage from infectious salpingitis is a principle cause of ectopic pregnancy. To examine the role of Chlamydia trachomatis in patients with ectopic pregnancy, 24 patients undergoing laparotomy for ectopic pregnancy were evaluated by assessment of chlamydial serology and chlamydial cultures of tubal biopsy specimens. The patients were divided into two groups based on the presence or absence of gross abnormalities in the fallopian tube contralateral to the ectopic gestation. Ten patients in group I showed gross evidence of chronic salpingitis in the contralateral tube; 14 patients in group II had normal-appearing contralateral tubes. Chlamydial cultures were negative in both groups. Chlamydial immunoglobulin M antibodies assayed by indirect microimmunofluorescence were negative in both groups (less than or equal to 1:32). Mean geometric immunoglobulin G titers for C. trachomatis were significantly higher in the patients with evidence of contralateral chronic salpingitis (78.9 versus 13.1). These findings suggest that C. trachomatis may be a major cause of oviductal damage, which predisposes to ectopic pregnancy.     

Pregnancy rates after tubal surgery in different etiological groups of infertility

An analysis was made of the history of 302 patients who underwent laparotomy for tubal infertility. The following potential risk factors and their relationship to the pregnancy rate and outcome of pregnancy were studied: various groups of gynecological laparotomy, salpingitis, gonorrhoea, complicated and uncomplicated appendicitis, induced and spontaneous abortion and IUD-usage. 234 of the 302 patients (77.5 per cent) had one or more of the potential risk factors in their history. Salpingitis was the most frequent risk factor (36.1 per cent). Regarding pregnancy rate after tubal surgery the most serious risk factor was a previously performed gynecological laparotomy, followed by salpingitis, gonorrhea and complicated appendicitis. We found a gradual decrease in the pregnancy rate with increasing number of risk factors.     

Chlamydia trachomatis infection in women with ectopic pregnancy

Fifty women with ectopic pregnancy and 49 control women with intrauterine pregnancy were interviewed and evaluated for evidence of Chlamydia trachomatis infection. Among women with ectopic pregnancy, 14 women were wearing an intrauterine contraceptive device or had a tubal ligation (group A), and 36 women had no readily identifiable risk factors (group B). Group B women had greater total numbers of sexual partners than did control women with intrauterine pregnancy (P less than .005). Group B women more often had C trachomatis antibody than group A (P = .03) and control women (P = .002). Of 27 C trachomatis cultures from fallopian tube tissue from women with ectopic pregnancy, none were positive. Fallopian tube tissue distant from the site of ectopic implantation was available for histopathology of 41 cases. Nine (22%) had extensive subepithelial plasma cell infiltration. All nine were among group B women (P = .06) and all seven with plasma cell salpingitis who were tested for C trachomatis antibody were seropositive (P = .004). It is concluded that a subset of women with ectopic pregnancy were at increased risk for acquiring a sexually transmitted disease by virtue of their sexual behavior and that women in this subset frequently have serologic evidence of C trachomatis infection and histologic evidence of plasma cell salpingitis. Because few of these women recall having had pelvic infection, the authors speculate that subclinical C trachomatis tubal infection producing plasma cell salpingitis may commonly underly ectopic pregnancy.     

Risk factors in ectopic pregnancy. Results of a population-based case-control study.

In a population-based case-control study, possible risk factors for ectopic pregnancy were compared in 119 patients with ectopic pregnancy and in 119 age-matched controls with intra-uterine pregnancy from each of the following categories: deliveries, spontaneous abortions and induced abortions. The following factors were found significantly more often in cases of ectopic pregnancy: a history of earlier ectopic pregnancy, a history of salpingitis, a history of earlier operation on the Fallopian tubes, a history of infertility, and a pregnancy that had occurred in spite of an intra-uterine contraceptive device. A history of appendectomy was also found significantly more often among the cases. There was no significant correlation between ectopic pregnancy and a history of no earlier pregnancy, earlier deliveries, earlier spontaneous or induced abortions or a history of other gynecological operations and increased risk of ectopic pregnancy. One or more of the risk factors were found in 76.5% of cases and 23% of controls.     

Repeated contralateral interstitial pregnancy

A case of repeated contralateral interstitial pregnancy is presented in a woman with previous sterility. Biopsies from both uterine corners have later shown salpingitis isthmica nodosa. The etiology, symptoms and treatment are discussed based on the literature.     

The contralateral corpus luteum and tubal pregnancy

One hundred fourteen cases of tubal pregnancy were examined for evidence of active or chronic salpingitis, other anatomic and functional etiologies, and the side of the corpus luteum relative to the pregnancy. A corpus luteum was found ipsilateral to the tubal pregnancy in 80 cases (70%) and contralateral in 18 (16%). In 16 cases (14%), the position of the corpus luteum could not be identified by inspection. No differences were noted among the groups in days from last normal menstrual period or the incidence of irregular bleeding. Of the 98 cases in which a corpus luteum was identified, 53 women (54%) had at least one condition that could be considered etiologic for tubal pregnancy, including 38 (39%) who had microscopic evidence of chronic salpingitis. No association was found between the laterality of the corpus luteum and the presence of risk factors, including mechanical factors. Possible explanations for absent corpora lutea in association with tubal pregnancies are discussed.     

Histopathologic findings in ectopic tubal pregnancy

In 141 consecutive cases of tubal ectopic pregnancy at Hermann Hospital in Houston, Texas, the histologic appearance of 129 surgically removed fallopian tubes containing ectopic pregnancies was reviewed and compared with an age- and race-matched control population. There was a higher incidence of chronic salpingitis (88 versus 2%) and salpingitis isthmica nodosa (SIN) (43 versus 5%). The ectopic pregnancy patients had a higher incidence of pelvic inflammatory disease, gonorrhea, previous abortions, bitubal ligation, intrauterine device use, and previous abdominal surgery. In our population, chronic salpingitis was the most commonly associated finding. The increase in SIN was associated with postinflammatory changes (89%). We also found that ectopic tubal pregnancies may grow either intratubally or extratubally by villous invasion into the wall and blood vessels; therefore, surgical salvage of the fallopian tube by extracting the products of conception will not always be curative.     

A significant association between spontaneous abortion and tubal ectopic pregnancy.

A retrospective study of 83 patients with pathologically documented tubal ectopic pregnancy demonstrated a statistically significant association (P less than 0.005) between prior spontaneous abortion and ectopic pregnancy. In this population with a low incidence of chronic salpingitis, it is suggested that delayed (post-midcycle) ovulation, causing preovulatory over-ripeness of the ovum, may be the common underlying etiologic factor. The clinical significance of this finding is also briefly discussed.     

Tubal histology in extra-uterine pregnancies

141 patients affected by tubal pregnancy have been treated by total salpingectomy at the Port-Royal university clinic between the 1st January 1977 and the 31st January 1984. Tubal pregnancy occurred in the majority of cases in a pathological Fallopian tube, of which the histological state was unrelated to the clinical observations made at laparotomy. Ampullary pregnancy (88% of cases) is secondary to a pathological ampulla in 94 p. cent of cases. The latter was chronic salpingitis in 92 p. cent of cases. Isthmic pregnancy (12% of cases) appears to us to be secondary to isthmic pathology in all cases, and is generally associated with ampullary lesions. There also chronic salpingitis preponderates, whilst endometriosis is very rare. The great frequency of pre-existing lesions which we have noted explains perfectly the high level of recurrences in situ observed after conservative surgery of the gravid tube.     

Objectivized diagnosis of acute pelvic inflammatory disease. Diagnostic and prognostic value of routine laparoscopy

At the University Hospital, Lund, Sweden, laparoscopy has been routinely used as a diagnostic aid in cases for acute pelvic inflammatory disease since 1960. No significant complications have been encountered. The material of the study comprises 905 cases covering an 8 year period, 1960-1967. The operation was always performed under general anesthesia. The laparoscope was inserted in the midline below the umbilicus and a cannula inserted 10 cm laterally to manipulate the pelvic organs. A previous clinical diagnosis was required. In 814 cases acute inflammatory disease was suspected on clinical grounds. In 532 of these cases (65%) acute salpingitis was visually confirmed. Observation through the instrument was seldom difficult or uncertain. In 98 cases (12%) laparoscopy revealed other pathologic conditions. In 184 cases (23%) no pathologic changes were found. In another 91 cases acute salpingitis was found unexpectedly at laparoscopy (or in some cases by exploratory laparotomy) undertaken on other provisional clinical diagnoses. Altogether 623 patients were visually diagnosed as having acute salpingitis. Acute appendicitis was found in 24 cases, ectopic pregnancy in 11 cases, pelvic endometriosis in 16 cases, and several other pelvic disorders occasionally. In the total series of 623 confirmed cases of acute salpingitis 223 (365) were of gonococcal origin. These were mostly in the younger, unmarried, and nulliparous patients. Previous curettage was responsible for most othe r cases. The authors conclude that the diagnosis of acute adnexal inflammation based on commonly accepted clinical criteria was found inaccurate to an unsatisfactory high degree as 12% proved to have other disorders, several of a serious nature. Also 23% had no inflammatory reaction of the tubes or other pelvic structures leaving 65% of cases correctly diagnosed on clinical grounds. The prognosis as to later tubal patency varied with the stage of development of the salpingitis. Later studies show that patency was more frequent in cases of salpingitis diagnosed and treated early before adnexal swelling or mass was diagnosed clinically. Gonococcal cases showed a lower subsequent bilateral occlusion than others. 5 of the salpingitis patients were later operated on for ectopic pregnancy.     

The combination of pregnancy and acute salpingitis in a case of uterus didelphys

A pregnant woman, with a uterus didelphys, developed abdominal pain. Laparotomy disclosed a severe infection of the tube of the non-pregnant horn. The diagnosis of acute salpingitis should be considered when a patient with a uterus didelphys develops unilateral abdominal pain. The present case seems to prove the blocking effect of an intrauterine pregnancy on an ascending infection.     

金属基质蛋白酶(MMP-2)及其激动剂和抑制剂在输卵管黏膜上皮的表达与输卵管妊娠的关系

目的:探讨基质金属蛋白酶-2(MMP-2)和膜型MMP(MT1-MMP)及其组织抑制剂TIMP-2与输卵管妊娠的关系。方法:运用免疫组化结合病理图像半定量分析方法,检测32例正常输卵管壶腹部标本(A组)、32例输卵管炎壶腹部标本(B组)、26例输卵管壶腹部妊娠标本(C组)中MT1-MMP、MMP-2及TIMP-2的表达情况。结果:TIMP-2在A组输卵管黏膜中表达最高,与B组、C组比有统计学差异,B、C组间比较无差异。MMP-2,MT1-MMP表达强度与TIMP-2相反,A组最低,B组的表达最高,C组的表达略低于B组,组间两两比较均有统计学差异(P<0.05)。结论:输卵管的慢性炎症会引起MMP-2的激动剂MT1-MMP表达增强,MMP-2/TIMP-2之间的动态平衡失衡,从而可能参与了输卵管妊娠的发生。     

Fecundity following IUD use (author's transl)

The article reviews all published retrospective studies regarding pregnancy after termination of IUD use. It is estimated that 30% of women become pregnant within 1 month after IUD removal, 60% within 3 months, and 90% within the year. Ectopic pregnancy is not more common in IUD wearers than in other women, but it is more common in cases of acute salpingitis, which seems to multiply the risk of ectopic pregnancy. Risk of salpingitis or of pelviperitonitis is multiplied by 1.6 or by 9.3, according to different authors, in women weare of IUDs. However, risk is increased also by multiple sexual partners, by frequency of coitus, and by age below 25. The IUD is less well tolerated by nulliparous than by multiparous women.     

The intrauterine contraceptive device and acute salpingitis: a multifactor analysis.

From an indigent population hospitalized with acute salpingitis, 163 patients were compared with 222 control patients from the minor trauma section of the emergency room. Four factors were significantly different between cases and controls: race, type of contraception, number of sex partners, and previous history of salpingitis. A discriminate analysis based on a linear logistic equation demonstrated that each risk factor was independent rather than a reflection of another risk factor. Thus factors associated with race, IUD use, multiple sexual partners, and previous salpingitis increase the risk of salpingitis in the population studied.