Full-Term Pregnancy after Antibiotic Treatment of Proved Endometrial Tuberculosis

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1 :'1 Full-Term Pregnancy after Antibiotic Treatment of Proved Endometrial Tuberculosis Isac Halbrecht, M.D., * and George Blinick, M.D. t THE OCCURRENCE OF full-term pregnancies after antibiotic therapy of histologically proved endometrial tuberculosis is rare. A thorough review of the literature reveals only 4 cases l - 4 diagnosed according to the strict criteria described below (i.e., bacteriological and histological proof of tuberculosis of the endometrium), in which full-term pregnancies have been reported following antibiotic therapy of endometrial tuberculosis. In all other cases of full-term pregnancies, reported as having occurred after treated or untreated endometrial tuberculosis, the evidence of tuberculous endometritis prior to pregnancy has been assumed on the basis of the discovery of pelvic tuberculosis immediately after pregnancy, or on the assumption of tuberculous endometritis by positive bacteriological methods alone The strict criteria for the diagnosis of endometrial tuberculosis are: (1) bacteriological demonstration of the tubercle bacilli from the endometrium by smear, culture, or animal inoculation; and (2) the demonstration of tuberculous endometritis by endometrial biopsy or curettage. At present, positive cultures or animal inoculations of the uterine secretions without positive, histological findings in the endometrial biopsy establish only the diagnosis of tubal tuberculosis. In these cases it must be assumed that tuberculous lesions limited to the tube are responsible for the passage of tubercle bacilli through the uterine cavity, producing positive cultures of the uterine secretions. At the present time, tubal tuberculosis has a prognosis after antibiotic... * Hasharon Hospital, Petah-Tiqvah, Israel. t Beth Israel Hospital, New York. 480

2 Vol. 11, No.5, 1960 ENDOMETRIAL TUBERCULOSIS 481 treatment for the occurrence of pregnancy and its normal progression to term much better than has treated endometrial tuberculosis, even after apparent complete healing. The report and discussion of any case of full-term pregnancy occurring after the antibiotic treatment of endometrial tuberculosis, proved by bacteriological and histological methods prior to pregnancy, is of the utmost importance in attempting to elucidate the pathogenesis of infertility produced by active or healed genital tuberculosis.. CASE REPORT Mrs. Z. S. was born in Menstruation, begun at the age of 14, occurred every 28 days for 6 days. Shortly after the onset of menstruation she was found to have an "exudate pleuritis" according to history. She was married at the age of 17 and, at the age of 19, endometrial tuberculosis was discovered by means of endometrial biopsy done for infertility (Fig. 1). Cultures of her menstrual discharge were positive for tuberculosis, as were the cultures of her vaginal secretions. Tubal insufflation showed patency of the tubes. Antibiotic therapy in the form of 1 gm. of streptomycin was given daily for 50 days. For the next 3 years, cultures of the menstrual discharge were repeated each month and were negative. In 1954, three years after antibiotic therapy was Fig. 1. Endometrial biopsy showing characteristic tubercles.

3 482 HALBRECHT & BLiNICK Fertility & Sterility completed, a hysterosalpingogram showed occlusion of the fimbriated end of the left tube and ampullary dilatation of the right tube which, nevertheless, was patent. Three years later, in 1957, she conceived but had an early spontaneous abortion in the second month of her pregnancy. No curettage was performed. Six months after the miscarriage, she again became pregnant and after an uneventful pregnancy, she spontaneously delivered a full-term, normal, female infant weighing 3100 gm. She is now again normally pregnant. DISCUSSION Until recently, a diagnosis of genital tuberculosis was associated with a prognosis of an incurable sterility. Antibiotic therapy for genital tuberculosis has improved the course of this disease, but the outlook for the cure of associated sterility has not been as favorably altered. In this regard, new considerations have arisen, making it necessary to subdivide genital tuberculosis into its various types-i.e., tubal, ovarian, endometrial, peritoneal, etc. Before antibiotic therapy, some cases of ectopic pregnancies were reported in patients with active or spontaneously healed tubal tuberculosis. 12 A considerable number of pregnancies have been reported following the treatment of tubal tuberculosis with antituberculous drugs. However, most of these have been ectopic pregnancies, while the rare intrauterine pregnancies have almost always ended in miscarriage. Thus, in treated tubal tuberculosis there has been an increase in both ectopic as well as intrauterine pregnancies, the latter seldom reaching term delivery. In contrast to these changes in the evolution of tubal tuberculosis, the outlook for those patients with proved endometrial tuberculosis has changed only slightly. Before the advent of antibiotic therapy, intrauterine pregnancies did not occur in women who were known to have endometrial tuberculosis prior to pregnancy. Since the use of these drugs there has been a small but appreciable increase in uterine pregnancy although early abortion is the general rule. This, in fact, happened in the first pregnancy of our present patient as well as in the pregnancies of 5 other observed patients which followed antibiotic therapy of proven endometrial tuberculosis. The present case of a full-term pregnancy following the antibiotic treatment of endometrial tuberculosis is the only one treated personally by the authors. The reasons for the failure to obtain full-term pregnancy in cases of healed endometrial tuberculosis are speculative. It is probable that the tubes are extensively involved in this advanced stage of genital tuberculosis, resulting in either absolute closure or profound anatomical and physiological altera-

4 Vol. 11, No.5, 1960 ENDOMETRIAL TUBERCULOSIS 483 tion in the function of the tubal mucosa and musculature. 13 Intrauterine adhesions have been found in some cases following antibiotic therapy and healing of endometrial tuberculosis. Spontaneous healing of endometrial tuberculosis, which is perhaps more frequent than hitherto recognized, may also produce intrauterine adhesions which, in tum, can be a cause of abortion. Possibly, tuberculosis produces changes in the metabolism of the endometrium (as yet imperfectly understood), thereby causing sterility and abortion even after clinical cure. Important circumstances favoring the successful outcome of the second pregnancy in our patient were her early marriage at the age of 17, three years after the onset of pulmonary tuberculosis, and the early discovery and therapy of the pelvic tuberculosis 2 years following marriage. It is interesting to recall that, while genital tuberculosis causes primary sterility in most European countries, it is frequently found to be the cause of secondary sterility in patients who had been pregnant in India or Latin America, where marriages at a very early age are not uncommon. The early diagnosis and prompt antibiotic treatment of genital tuberculosis in females is therefore the best way of preventing permanent sterility and of enhancing the possibility of full-term pregnancies. In view of the 5 cases of endometrial tuberculosis in which full-term normal pregnancies followed antibiotic therapy, it seems that antibiotic therapy rather than radical surgery is the best approach to such cases at the present time. SUMMARY Accurate diagnosis of endometrial tuberculosis requires histological as well as bacteriological confirmation of endometrial involvement. A report of the occurrence of a successful full-term pregnancy after antibiotic therapy of endometrial tuberculosis is added to 4 similar cases previously reported. The importance of the early detection and prompt antibiotic treatment of endometrial tuberculosis is stressed. REFERENCES 1. BOBROW, M. D., POSNER, CR. A., and FRIEDMAN, S. A successful pregnancy after endometrial tuberculosis. Am. /. Obst. & Gynec. 74: 1136, NORBURN, L. M., and WALKER, A. H. C. Two cases of proved endometrial tuberculosis followed by successful pregnancy. J. Obst. & Gynaec. Brit. Emp. 63: 173, 1956.

5 484 HA LB RECHT & BLI NICK Fertility & Sterility 3. KULLANDER, S. Endometrial tuberculosis treated with PAS: Report of a case with subsequent pregnancy. Glasgow M. ]. 33:395, MACDoNALD, C. R. Discussion of a paper by S. BENDER, Pregnancy following pelvic tuberculosis. ]. Obst. & Gynaec. Brit. Emp. 61 :514, JEDBERG, H. Female genital tuberculosis and pregnancy. scandinav. 35:534,1956. Acta obst. et gynec. 6. BRET, A. J., and LEGROS, R. 644,1955. Grossesse et Tuberculose Genitale. Presse Med. 33: 7. HALLUM, J. L., and THOMAS, H. E. Full-time pregnancy after proved endometrial tuberculosis. ]. Obst. & Gynaec. Brit. Emp. 62:548, HERRING, J. S. Delivery following apparently healed genital tuberculosis. Am. J. Obst. & Gynec. 64:710, DRASNAR, J., and LUNDOVA, A. Geburten nach errolgreicher Behandlung der Genitaltuberculose. Gynaecologia 145:387, WOOD, J. Pelvic tuberculosis. International Professors' Days, Symposium on Sterility, New York, EARN, A. A. Living births following drug therapy for infertility with proven genital tuberculosis. J. Obst. & Gynaec. Brit. Emp. 65:739, RYDEN, A. B. V. The treatment of tuberculous salpingitis. scandinav. 37:114, Acta obst. et gynec. 13. STUDDIFORD, W. E. 69:379, Pregnancy and pelvic tuberculosis. Am. J. Obst. & Gynec.