Acknowledgement: We acknowledge the funding by the Population council for small grant project and the cases of PID were selected from this ongoing project.
Research Question: Do abortions lead to PID?
Objective: To know the association between PID and Abortion.
Study Design: Case control study.
Setting: Shree Sayaji General Hospital (S.S.G.H.), Government Medical College, Vadodara.
Participants: Women attending Gynae Clinics and Curative and Preventive General Practice
Sample Size: 150 cases and 150 controls
Results: The exposure of natural abortion was 26.56% in cases, which was substantially higher as compared to 9.35% in controls (p=0.0002). The odds ratio for occurrence of PID in those with a history of natural abortions as against those without it was 3.52 [95% confidence interval (CI) = 1.81 to 6.83]. The odds ratio for PID with induced abortion as a risk factor was 2.09 (CI: 0.99-4.40) and (p=0.073).
Both natural abortions and induced abortions are associated with PID.
Pelvic inflammatory disease (PID) is one of the most serious infections faced by women today. It is a common problem encountered in gynaecologic infertility, family planning, post natal, legal abortions and sterilization clinics in India and abroad.(1)
Bhatia has reported a prevalence of 5.2% of acute PID in South India on the basis of symptomatology only. A study in Bombay urban slums reported a prevalence of 16.5% while a West Bengal study in urban Calcutta reports 17.2% PID.(2)
Pelvic inflammatory disease (PID) is associated with major medical and economic consequences for women of reproductive age. Identification of the risk factors associated with PID is crucial for prevention of these consequences.(3) Prevalence of pelvic inflammatory disease (PID) is affected by various community and individual risk factors. Various cultural and behavioural factors influence community prevalence of sexually transmitted disease (STD), illegal abortion, puerperal sepsis and contraceptive usage – all of which influence the risk of PID. The relative importance of these factors varies by region.(4)
Wasserheit estimated that in SE Asia, post abortion infection is the leading cause of PID and
23% of PID in Pakistan are associated with unsafe abortion.(5)
With this in the backdrop, we thought of carrying out a case control study to know the association between PID and Abortion.
MATERIAL AND METHODS
This study was conducted at Shree Sayaji General Hospital (S.S.G.H.), a regional referral hospital attached to a teaching hospital – Government Medical College, Vadodara.
Case definitions for Cases, controls and exclusion criteria were defined. Some important risk factors/markers associated with PID include young age, a current STD infection or a previous gonococcal infection, multiple sex partners, and the use of an intrauterine contraceptive device.(3) So, in order to control confounders the following exclusion criteria were laid down:
1. Those who have multiple sexual partners
2. Copper-T users and condom users
Selection of cases:
The Obstetrics and Gynecology department at S.S.G.H. sees about 100 gynecological cases daily on an Outdoor patient basis. Of these, 8-10% suffers from pelvic inflammatory disease. In the present study, cases were taken as those clinically diagnosed, by the Gynaecologist, to be suffering from PID. 150 such patients, attending Gynaecology OPD of S.S.G.H. over a period of one year, were selected with the following uniformly accepted criteria for PID diagnosis: Complain of lower abdominal pain, OR Vaginal discharge, OR Adenexal tenderness leading to pain. Most of the patients, who had complaints of more than 1 year, were categorized as Chronic PID. After taking consent, we obtained information by conducting in depth interviews up to 3 sessions with each patient.
Selection of controls:
Controls were women attending C.P.G.P., an outdoor facility which is the first point of contact for all new cases, for health problems other than those related to obstetrics and gynecology. These female patients were selected from C.P.G.P. an outdoor facility, where most new cases would come for treatment. C.P.G.P. has adequately comfortable offices, which provided necessary privacy for interviews of the control group. 150 controls, matched for age by 5yr age group, were selected and interviewed after consent.
Abortions: Termination of pregnancy before the fetus is capable of life outside the uterus.
Natural abortions: (sometimes called miscarriages) are those in which termination is not provoked
Induced abortions are those caused by deliberate interference.
The mean age in cases was 32.56 ± 7.31 and in controls was 32.58 ± 8.05. The difference was statistically not significant (Table-I). In 10 cases information on abortion detail was not available as they are very sensitive personal information, which they chose not to divulge.
Data processing and Statistical analysis:
The entire information from the questionnaire of cases and controls was coded and data fed into computer and analysed using statistical software EPI-Info.(6)
The exposure of natural abortion was 26.56% in cases, which was substantially higher as compared to 9.35% in controls (p=0.0002). The exposure of induced abortion was 15.38% in cases, which was substantially higher as compared to 8.00% in controls (p=0.0002). The odds ratio for PID with natural abortions as a risk factor was 3.52 (95% CI: 1.81 to 6.83). This suggests etiological fraction of 71.65% for PID (95% CI: 44.8% to 85.4%) among natural abortions (p=0.0002). (Table III)
Table I: Age group distribution of cases and control
Table II: Association between natural abortion and induced abortion
|Total abortions among cases||Total abortions among controls||Total|
|Natural abortions||38 (63.33%)||14 (53.85%)||52|
|Induced abortions||22 (36.67%)||12 (46.15%)||34|
|Odds ratio 1.48 (0.58<OR<3.76) P=0.408|
Table III: Association between natural abortion and PID
|Total abortions among cases||Total abortions among controls||Total|
|Natural abortions +||38 (26.58%)||14 (9.33%)||52|
|Natural abortions –||105 (73.42%)||136 (90.60%)||241|
|Odds ratio 3.52 (1.81<OR<6.83) P=0.0002|
Table IV: Association between induced abortions and PID.
|Total induced abortions among cases||Total induced abortions among controls||Total|
|Induced abortions +||22 (15.38%)||12 (8.0%)||34|
|Induced abortions –||121 (84.61%)||138 (92.0%)||259|
|Odds ratio 2.09 (0.99<OR<4.40) P=0.073|
The odds ratio for induced abortions, as a risk factor was 2.09 with (95% CI: 0.99 to 4.40). (Table III) An induced abortion was not significantly higher in cases than controls (p=0.073). (Table IV)
We thought abortions as a risk factor because
In case of natural abortions:
1. Retained product of conception and excessive bleeding, both are favorable media for growth of bacteria, as they are rich media for bacterial growth.
2. In those women who are already moderate to severely anemic, further blood loss would enhance chances of infection.
In the induced abortion, external instrumentation and manipulation also increases chances of infection.
Induced abortion exists in every society with major difference in women who have access to a legal and safe procedure, with minimal risk for their health particularly if performed early in a pregnancy, and in others, where it is usually illegal, they expose themselves to unsafe practice that entail high morbidity and mortality.
Because of insufficient choice of modern contraception, poor access to quality abortion service, including untrained health providers with inadequate knowledge of modern induced abortion techniques, the practice although legal can still be a serious health problem. Typically this appears to be the situation in our country.
In some developing countries where abortion is legal, services are so restricted that the majority of abortions are still performed unsafely by traditional practitioners and are therefore unrecorded.
According to the Consortium on National Consensus for Medical Abortion in India, every year an average of about 11 million abortions take place annually and around 20,000 women die every year due to abortion related complications. Most abortion-related maternal deaths are attributable to illegal abortions.(7)
The greatest risk of PID associated with induced abortion occurs in circumstances where sterile conditions are not maintained.
In present study we cannot say that abortions cause PID or PID causes abortions. We can only say that an association exists and it does not mean any causal relationship. One can only say that risk of PID is increased with abortions and this difference is statistically significant.
A study was done by Dalaker regarding early complications of induced abortion in primigravidae noticed that the overall rate of PID after the abortion was 4.1%.(8)
Another study carried out by Chaudhary regarding the complications rate of termination of pregnancy (TOP) found that rate for minor complication after TOP was 3.7% which included failed termination of pregnancy, excessive hemorrhage not requiring blood transfusion, etc. and a 1.8% rate of PID was found.(9)
A study was conducted by Gogate among women presenting to clinics in Mumbai (India) for pelvic pain found that 26% with confirmed PID reported to have undergone an abortion as compared to 2% of women without PID.(5)
Both natural abortions and induced abortions are contributing to PID but there is no significant difference between natural abortions and induced abortions (p=0.408) (Table II). Similar finding in one case control study done by Fabio Parazzini regarding the relation between induced abortion and risk of subsequent miscarriage concluded that there was no
strong association between induced and spontaneous abortion.(10)
The odds ratio for PID with natural abortions as risk factors was 3.52 with 95% confidence interval being 1.81 to 6.83. This suggests aetiological function of 71.65% for pelvic inflammatory disease with 95% confidence interval of 44.8% and 85.4% among natural abortions. (Table III)
The natural abortion was substantially higher in cases as much as 26.58% compared to controls at 9.33%. The difference was statistically significant (p=0.0002).
The odds ratio for induced abortions as a risk factor being 0.99 to 4.40 indicates etiological function 52.2% for pelvic inflammatory disease with 95% confidence interval of 0.7% to
77.3% among induced abortions. An induced abortion was not significantly higher in cases than controls (p=0.073) (Table IV). This may be due to less sample size.
In natural abortion and induced abortion antibiotics were given or not, we asked the patient the question pertaining to antibiotic prescription but the patients were not able to differentiate between antibiotic and pain killers and they were not able to reply to the status of treating doctor whether they were trained or untrained, allopathic or alternative medicine doctors because of lower education status. In reply specifically regarding to antibiotic usage they replied that it was only the doctor who knew what was given.
Both natural and induced abortions are associated with PID but there is no difference between natural abortion and induced abortions in causing PID.
1. Pachauri S. Defining a reproductive health package for India: A proposed Framework.
Regional Working Paper No 4 The Population Council 1995.
2. Bhatia. Self reported symptom of Gynecological morbidity and their treatment in
South India. Studies in Family planning. 1994;26(4).
3. Jossens MO, Eskenazi B, Schachter J, Sweet RL. Risk factors for pelvic inflammatory disease. A case control study. Sexually Transmitted Diseases 1996;23(3):239-47.
4. Brabin L ,Raleigh VS, Dumella S. Pelvic inflammatory disease: A clinical syndrome with social causes. Annals of Tropical Medicine and parasitology 1992;86(1):1-9.
5. Shireen J, Jejeebhoy, Michael Alan Koenig, Christopher Elias. Investigating reproductive tract infections and other gynaecological problems: Cambridge university press; 2003.
6. Dean AG, Coulombier D, Brendel KA, Smith DC, Burton AG, Dicker RC, et al. A word
processing, Database,and Statistical Programme for Public Health on IBM-compatible
Microcomputers. Centers for Disease Control and Prevention. Atlanta, Georgia, USA
2001. Epi Info, Version6.04_d.
7. Introduction & Current status of abortion in India. Available from:
8. Dalaker K, Sundfør K, Skuland J. Early complications of induced abortion in primigravidae. Ann Chir Gynaecol 1981;70(6):331-6.
9. Choudhary N, Saha SC, Gopalan S. Abortion procedures in a tertiary care institution in India. International Journal of Gynecology & Obstetrics 2005;91(1):81-6.
10. Fabio Parazzini, Liliane Chatenoud, Luca Tozzi, Elisabetta DiCintio, Guido Benzi, Luigi Fedele. Induced abortion in the first trimester of pregnancy and risk of miscarriage British Journal of Obstetrics and Gynaecology 1998;105:418-21
Date : 31st March 2011
Authors: Patel S V (Associate Professor), Baxi R K (Professor), Kotecha P V (Technical Advisor), Mazumadar VS (Professor andHead), Mehta K G (Junior lecturer), Bakshi H N (Lecturer), Diwanji M (ResearchAssociate)
#Dept. of Preventive and Social Medicine, Medical College, Baroda; @Academyfor Educational Development, A2Z Project
CorrespondingAuthor: Dr.Patel SangitaV.
Source(s) of support:FUNDING BY POPULATION COUNCIL
Dr. V. S. Mazumdar
MD, DPH, DCH, DIH
Dr. R. K. Baxi
MD, DNB(MCH), DCH, PGD(Adolescent Pediatrics)