Case Study of Pelvic Inflammatory Disease and its association with Abortion

31 Mar

Acknowledgement:  We acknowledge the funding by the Population council for small grant project and the cases of PID were selected  from this ongoing project.

ABSTRACT

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

(C.P.G.P) O.P.D.

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).

Conclusions:

Both natural abortions and induced abortions are associated with PID.

INTRODUCTION

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)

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 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

Age Group Cases Control
16-20 02 06
21-25 28 24
26-30 38 41
31-35 42 38
36-40 21 20
>40 19 21

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
Total 60 26 86
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
Total 143 150 293
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
Total 143 150 293
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)

DISCUSSIONS

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.

CONCLUSIONS

Both natural  and  induced  abortions  are  associated  with  PID  but  there  is no  difference between natural abortion and induced abortions in causing PID.

REFERENCES

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:

http://www.aiims.edu/aiims/events/Gynaewebsite/ma_finalsite/introduction.html.

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

India,NewDelhi.

CorrespondingAuthor: Dr.Patel SangitaV.

E-mail:sangita_psm@yahoo.co.in

Source(s) of support:FUNDING BY POPULATION COUNCIL

ConflictingInterest:NIL

Contact :
Dr. V. S. Mazumdar
MD, DPH, DCH, DIH
9825676499
vihang.mazumdar@gmail.com

Dr. R. K. Baxi
MD, DNB(MCH), DCH, PGD(Adolescent Pediatrics)
9426748210
baxirk@gmail.com
www.rkbaxi.com

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One Response to “Case Study of Pelvic Inflammatory Disease and its association with Abortion”

  1. len March 20, 2012 at 10:55 am #

    vaginal bleeding after oral contraceptive.is this ectopic pregnancy?

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