Pelvic Inflammatory Disease and Infertility
ABSTRACT & COMMENTARY
Source: Lepine LA, et al. Severity of pelvic inflammatory disease as a predictor of the probability of live-births. Am J Obstet Gynecol 1998;178:977-981.
The world's largest and longest prospective cohort study of women with acute pelvic inflammatory disease (PID) was conducted in Lund, Sweden, over a 24-year period beginning in 1960. Prior reports from this database have determined the risk of ectopic pregnancy and infertility by looking at the separate effects of the number and severity of episodes of PID. This study by Lepine and colleagues looked at the Lund cohort to evaluate the association between severity of PID and the probability of achieving a live birth, while accounting for subsequent episodes of PID. The study group consisted of 288 women with symptoms of acute PID who underwent laparoscopy and were categorized by the degree of salpingitis into mild, moderate, or severe PID. All women attempted pregnancy at some point during the 12 years after their index PID episodes, and appropriate exclusions were made.
The cumulative proportion of women achieving a live birth within 12 years of the initial episode of PID was 90% for mild, 82% for moderate, and 57% for severe disease. Women with more severe disease required more time to conceive.
After the index episode of PID, 243 women had between one and five subsequent episodes of PID. Among these women, the cumulative live birth rate at 12 years was 88% for women with mild, 63% for those with moderate, and 25% for those with severe initial PID. Women with severe initial disease and subsequent PID episodes were eight times more likely to fail to achieve a live birth than women with a single mild episode. In women with initial mild disease, subsequent episodes did not affect birth rate.
COMMENT BY STEPHANIE ABBUHL, MD
Women with severe PID by laparoscopy experienced the most profound effect of repeated PID episodes. A 25% probability of a live birth over 12 years is a sobering finding. Despite some potential flaws in this study, it suggests that the severity of PID is more important than the absolute number of episodes. Emergency physicians have an enormous responsibility in caring for women with suspected PID. It is critical to have a low threshold for diagnosis, treat aggressively, treat sexual partners, explain the importance of compliance with antibiotics, provide education, and arrange appropriate follow-up.
The CDC has just recently published its 1998 Guidelines for Treatment of Sexually Transmitted Diseases.1 The guidelines suggest that empiric treatment be initiated when all of the following minimal criteria are present and no other cause for illness can be identified: lower abdominal tenderness, adnexal tenderness and cervical motion tenderness. The recommended treatment regimens emphasize the importance of anaerobic coverage, in addition to covering gonorrhea and chlamydia. There are two primary oral treatment regimens. Regimen A is ofloxacin 400 mg bid for 14 days plus metronidazole 500 mg BID for 14 days. Regimen B is ceftriaxone 250 mg IM once or cefoxitin 2 g IM plus probenecid 1g PO once, plus doxycycline 100 mg po bid for 14 days. Some experts would consider the addition of metronidazole to regimen B for better anaerobic coverage. Of note, the regimens do not include the use of oral cephalosporins (cefixime) that are recommended for gonorrheal cervicitis and urethritis. Also, while azithromycin is also recommended for cervicitis and urethritis, it is currently not recommended for PID because of insufficient data at this time. Criteria for hospitalization are suggested in the guidelines; however, there are no good data yet to define whom to admit and treat with parenteral therapy vs. oral outpatient therapy.
Reference
1. CDC. 1998 Guidelines for Treatment of Sexually Transmitted Diseases. MMWR Morb Mort Wkly Rep 1998;47:(RR1).
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