Clinical predictors of endometritis in women with symptoms and signs of pelvic inflammatory disease

Prediction of pelvic inflammatory disease among young, single, sexually active women

OBJECTIVES

To assess prediction strategies for pelvic inflammatory disease (PID).

STUDY DESIGN

One thousand one hundred seventy women were enrolled based on a high chlamydial risk score. Incident PID over a median of 3 years was diagnosed by either histologic endometritis or Centers for Disease Control and Prevention criteria. A multivariable prediction model for PID was assessed.

RESULTS

Women enrolled using the risk score were young, single, sexually active, and often had prior sexually transmitted infections. Incident PID was common (8.6%). From 24 potential predictors, significant factors included age at first sex, gonococcal/chlamydial cervicitis, history of PID, family income, smoking, medroxyprogesterone acetate use, and sex with menses. The model correctly predicted 74% of incident PID; in validation models, correct prediction was only 69%.

CONCLUSIONS

Our data validate a modified chlamydial risk factor scoring system for prediction of PID. Additional multivariable modeling contributed little to prediction. Women identified by a threshold value on the chlamydial risk score should undergo intensive education and screening.

Molecular identification of bacteria associated with bacterial vaginosis

BACKGROUND

Bacterial vaginosis affects millions of women and is associated with several serious health conditions. The cause of bacterial vaginosis remains poorly understood despite numerous studies based on cultures. Bacteria in microbial communities can be identified without cultivation by characterizing their ribosomal DNA (rDNA) sequences.

METHODS

We identified bacteria in samples of vaginal fluid with a combination of broad-range polymerase-chain-reaction (PCR) amplification of 16S rDNA with clone analysis, bacterium-specific PCR assay of 16S rDNA, and fluorescence in situ hybridization (FISH) performed directly on vaginal fluid from 27 subjects with bacterial vaginosis and 46 without the condition. Twenty-one subjects were studied with the use of broad-range PCR of 16S rDNA, and 73 subjects were studied with the use of bacterium-specific PCR.

RESULTS

Women without bacterial vaginosis had 1 to 6 vaginal bacterial species (phylotypes) in each sample (mean, 3.3), as detected by broad-range PCR of 16S rDNA, and lactobacillus species were the predominant bacteria noted (83 to 100 percent of clones). Women with bacterial vaginosis had greater bacterial diversity (P<0.001), with 9 to 17 phylotypes (mean, 12.6) detected per sample and newly recognized species present in 32 to 89 percent of clones per sample library (mean, 58 percent). Thirty-five unique bacterial species were detected in the women with bacterial vaginosis, including several species with no close cultivated relatives. Bacterium-specific PCR assays showed that several bacteria that had not been previously described were highly prevalent in subjects with bacterial vaginosis but rare in healthy controls. FISH confirmed that newly recognized bacteria detected by PCR corresponded to specific bacterial morphotypes visible in vaginal fluid.

CONCLUSIONS

Women with bacterial vaginosis have complex vaginal infections with many newly recognized species, including three bacteria in the Clostridiales order that were highly specific for bacterial vaginosis.

What's new in bacterial vaginosis and trichomoniasis?

The use of biochemical profiles and new molecular microbiologic methodologies is transforming our understanding of BV. Most important is the recognition of different subgroups of women who have BV who are at variable risk of certain obstetric and gynecologic complications. New diagnostic tests may soon be available that will allow women to test self-obtained specimens. Treatment of BV has lagged, although innovative methods appear to be helpful in managing recurrent diseases.

Pelvic Inflammatory Disease in Adolescents

Pelvic inflammatory disease (PID) is a polymicrobial infection typically occurring in sexually active females. It occurs when microorganisms ascend from the lower genital tract into the upper genital tract. The clinical presentation varies in severity, with most patients presenting with mild disease. Complications include tubo-ovarian abscess, ectopic pregnancy, infertility, and chronic pain. The newly revised criteria issued by the Centers for Disease Control and Prevention now include either cervical motion tenderness or adnexal tenderness with unchanged additional criteria.

[Side effects of induced abortion: results from a population-based survey]

OBJECTIVES

This study compares the gynaecological symptoms of women who have undergone an induced abortion to those who have not. We also compare the gynaecological side effects, in particular the infectious symptoms, following an induced abortion, according to the abortion technique, medical and surgical, in the year after the abortion.

PATIENTS AND METHODS

A representative sample of 2863 women, aged 18 to 44, was interviewed by telephone between September 2000 and January 2001. Of these women, 401 declared an abortion in the last 5 years. Analysis of the gynaecological side effects according to the abortion technique was performed among the 199 women who terminated their pregnancy before the 8th week of amenorrhoea.

RESULTS

Women with a history of induced abortion had a higher sexual risk profile than those with no such history. They also more frequently reported genital infectious symptoms. The comparison between medical and surgical abortions shows that women who had a medical abortion were more likely to report heavy and prolonged bleeding. On the contrary, we found no difference of infectious symptoms between the two techniques.

DISCUSSION AND CONCLUSION

Our study does not support the idea of a reduction of infectious complications related to medical as opposed to surgical abortions. However, given the rapid diffusion of medical abortion, it seems important to carry on the investigations on the side effects related to medical abortions, in order to prevent them if necessary.

Can the diagnosis of pelvic inflammatory disease be excluded without a bimanual examination?

Now that urine-based tests are available for detection of Chlamydia and gonorrhea, we sought to determine whether history alone could be used to exclude pelvic inflammatory disease (PID) and thus preclude a bimanual examination. The study design was a retrospective chart review. The study population included females aged 15-24 years diagnosed with PID. Outcome measures were documentation of screening symptoms (abdominal pain, dyspareunia, or abnormal vaginal bleeding) in the medical record. Our primary analysis was sensitivity of screening symptoms for identifying patients with PID. At least 1 of the 3 screening symptoms was reported by 93% of the PID group. If absence of all 3 screening symptoms were used as a screening instrument to exclude a bimanual examination, many women with lower genital tract symptoms could be evaluated noninvasively. However, this approach could result in delayed diagnosis of PID in a small number of patients. Before this strategy is adopted, a large prospective study is needed.

The antimicrobial treatment of subacute endometritis: a proof of concept study

OBJECTIVE

Our purpose was to evaluate the antimicrobial therapy effect on clinical and laboratory findings among women at risk for endometritis.

STUDY DESIGN

A prospective antimicrobial treatment trial of 153 women was performed to characterize subacute endometritis and to determine the treatment effect on endometritis resolution.

RESULTS

After antimicrobial treatment, significant reductions occurred in abnormal bleeding (60% vs 29%), mucopurulent cervicitis (20% vs 6%), uterine tenderness (20% vs 6%), and histologic endometritis (38% vs 4%), all P<.001. In women with prior pelvic inflammatory disease (PID), endometritis was present in 43% with and 28% without current Chlamydia trachomatis or Neisseria gonorrhoeae. In women without prior PID, endometritis was present in 23% with and 12% without current C trachomatis or N gonorrhoeae (P=.002 for trend).

CONCLUSIONS

In women without a clinical diagnosis of PID, antimicrobial therapy decreased abnormal clinical findings and histologic endometritis. Prior PID is additive with current cervical infection as a risk for endometritis.

Predictive value of clinical diagnostic codes for the CDC case definition of pelvic inflammatory disease (PID): implications for surveillance

BACKGROUND

Reporting of pelvic inflammatory disease (PID) from private providers could be incomplete because of time and staff constraints, lack of knowledge of reporting requirements and of case definitions. Reporting burden can be alleviated with the use of administrative data.

GOAL

The goal of this study was to determine the validity of clinical diagnostic codes assigned in electronic medical records (EMR) for identifying PID and their use in enhancing surveillance.

STUDY DESIGN

A random sample of 296 records with a PID International Classification of Diseases, 9th Revision (ICD-9), code (614.9) were reviewed to assess for the presence of the Centers for Disease Control and Prevention (CDC) criteria for the case definition of PID. We used the records meeting the CDC clinical case definition criteria as the reference standard to determine the sensitivity, specificity, and predictive values of various data elements.

RESULTS

Used alone, the positive predictive value (PPV) of ICD-9 code 614.9 for a CDC case definition of PID was 18.1%. The PPV increased to 100% and 56% when the ICD-9 code visit was associated with a positive test for Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT), respectively.

CONCLUSION

In this multispecialty group practice, a positive test for GC and CT coupled with ICD-9 code 614.9 could be used to enhance reporting of cases of PID.

Histologic Endometritis in Asymptomatic Human Immunodeficiency Virus–Infected Women

OBJECTIVE

To estimate the prevalence, risk factors, clinical symptoms and signs, and response to antimicrobial therapy of histologic endometritis in human immunodeficiency virus (HIV)-infected women without clinical salpingitis.

METHODS

This was a cross-sectional study of 42 HIV-infected women enrolled from a single clinic. Subjects underwent standardized history, examination, and laboratory determinations, including endometrial biopsy. Women with suspected pelvic inflammatory disease were excluded. All women were given antibiotics and repeat evaluation in 5-7 weeks. Histologic endometritis was defined by at least one stromal plasma cell per 120x field and five or more surface polymorphonuclear leukocytes per 400x field. Chi-square and Fisher exact tests were used as appropriate.

RESULTS

Histologic endometritis was present among 16 (38%) of 42 evaluable HIV-infected women, none of whom had Chlamydia trachomatis or Neisseria gonorrhoeae. Douching three or more times per month, history of ectopic pregnancy, and two or more prior urinary tract infections were associated with endometritis, as was elevated erythrocyte sedimentation rate (P < or = .05). Physical examination findings and mean CD4+ lymphocyte count were similar among those with and without endometritis. In the nine HIV-infected women with a repeat biopsy, endometritis decreased from four (44%) to two (22%) after treatment (P = .30).

CONCLUSION

The prevalence of histologic endometritis in HIV-infected women was high despite few examination findings and no demonstrated pathogens. Endometritis in HIV-infected women might be related to pathogens not evaluated, to prior infection, or to reduced immunity from HIV.

Abnormal vaginal bleeding

The complaint of abnormal vaginal bleeding in a non-pregnant patient is not a common presentation to a general ED. However, the bleeding may in itself be significant or it may be a harbinger of serious underlying pathology. A systematic approach to diagnosis is required. An initial approach to vaginal bleeding can be to categorize the bleeding by the anatomical site. This article discusses some of the common causes of upper tract or uterine bleeding and outlines the basic approach to diagnosis and management.

Pelvic inflammatory disease and sepsis

Pelvic inflammatory disease affects approximately 1 million women per year in the United States alone and has a variety of causative organisms. Because the diagnosis of PID is based on clinical judgment, health care providers need to be guided by the CDC recommendations for diagnosing and treating PID. Because presenting symptoms are often vague, the health care provider should assess female patients for risky behaviors that may lead to PID and should use screening data when making clinical judgments and differential diagnoses. Whenever possible, female patients with PID should be treated as outpatients. If diagnosis and treatment are not performed in a timely manner, PID may cause sepsis, septic shock, and even death. Even if they survive, as many as 15% to 20% of these women experience long-term sequelae of PID, such as ectopic pregnancy, tubo-ovarian abscess, infertility, dyspareunia, and chronic pelvic pain. The best treatments for PID are interventions that lead to prevention and early detection. The critical care nurse has an important role in recognizing the variables that may lead to PID-related sepsis and in encouraging health-seeking and health-maintenance behaviors among women with these diagnoses.

Pelvic inflammatory disease: how should it be managed?

PURPOSE OF REVIEW

To review the published literature on pelvic inflammatory disease over the past year and put into context the major findings.

RECENT FINDINGS

remains the commonest identified cause of pelvic inflammatory disease, and yet our understanding of how it causes mucosal damage and the factors explaining why only a subgroup of women develop pelvic inflammatory disease are not known. The increasing evidence for a chlamydial toxin may help to explain how tissue damage occurs and the indolent nature of many chlamydial infections. The evidence for as an important sexually transmitted cause of pelvic inflammatory disease is growing, with implications for treatment regimens and diagnostic testing. Power Doppler ultrasound has been reported to be both sensitive and specific in diagnosing pelvic inflammatory disease, although larger studies are needed to confirm these early results. Outpatient treatment with cefoxitin and doxycycline appears to be as effective when given in an outpatient setting compared with inpatient management with the same agents in a large randomized controlled trial with almost 3 years' follow-up.

SUMMARY

There remain many gaps in our knowledge of pelvic inflammatory disease, but the reviewed studies increase our understanding of the pathogenesis of infection, and offer the possibility of better diagnosis and reassurance about the long-term success of antibiotic treatment.

Identification of symptoms that indicate a pelvic examination is necessary to exclude PID in adolescent women

BACKGROUND

Diagnosis of chlamydia, gonorrhea, and vaginitis is now possible in adolescents using urine testing and vaginal swabs obtained by care provider or patient. However, a complete pelvic examination is necessary to diagnose pelvic inflammatory disease (PID). It is thus important to identify patients who might have pelvic inflammatory disease to assure complete gynecologic assessment of genitourinary symptoms.

PURPOSE

To determine whether adolescent patients with pelvic inflammatory disease report predictable symptoms during the medical interview and to determine what proportion of patients diagnosed with PID report at least one predictor symptom.

DESIGN

Observational study.

SETTINGS

Hospital-based adolescent clinic and Job Corps health service.

PATIENTS

A convenience sample (n = 193) of adolescent and young adult women who had a pelvic examination performed to evaluate a wide range of genitourinary symptoms.

MAIN OUTCOME MEASURE

Clinical diagnosis of pelvic inflammatory disease.

ANALYSIS

Sensitivity, specificity, and positive and negative predictive value of predictor symptoms for identifying patients given a diagnosis of pelvic inflammatory disease.

RESULTS

Twenty (10.4%) patients received a clinical diagnosis of PID. Lower abdominal pain was the most common symptom (90.0%) reported by these patients. All of the patients with PID reported either lower abdominal pain or dyspareunia in the medical history compared with 97 (56.1%) of those without PID. The presence of lower abdominal pain and/or dyspareunia in the clinical history yielded a sensitivity of 100%, specificity of 44%, and positive and negative predictive value of 17% and 100%, respectively, for identifying patients given a diagnosis of PID.

CONCLUSION

This study identified two symptoms reported in the medical history (lower abdominal pain and dyspareunia) that were associated with a clinical diagnosis of pelvic inflammatory disease. If lack of these two symptoms was used as a criterion for omitting a pelvic examination, more than one third of the patients in this study could have been evaluated for cervical and vaginal infections with urine and directly obtained vaginal swabs. Although some of these patients might have required a pelvic examination to exclude other causes of abnormal vaginal bleeding, at least 30% of the total sample could have been evaluated without a speculum and bimanual examination. If further studies support these findings, patients with symptoms suggestive of uncomplicated genitourinary infection (e.g., vaginal discharge, vaginal pruritus, or dysuria) who deny lower abdominal pain and dyspareunia can be evaluated with urine and vaginal samples in place of a speculum and bimanual examination.

Influence of infection with Chlamydia trachomatis on pregnancy outcome, infant health and life-long sequelae in infected offspring

This chapter deals with genital chlamydial infections in pregnancy and postpartum. There is increasing evidence that Chlamydia trachomatis infection may result in a number of adverse pregnancy outcomes, including early and late abortion, intrauterine infections of the fetus, stillbirth, prematurity, premature rupture of the membranes (PROM) and postpartum endometritis. Ectopic pregnancy is commonly associated with a previous tubal chlamydial infection where immunological reactions seem to play a role. C. trachomatis infection may be acquired as an intrauterine infection, as well as during transit through the birth channel, and this may result in neonatal conjunctivitis and/or pneumonia. The role of chlamydial infection in the sudden death syndrome has also been considered, but evidence so far is minimal. Neonatal chlamydial infection may cause life-long sequelae, such as obstructive lung disease. Genital chlamydial infections have been associated with problems in insemination and attempts at in vitro fertilization. The chapter also deals with screening of pregnant women for C. trachomatis and the treatment of infected mothers and their offspring.

An update on pelvic inflammatory disease

A review of the publications on pelvic inflammatory disease (PID) over the past 18 months reveals a number of common themes. This brief article highlights some relevant papers which may be of interest and summarises their main messages.

Accuracy of five different diagnostic techniques in mild-to-moderate pelvic inflammatory disease

OBJECTIVE

To evaluate the clinical diagnosis of pelvic inflammatory disease (PID) compared with the diagnosis of PID made by laparoscopy, endometrial biopsy, transvaginal ultrasound, and cervical and endometrial cultures.

STUDY DESIGN

A diagnostic performance test study was carried out by cross-sectional analysis in 61 women. A group presenting PID (n = 31) was compared with a group (n = 30) presenting another cause for non-specific lower abdominal pain (NSLAP). Diagnosis provided by an evaluated method was compared with a standard diagnosis (by surgical findings, histopathology, and microbiology). The pathologist was unaware of the visual findings and presumptive diagnoses given by other methods.

RESULTS

All clinical and laboratory PID criteria showed low discrimination capacity. Adnexal tenderness showed the greatest sensitivity. Clinical diagnosis had 87% sensitivity, while laparoscopy had 81% sensitivity and 100% specificity; transvaginal ultrasound had 30% sensitivity and 67% specificity; and endometrial culture had 83% sensitivity and 26% specificity.

CONCLUSIONS

Clinical criteria represent the best diagnostic method for discriminating PID. Laparoscopy showed the best specificity and is thus useful in those cases having an atypical clinical course for discarding abdominal pain when caused by another factor. The other diagnostic methods might have limited use.