An assessment of pre-operative microbial screening on the prevention of post-abortion pelvic inflammatory disease

'Miscarriage or abortion?' Understanding the medical language of pregnancy loss in Britain; a historical perspective

Clinical language applied to early pregnancy loss changed in late twentieth century Britain when doctors consciously began using the term 'miscarriage' instead of 'abortion' to refer to this subject. Medical professionals at the time and since have claimed this change as an intuitive empathic response to women's experiences. However, a reading of medical journals and textbooks from the era reveals how the change in clinical language reflected legal, technological, professional and social developments. The shift in language is better understood in the context of these historical developments, rather than as the consequence of more empathic medical care for women who experience miscarriage.

A randomised comparison of strategies for reducing infective complications of induced abortion

OBJECTIVES

To determine lower genital tract carriage rates of C. trachomatis, N. gonorrhoeae and bacterial vaginosis among women seeking termination of pregnancy. To compare two clinical management strategies for minimising the risks of infective morbidity after induced abortion.

DESIGN

Prevalence of infections was assessed by screening women undergoing abortion. Clinical management strategies were compared by a randomised trial.

SETTING

The gynaecology departments of four hospitals in Scotland.

PARTICIPANTS

1672 women undergoing induced abortion.

INTERVENTIONS

Women randomised to prophylaxis received metronidazole 1 g rectally before abortion plus doxycycline 100 mg twice daily for seven days. Women randomised to screen-and-treat received appropriate antibiotics only if screening proved positive for one or more infection.

MAIN OUTCOME MEASURES

Prevalences of infections; morbidity in the eight weeks following abortion as assessed by reported symptoms, general practitioner consultation and prescription rates and hospital re-attendances; costs to the NHS of alternative managements.

RESULTS

Prevalence rates: C. trachomatis 5.6%; N gonorrhoeae 0.19%; bacterial vaginosis 17.5%. Overall, women allocated to receive prophylaxis had lower rates of measures of short term infective morbidity than those allocated to screen-and-treat. These differences only reached statistical significance for women who were reported negative on screening. The direct costs to the NHS of prophylaxis and screen-and-treat were calculated to be 8.17 and 18.34 per woman, respectively.

CONCLUSIONS

Prevalences of lower genital tract infections which have been implicated in increased rates of infective morbidity after abortion are similar to those reported elsewhere. Universal antibiotic prophylaxis is at least as effective as a policy of screen-and-treat in minimising the risk of short term infective morbidity and is far more cost efficient.

[Antibiotic prophylaxis in cesarean section and voluntary termination in pregnancy]

Infection is the main complication after voluntary termination of pregnancy through vacuum aspiration, with an infection rate of 3.6% in the subsequent three weeks. This rate is comparable to that observed in the so-called clean surgical procedures. However the consequences on fertility remain unknown. Studies using systematic antibiotic administration in all vacuum aspirations (voluntary termination of pregnancy and spontaneous abortion) demonstrated the value of such a preventive measure. Factors of risk are difficult to identify and systematic bacteriological specimen collection in all patients undergoing a termination of pregnancy is quite impossible to do. Therefore, the best strategy consists in the oral administration of 200 mg of doxycycline before the aspiration and 200 mg 12 hours later. The incidence of operative-site infection and endometritis after Caesarean section without perioperative antimicrobial prophylaxis varies from 5 to 85%. A variety of risk factors have been identified such as low social category, rupture of membranes, the number of vaginal examinations, labour, and emergency sections. Most clinical trials have shown no significant difference in the efficacy of various antibiotic regimens. However, prophylactic antibiotics decrease significantly the rate of infections. We recommend one or three doses of intravenous prophylactic antibiotic, after clamping and section of the umbilical cord in high risk patients. Cephalosporin of 1st or 2nd generation or ampicillin associated with an inhibitor of beta-lactamases are recommended.

A further look at infection at the time of therapeutic abortion

Microbiological investigations and clinical follow-up were performed on 516 patients undergoing first-trimester termination of pregnancy, over a 2-year period. Chlamydia trachomatis was isolated by pre-operative microbiological screening in 6.7% of patients, gonococcus in 0.4% and Trichomonas vaginalis in 2%. Candida spp and Gardnerella vaginalis were isolated from 16% and 28% of the women, respectively. Patients who had positive cervical chlamydial isolation were significantly younger (less than 22 years) than those who did not. Doctor's clinical diagnosis of genital tract infection was found to be associated with a positive screening result but not with the likelihood of postabortal pelvic infection. Among the 175 patients followed up in the outpatient clinic, 4 of the 15 patients with a positive result for N. gonorrhoeae, C. trachomatis and/or T. vaginalis developed postoperative pelvic infection, which is significantly more than the group who did not harbour any of these three organisms (9/114).