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Etiology of pelvic infections treated by the gynecologic service of the Kasturba Hospital, Delhi, India
Etiology of pelvic infections treated by the gynecologic service of the Kasturba Hospital, Delhi, India M.
KOCHAR,
F.R.C.S.E.,
F.R.C.O.G.
New Delhi, India Selected etiologic and clinical characteristics of pelvic infections associated with gynecologic surgical procedures and other conditions were studied. During a 5 year period, 1,800 patients were admitted to Kasturba Hospital. Infections following sterilization by vaginal tubectomy were common while septic-induced abortion was the leading cause of maternal morbidity. Medical management was successful in most of the patients. (AM. J. OBSTET. GYNECOL. 138:872, 1980.)
PELVIC INFECTIONS are common problems encountered in gynecologic, infertility, family planning, postnatal, legal abortion, and sterilization clinics in India. These infections may be caused by specific pathologic microorganisms, such as Neisseria gonorrhoeae and Mycobacterium tuberculosis, or nonpathologic bacteria. Genital tuberculosis, though rare in Western countries, is still quite prevalent in India.‘, * Patients with this disease often have no signs or symptoms and often are diagnosed during routine evaluations or investigations for primary and secondary amenorrhea. Depending on socioeconomic status, minor symptoms due to pelvic infections often are ignored by the patient and medical care is sought only when acute symptoms develop or when menstrual disorders or infertility occurs. In spite of sex education in schools, increased awareness of venereal diseases, and better methods of diagnosis and management, pelvic infections still are not being treated properly. As a result, they frequently progress to pelvic abscesses, adhesions, and chronic symptoms. In the presence of liberalized abortion laws, increasing numbers of women are seeking legal abortions. Unless abortion procedures are performed in the first trimester in recognized clinics under hygienic conditions, pelvic infection will be a common occurrence, with subsequent secondary infertility, menstrual disorders, and lower abdominal pain. This article reviews the general experience of the
From Reprint Medical India.
872
the
Kasturba Hospital,
New Delhi,
India.
requests: M. Kochar, F.R.C.S.E., F.R.C.O.G., Superintendent, Kasturba Hospital, New Delhi-z,
gynecologic service of the Kasturba Hospital with respect to selected etiologic and clinical aspects of pelvic infections.
Method For all patients admitted to the gynecologic service of Kasturba Hospital, recording of a history and a complete physical examination, including a pelvic examination, are done routinely. In addition, the following tests are performed: (1) blood-hemoglobin, white cell differential count, erythrocyte sedimentation rate. and blood culture, when indicated; (2) VDRL,* urine-routine, microscopic, and culture, if necessary: (3) wet smear for Trichomonas and monilial infection; (4) Gram stain for gonococcal infection; and (5) high vaginal swab for culture and sensitivity. All patients with pelvic infections present on admission or developing as a result of gynecologic interventions received medical therapy consisting of antibiotics. Penicillin, streptomycin, and chloramphenicol (in severely ill patients) were used initially until the results of culture and sensitivity testing were known. Some patients also received antiinflammatory medications such as cortisone. Pelvic diathermy occasionally was done in cases of chronic infection. Surgery was reserved for patients who failed to respond to medical therapy. Diagnostic laparoscopy was performed when the diagnosis was in doubt, in case of unexplained infertility. for menstrual disorder, for primary and secondary amenorrhea, and in some patients complaining of pain without positive findings on pelvic examination. *Venereal
Disease Research Laboratories.
Etiology of PID in Delhi. India
Table I. Pelvic infection (PI) rate in gynecologic patients sorted by surgical and nonsurgical causes
873
Table II. Predominant symptoms and signs among 1,800 women with pelvic infections
‘VO. “f
Cnu.se.s of PI
patients
Surgirfll intenwltions: I, Vaeinal sterilization Vaiinal sterilization with medical termination of pregnancy I.aparosropy sterilization Laparoscopy sterilization with medical termination of pregnancy Abdominal sterilization Minilaparotomy Minilaparotomy with medical termination of pregnancy Culdoscopv Medical termination of pregnancv
Nonnqical interventions: 10. Abortions including 11, Intrauterine device 12. Puerperium 13. InfertilitySubtotal *Number
1,718 724
13,924
2,194 3,388 469
111
No. of Pls (%) 167 (9.7) 108 (15.0) 118 (0.85) 41 (1.9) 100 (2.95) 8 (1.7) 12 (10.8)
152 - 4 338
5 JFJl
(3.3) (0.3)
?7.0 18
689
(2.6)
14,769
317 405 233
(2.1) (0.38)
Symptoms Abdominal pain Infertility, primary and secondary Amenorrhea Signs Tubo-ovarian mass, pelvic and cellulitis Vaginal discharge Fever
Bleeding per vagina Severe anemia Peritonitis with gastroenteritis Bartholin abscess Septicemia with renal failure
Table septic
106,580
NA* NA NA
156 1,111
not available.
abscess,
III. Diagnostic
laparoscopy
results,
Pelvic infection with tubo-ovarian mass or hydrosalpinx Genital or abdominal tuberculosis Other Total
540 cases Casec
%
IJO
27.9
26
3x4 540
4.8
(i7.4 100
Results During the 5 year period from 1975 to 1979,63,308 patients were admitted to the gynecologic service. Among these were 1,800 patients (2.8%) with pelvic infections. Their ages varied between 19 and 35 years and included both nulliparous and multiparous women. Table I summarizes the number and rate of pelvic infections (Pls) in women undergoing gynecologic surgery by type of surgical procedure. This table also includes the additional conditions associated with PI, i.e., abortions, insertion of intrauterine devices, puerperium. and infertility. A total of 27,018 women underwent a surgical procedure and pelvic infections developed in 689 (2.6%). Patients who underwent sterilization by vaginal tubectomy and minilaparotomy with abortion had the highest PI rate (9.7% and 10.8%. respectively). Symptoms and signs in women with PI are presented in Table I I. Lower abdominal pain is the most common symptom while vaginal discharge, tuboovarian masses, and pelvic cellulitis were the most common signs. A total of 540 women (30%) underwent diagnostic laparoscopy. The findings are presented in Table III. Tuba-ovarian masses or hydrosalpinx associated with PI occurred in 27.9% of the women. Abdominal tuberculosis was diagnosed in 4.8%. Medical therapy failed in HO cases (4.4%). Total hys-
Table
IV. Deaths due to pelvic infection Spea$c cau.se
Septic-induced abortion Puerpural sepsis Others Total
Deaths
YC
20 12 11
46.5
43
27.9 25.6 100
terectomies were necessary in only 10 women; the remainder responded to more conservative measures such as removal of tubo-ovarian masses, needle colpotom);, abscess drainage, and other repair procedures. Table IV summarizes the cause of death among the 1,800 patients with PI. The mortality rate was 2.4% (43 women) with the ma.jority (46.5%) succumbing to infection resulting from septic and induced abortions.
Discussion As our data demonstrate, pelvic infections are common in young women. Excluding PI following sterilization by tubectomy. many diagnoses of PI were made in women who were of low parity or in infertile women. The most common infecting organisms were Escherichia coli and anaerobic bacteria. Isolation of h’. ,qnorrhoeae was uncommon either because patients ignore their symptoms and do not attend our clinics OI
874
Kochar
they seek treatment at nearby special venereal disease clinics. In India, intrauterine devices (IUDs) are commonly used contraceptives. The incidence of PI following insertion was low (0.38%) compared to rates reported b) Gulati and Kapoor’ and Wilson and associates” (2.4% and 7.7%, respectively). Patients who underwent tubectomy following removal of their IUDs showed a higher incidence of PI. Because of the high incidence of PI following sterilization by vaginal tubectomy, this procedure has virtually been abandoned in Kasturba Hospital. In spite of liberalized abortion laws, septic-induced abortion is still common, and patients often are admitted in advanced moribund conditions resulting from widespread infection. Almost half of the
deaths occurred in women with septic-induced aho]-tions. This condition was seen most frequentI>, in unmarried, young women in whom the abortion was peg formed in the second trimester by untrained persons. Puerperal sepsis is common since many patients’ babies are delivered at home under less-than-ideal conditions. These women seek care when their conditions become serious and death may result. Medical therapy was successful in the vast majorit) of our cases, and we recommend surgery only for treatment failures. We urge complete treatment following adequate diagnostic evaluation to prevent the occurrence of resistant organisms. In addition, public education, personal hygiene, early medical care, and sex education in schools ma); be effective in reducing the incidence of pelvic infections.
REFERENCES
1.
Gulati, N., and Kapoor, U.: Chronic pelvic inflammatory disease, J. Obstet. Gynaecol. India 29: 1213, 1979.
2. Shah, H. inflammation,
N.,
Patel, M. D., and Nagpal, S.: Pelvic J. Obstet. Gynaecol. India 28:430, 1978.
3. Wilson, J. R., Ledges, W. J., Andros, G. J., et al.: Genital
tract infection with an intra-uterine
contraceptive device, a
histopathologic
of the Second
study,
Proceedings
Interna-
tional Conference on Intra-Uterine Contraception, New York, Oct. 2-3, 1964, International Congress Serial No. 86. Amsterdam,
1965,
Excerpta
Medica,
p. 178.
KOCHAR,
F.R.C.S.E.,
F.R.C.O.G.
New Delhi, India Selected etiologic and clinical characteristics of pelvic infections associated with gynecologic surgical procedures and other conditions were studied. During a 5 year period, 1,800 patients were admitted to Kasturba Hospital. Infections following sterilization by vaginal tubectomy were common while septic-induced abortion was the leading cause of maternal morbidity. Medical management was successful in most of the patients. (AM. J. OBSTET. GYNECOL. 138:872, 1980.)
PELVIC INFECTIONS are common problems encountered in gynecologic, infertility, family planning, postnatal, legal abortion, and sterilization clinics in India. These infections may be caused by specific pathologic microorganisms, such as Neisseria gonorrhoeae and Mycobacterium tuberculosis, or nonpathologic bacteria. Genital tuberculosis, though rare in Western countries, is still quite prevalent in India.‘, * Patients with this disease often have no signs or symptoms and often are diagnosed during routine evaluations or investigations for primary and secondary amenorrhea. Depending on socioeconomic status, minor symptoms due to pelvic infections often are ignored by the patient and medical care is sought only when acute symptoms develop or when menstrual disorders or infertility occurs. In spite of sex education in schools, increased awareness of venereal diseases, and better methods of diagnosis and management, pelvic infections still are not being treated properly. As a result, they frequently progress to pelvic abscesses, adhesions, and chronic symptoms. In the presence of liberalized abortion laws, increasing numbers of women are seeking legal abortions. Unless abortion procedures are performed in the first trimester in recognized clinics under hygienic conditions, pelvic infection will be a common occurrence, with subsequent secondary infertility, menstrual disorders, and lower abdominal pain. This article reviews the general experience of the
From Reprint Medical India.
872
the
Kasturba Hospital,
New Delhi,
India.
requests: M. Kochar, F.R.C.S.E., F.R.C.O.G., Superintendent, Kasturba Hospital, New Delhi-z,
gynecologic service of the Kasturba Hospital with respect to selected etiologic and clinical aspects of pelvic infections.
Method For all patients admitted to the gynecologic service of Kasturba Hospital, recording of a history and a complete physical examination, including a pelvic examination, are done routinely. In addition, the following tests are performed: (1) blood-hemoglobin, white cell differential count, erythrocyte sedimentation rate. and blood culture, when indicated; (2) VDRL,* urine-routine, microscopic, and culture, if necessary: (3) wet smear for Trichomonas and monilial infection; (4) Gram stain for gonococcal infection; and (5) high vaginal swab for culture and sensitivity. All patients with pelvic infections present on admission or developing as a result of gynecologic interventions received medical therapy consisting of antibiotics. Penicillin, streptomycin, and chloramphenicol (in severely ill patients) were used initially until the results of culture and sensitivity testing were known. Some patients also received antiinflammatory medications such as cortisone. Pelvic diathermy occasionally was done in cases of chronic infection. Surgery was reserved for patients who failed to respond to medical therapy. Diagnostic laparoscopy was performed when the diagnosis was in doubt, in case of unexplained infertility. for menstrual disorder, for primary and secondary amenorrhea, and in some patients complaining of pain without positive findings on pelvic examination. *Venereal
Disease Research Laboratories.
Etiology of PID in Delhi. India
Table I. Pelvic infection (PI) rate in gynecologic patients sorted by surgical and nonsurgical causes
873
Table II. Predominant symptoms and signs among 1,800 women with pelvic infections
‘VO. “f
Cnu.se.s of PI
patients
Surgirfll intenwltions: I, Vaeinal sterilization Vaiinal sterilization with medical termination of pregnancy I.aparosropy sterilization Laparoscopy sterilization with medical termination of pregnancy Abdominal sterilization Minilaparotomy Minilaparotomy with medical termination of pregnancy Culdoscopv Medical termination of pregnancv
Nonnqical interventions: 10. Abortions including 11, Intrauterine device 12. Puerperium 13. InfertilitySubtotal *Number
1,718 724
13,924
2,194 3,388 469
111
No. of Pls (%) 167 (9.7) 108 (15.0) 118 (0.85) 41 (1.9) 100 (2.95) 8 (1.7) 12 (10.8)
152 - 4 338
5 JFJl
(3.3) (0.3)
?7.0 18
689
(2.6)
14,769
317 405 233
(2.1) (0.38)
Symptoms Abdominal pain Infertility, primary and secondary Amenorrhea Signs Tubo-ovarian mass, pelvic and cellulitis Vaginal discharge Fever
Bleeding per vagina Severe anemia Peritonitis with gastroenteritis Bartholin abscess Septicemia with renal failure
Table septic
106,580
NA* NA NA
156 1,111
not available.
abscess,
III. Diagnostic
laparoscopy
results,
Pelvic infection with tubo-ovarian mass or hydrosalpinx Genital or abdominal tuberculosis Other Total
540 cases Casec
%
IJO
27.9
26
3x4 540
4.8
(i7.4 100
Results During the 5 year period from 1975 to 1979,63,308 patients were admitted to the gynecologic service. Among these were 1,800 patients (2.8%) with pelvic infections. Their ages varied between 19 and 35 years and included both nulliparous and multiparous women. Table I summarizes the number and rate of pelvic infections (Pls) in women undergoing gynecologic surgery by type of surgical procedure. This table also includes the additional conditions associated with PI, i.e., abortions, insertion of intrauterine devices, puerperium. and infertility. A total of 27,018 women underwent a surgical procedure and pelvic infections developed in 689 (2.6%). Patients who underwent sterilization by vaginal tubectomy and minilaparotomy with abortion had the highest PI rate (9.7% and 10.8%. respectively). Symptoms and signs in women with PI are presented in Table I I. Lower abdominal pain is the most common symptom while vaginal discharge, tuboovarian masses, and pelvic cellulitis were the most common signs. A total of 540 women (30%) underwent diagnostic laparoscopy. The findings are presented in Table III. Tuba-ovarian masses or hydrosalpinx associated with PI occurred in 27.9% of the women. Abdominal tuberculosis was diagnosed in 4.8%. Medical therapy failed in HO cases (4.4%). Total hys-
Table
IV. Deaths due to pelvic infection Spea$c cau.se
Septic-induced abortion Puerpural sepsis Others Total
Deaths
YC
20 12 11
46.5
43
27.9 25.6 100
terectomies were necessary in only 10 women; the remainder responded to more conservative measures such as removal of tubo-ovarian masses, needle colpotom);, abscess drainage, and other repair procedures. Table IV summarizes the cause of death among the 1,800 patients with PI. The mortality rate was 2.4% (43 women) with the ma.jority (46.5%) succumbing to infection resulting from septic and induced abortions.
Discussion As our data demonstrate, pelvic infections are common in young women. Excluding PI following sterilization by tubectomy. many diagnoses of PI were made in women who were of low parity or in infertile women. The most common infecting organisms were Escherichia coli and anaerobic bacteria. Isolation of h’. ,qnorrhoeae was uncommon either because patients ignore their symptoms and do not attend our clinics OI
874
Kochar
they seek treatment at nearby special venereal disease clinics. In India, intrauterine devices (IUDs) are commonly used contraceptives. The incidence of PI following insertion was low (0.38%) compared to rates reported b) Gulati and Kapoor’ and Wilson and associates” (2.4% and 7.7%, respectively). Patients who underwent tubectomy following removal of their IUDs showed a higher incidence of PI. Because of the high incidence of PI following sterilization by vaginal tubectomy, this procedure has virtually been abandoned in Kasturba Hospital. In spite of liberalized abortion laws, septic-induced abortion is still common, and patients often are admitted in advanced moribund conditions resulting from widespread infection. Almost half of the
deaths occurred in women with septic-induced aho]-tions. This condition was seen most frequentI>, in unmarried, young women in whom the abortion was peg formed in the second trimester by untrained persons. Puerperal sepsis is common since many patients’ babies are delivered at home under less-than-ideal conditions. These women seek care when their conditions become serious and death may result. Medical therapy was successful in the vast majorit) of our cases, and we recommend surgery only for treatment failures. We urge complete treatment following adequate diagnostic evaluation to prevent the occurrence of resistant organisms. In addition, public education, personal hygiene, early medical care, and sex education in schools ma); be effective in reducing the incidence of pelvic infections.
REFERENCES
1.
Gulati, N., and Kapoor, U.: Chronic pelvic inflammatory disease, J. Obstet. Gynaecol. India 29: 1213, 1979.
2. Shah, H. inflammation,
N.,
Patel, M. D., and Nagpal, S.: Pelvic J. Obstet. Gynaecol. India 28:430, 1978.
3. Wilson, J. R., Ledges, W. J., Andros, G. J., et al.: Genital
tract infection with an intra-uterine
contraceptive device, a
histopathologic
of the Second
study,
Proceedings
Interna-
tional Conference on Intra-Uterine Contraception, New York, Oct. 2-3, 1964, International Congress Serial No. 86. Amsterdam,
1965,
Excerpta
Medica,
p. 178.