Prophylactic antibiotics for curettage abortion

Prophylactic antibiotics for suction curettage in incomplete abortion

OBJECTIVE

The purpose of this study was to investigate the efficacy of 200 mg of prophylactic doxycycline in preventing pelvic infection after curettage for spontaneous (incomplete) abortion.

METHODS

A randomized, prospective, double-blinded study was carried out involving 300 women with an incomplete abortion who were given either placebo or 200 mg of doxycycline orally 30-60 min prior to curettage. A hematocrit, WBC count, pregnancy test, syphilis serology, Neisseria gonorrhoeae culture, and Micro Trak (monoclonal antibody test, Syba, San Jose, CA) for Chlamydia trachomatis were performed. The patients were scheduled for follow-up 2 weeks later. Antibiotic administration for any reason as well as the postoperative infection rate in these women was assessed.

RESULTS

Eleven women were excluded from analysis, leaving 289 evaluable. N. gonorrhoeae was isolated from 6 (2%) women and C. trachomatis from 8 (3%) women, and the syphilis serology was serofast in 4 (1%) women. Endometritis complicated the procedure in 4 women who received placebo and in 1 woman who received doxycycline (P = 0.22).

CONCLUSION

Prophylactic doxycycline is not effective in preventing pelvic infection after curettage for spontaneous (incomplete) abortion.

Antibiotics for incomplete abortion

BACKGROUND

Unsafe abortions result not only in costs for acute care but may also be responsible for longer-term complications such as pelvic inflammatory disease, damage to reproductive organs, and secondary infertility. If effective, antibiotic prophylaxis at the time of the procedure can potentially prevent these adverse consequences.

OBJECTIVES

The value of routine antibiotics before surgical evacuation of the uterus in women with incomplete abortion is controversial. In some health centres antibiotic prophylaxis is advised; in others antibiotics are only prescribed when there are signs of infection. The objective of this review is to evaluate the effectiveness of routine antibiotic prophylaxis to women with incomplete abortion.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register, Pubmed/MEDLINE, EMBASE and Popline. Date of last search: January 2007.

SELECTION CRITERIA

Randomised trials comparing a policy of routine antibiotic prophylaxis with no routine prophylaxis were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Data extraction was conducted by two reviewers independently. Trial quality was assessed.

MAIN RESULTS

One study involving 140 women was included. A second well-conducted trial was excluded because of high losses to follow-up. No differences were detected in postabortal infection rates with routine prophylaxis or control. However, compliance with antibiotic treatment was also low.

AUTHORS' CONCLUSIONS

There is not enough evidence to evaluate a policy of routine antibiotic prophylaxis to women with incomplete abortion.

Antibiotics for incomplete abortion

OBJECTIVES

The value of routine antibiotics before surgical evacuation of the uterus in women incomplete abortion is controversial. In some health centres antibiotic prophylaxis is advised in others antibiotics are only prescribed when there is signs of infection. The objective of this review is to evaluate the effectiveness of routine antibiotic prophylaxis to women with incomplete abortion.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register, MEDLINE and Popline. Date of last search: January 1999.

SELECTION CRITERIA

Randomised trials comparing a policy of routine antibiotic prophylaxis with no routine prophylaxis were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Data extraction was conducted by two reviewers independently. Trial quality was assessed.

MAIN RESULTS

One study involving 140 women was included. A second well-conducted trial was excluded because of high losses to follow-up. No differences were detected in postabortal infection rates with routine prophylaxis or control. However, compliance with antibiotic treatment was also low.

REVIEWER'S CONCLUSIONS

There is not enough evidence to evaluate a policy of routine antibiotic prophylaxis to women with incomplete abortion.

Is curettage needed for uncomplicated incomplete spontaneous abortion?

Spontaneous abortion occurs in 15% to 20% of all human pregnancies. Since the late 1800s, the management of incomplete spontaneous abortion has focused on using curettage to empty the uterus as quickly as possible. This practice began to reduce blood loss and infection and has been unquestioned for 4 decades. In today's medical climate, few spontaneous abortions are the resuslt of illegal manipulation, given the availability of legal pregnancy termination. Antibiotics and transfusions are available, should complications arise in conservatively managed cases. Two prospective randomized trials suggest that conservative management may be advantageous for women who have stable vital signs without evidence of infection. They will have fewer perforations and, possibly, fewer infections and uterine synechiae with expectant or medical management. Larger trials should be undertaken to critically assess surgical evacuation compared to medical management, factoring in the psychologic impact of treatment. We believe that medical management will prove to be the most appropriate treatment for uncomplicated spontaneous incomplete abortion in the 21st century.

Preventing pelvic infection after abortion

Pelvic infection is the commonest complication of legal abortion. The presence of lower genital tract infections increases the risk of complications, and women requesting abortion are at significant risk of harbouring sexually transmitted diseases (STD). Prophylactic antibiotic treatment can decrease the rate of post-abortal sepsis, but the optimum regime is unclear. In particular, patients with Chlamydia trachomatis infection, and bacterial vaginosis would appear to be at increased risk, and detection and treatment of these conditions can lower this risk. The opportunity to screen and treat for STD presents itself in this setting, allowing patients and their sexual contacts to benefit, with a decrease in the infected pool in the community.

Induced abortion: an audit of reported current practice among consultant gynaecologists in Scotland

OBJECTIVE

To obtain an overview of current abortion practice in Scotland for comparison with agreed criteria for good quality care based on literature review.

DESIGN

Postal questionnaire survey.

SUBJECTS

All 132 consultant gynaecologists practising in the NHS in Scotland.

RESULTS

Response rate 92%. The survey revealed regional inequalities in the availability of services, particularly with regard to early medical abortion and second trimester procedures. It also revealed great individual variations in many areas of practice notably in screening for genital tract infection, the use of cervical predilatation, contraceptive provision, and follow up. Several aspects of practice compared poorly with the agreed criteria for good quality care.

CONCLUSIONS

The postal questionnaire approach achieved a good response rate and has provided an informative overview of current practice on a national basis. Variations in the provision of services and in clinical practice, both among regions and among individual consultants, have been identified. Elements of abortion care in which great variations exist and in which current practice compares poorly with the agreed criteria have been highlighted as appropriate areas for the development of national guidelines and for educational initiatives. Such a questionnaire approach to assessing current practice can complement, and possibly replace, some aspects of casenote review audit.

[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.

Pelvic inflammatory disease and intrauterine devices: prophylactic antibiotics to reduce febrile complications

In the present study, we tried to determine whether IUD insertion related PID and febrile complications could be prevented by prophylactic use of antibiotics. We studied 300 patients who were admitted to our family planning clinic for IUD contraception. Of these, 150 patients received prophylactic Doxycycline (group 1) and the second 150 received no therapy (group 2). Five cases experienced fever with or without leucocytosis and none required hospitalization. PID was observed in one woman in each group. Positive culture (gonorrhea) was obtained in one woman who was then treated by relevant antibiotics; the other woman required hospitalization for two days. The overall infection rates for group 1 and 2 were 2.1% and 2.9%, respectively and this difference was not significant. The incidence of PID infection and febrile complications was found to be very low for both groups when compared to other studies, suggesting that aseptic conditions with proper insertion reduce the risk of infection.

A double-blind randomized study of the effect of erythromycin in preventing pelvic inflammatory disease after first trimester abortion

OBJECTIVE

To assess the prophylactic use of erythromycin in prevention of post-abortal pelvic inflammation disease (PID) in first trimester abortion.

DESIGN

Double-blind, randomized controlled trial.

SETTING

Department of Surgery, County Hospital, Denmark.

SUBJECTS

Four hundred and thirty two women who were to undergo induced abortion before 12 weeks gestation were randomized to be treated either with prophylactic erythromycin or a placebo.

INTERVENTION

The women were randomized to receive a placebo or erythromycin, 500 mg twice a day for 7 1/2 days starting the evening before the abortion. All the women were investigated for Chlamydia trachomatis and Neisseria gonorrhoea before the abortion.

MAIN OUTCOME MEASURES

Frequency of cervical C. trachomatis and N. gonorrhoea and frequency of PID after abortion.

RESULTS

Fifty four women were excluded after randomization. The frequency of PID was 11% (20/189) in the erythromycin group and 16% (30/189) in the placebo group (P = 0.13, chi 2-test). The prevalence of C. trachomatis was 19% (15/78) in women less than or equal to 20 years of age, 13% (14/109) in women between 21 and 25 years and 2% (5/241) in women greater than or equal to 26 years of age. In women positive for C. trachomatis erythromycin prophylaxis significantly reduced the frequency of PID to 8% (1/13) compared with 43% (6/14) in the placebo group (P = 0.051, logistic regression analysis). Erythromycin had no effect on other potential high risk groups (first pregnancy, nulliparous, less than 20 years of age, and women with previous PID).

CONCLUSION

Prophylactic erythromycin is not warranted for all women having an abortion. Cervical C. trachomatis is a risk factor for postabortal PID, and prophylaxis with erythromycin significantly reduces the frequency of PID. However, only a few women with PID had cervical C. trachomatis, and the prevention of post-abortal PID remains a major challenge requiring further studies.

Prevention of IUD-related pelvic infection: the efficacy of prophylactic doxycycline at IUD insertion

It is believed that much of the small increased risk for developing pelvic inflammatory disease (PID) associated with the use of an intrauterine device (IUD) appears to be caused by bacterial contamination of the endometrial cavity at the time of insertion. Previous research suggests that use of prophylactic antibiotics immediately prior to IUD insertion may reduce the risk of developing PID. This paper presents results from a randomized clinical trial of 1485 women in Ibadan, Nigeria evaluating the effectiveness of 200 mg of doxycycline (versus placebo) given orally at the time of IUD insertion in reducing the incidence of PID during the first three months of IUD use. Rate of PID infection in the doxycycline-treated group was not significantly lower than that in the placebo-treated group. The rate of unscheduled IUD-related visits to the clinic also was not significantly lower among the doxycycline-treated group. However, the incidence of PID was low (21 cases) for both study groups. Aseptic conditions during IUD insertion, follow-up visits with short intervals to monitor health, and treatment of opportunistic infections may have reduced the potential of PID within this population.

Postabortal pelvic sepsis in association with Chlamydia trachomatis

Cervical swabs for Chlamydia trachomatis culture were taken from 527 women presenting for elective termination of pregnancy. Twenty-six patients (4.9%) harboured C. trachomatis; 21 (81%) of these were less than 25-years-old and 21 (81%) were nulliparas. Postoperative pelvic sepsis developed in 11.5% of chlamydia-positive women, in contrast to 3.6% of chlamydia-negative women. Consequently it is suggested that all patients, especially those younger than 25 years, presenting for termination of pregnancy or in whom an intrauterine device is to be inserted should be screened and have treatment commenced for C. trachomatis prior to the operative procedure.

Preventing IUCD-related pelvic infection: the efficacy of prophylactic doxycycline at insertion

Most of the small increased risk in pelvic inflammatory disease (PID) associated with the intrauterine contraceptive device (IUCD) appears to be caused by bacterial contamination of the endometrial cavity at the time of insertion. This randomized clinical trial of 1813 women in Nairobi, Kenya, assessed the effectiveness of 200 mg of doxycycline given orally at the time of insertion in reducing the occurrence of PID. The rate of this infection in the doxycycline-treated group was 31% lower than that in the placebo-treated group (1.3 and 1.9%, respectively; RR 0.69; 95% CI 0.32 to 1.5). The rate of an unplanned IUCD-related visit to the clinic was also 31% lower in the doxycycline-treated group (RR 0.69; 95% CI 0.52 to 0.91). Although the significance level (P = 0.17) for the reduction is PID does not meet the conventional standard of 0.05, the results may be suggestive of an effect. Moreover, the reduction in IUCD-related visits (P = 0.004) not only represents an important decrease in morbidity but also substantiates the reduction found for PID. Further studies are needed to corroborate these results. Consideration should be given to the prophylactic use of doxycycline at the time of IUCD insertion as an approach to preventing PID and other IUCD-related morbidity.

The significance and scope of reproductive tract infections among Third World women

Due to biomedical, behavioral and societal factors, reproductive tract infections are widespread in the Third World. Without early diagnosis and accurate therapy, their complications severely compromise women's health, fertility and productivity; infant health and survival; and the effectiveness of family planning programs. Clinicians and public health planners can address these treatable syndromes through research and services in socially acceptable settings including family planning, prenatal and MCH clinics. Specific approaches are discussed.

A double-blind, multiple-dose, placebo-controlled, cross-over study to compare the incidence of gastrointestinal complaints in healthy subjects given Doryx R and Vibramycin R

Ninety-eight healthy subjects completed a double-blind, placebo-controlled, multiple-dose cross-over study to compare the incidence of gastrointestinal side effects of Doryx (Parke-Davis, Morris Plains, NJ) capsules (enteric-coated doxycycline hyclate pellets) and Vibramycin (Pfizer, New York, NY) capsules (doxycycline hyclate powder). Doryx produced statistically significantly fewer episodes of nausea, vomiting, stomach of abdominal discomfort, and decreased appetite than did Vibramycin. For every symptom, Vibramycin produced statistically significantly more symptom reports than did placebo. Although Doryx produced significantly more reports of nausea than did placebo, there was no significant difference for the other symptoms. Based on these results, Doryx is superior to Vibramycin when considering the incidence of gastrointestinal side effects.

Prophylactic antibiotics for suction curettage abortion: results of a clinical controlled trial

The prophylactic use of 300 mg doxycycline at the time of an abortion was evaluated in a randomized controlled trial. In the group with negative chlamydia screening results, only two (0.4%) of 502 patients who received prophylactic treatment developed pelvic infection, compared with 15 (3.0%) of 497 patients who received placebos (p = 0.001). The same effectiveness was found in women with positive chlamydia screening results. Vomiting was the major side effect of the medication and could limit its use. A simulation of selective prophylaxis in women with negative chlamydia screening results showed that its selective use in patients with a history of gonorrhea or in nulliparous women with multiple sex partners could be nearly two thirds as effective as general prophylaxis.

Morbidity after termination of pregnancy in first trimester

The outcome of termination of pregnancy was observed in relation to the preoperative clinical and microbiological findings in 167 women attending a day care abortion unit in Liverpool. Before termination, Chlamydia trachomatis was isolated from the cervix of 19 (11%) of the patients and high counts (greater than 10(4) colour changing units (ccu) per ml of specimen) of mycoplasmas were found in 30 (18%). Coexistent infections with chlamydiae and high counts of mycoplasmas occurred in only seven (4%) women. Trichomonas vaginalis, yeasts, or pathogenic bacteria were found in vaginal swabs from 30 (18%) women. After undergoing termination, seven (4%) women developed pelvic inflammatory disease (PID), five (71%) of whom had yielded C trachomatis before undergoing termination. A further 13 (8%) patients developed minor morbidity of the upper genital tract; high count mycoplasmal infection had been found in seven (54%) and chlamydial infection in three (23%) of these women before termination. In contrast, C trachomatis had been isolated from only 11 (8%) and high counts of mycoplasmas from 23 (16%) of the 147 women who had uneventful recoveries after undergoing termination. No correlation was apparent between the presence of vaginal pathogens before termination and the development of untoward sequelae postoperatively. Neither the history nor clinical examination before termination would have indicated that chlamydial or mycoplasmal infections were present, or that postoperative complications were likely to occur. Abnormal cervical cytology, however, was found in 86 (52%) of women overall, including 15 (79%) of the 19 women with chlamydial infection.

Comparison of preventive use of metronidazole and ampicillin in women with a history of pelvic inflammatory disease undergoing first-trimester abortion

In a double-blind controlled trial the efficacy of prophylactic metronidazole and pivampicillin to women with a history of pelvic inflammatory disease (PID) undergoing first-trimester abortion was assessed. Thirty-eight women received pivampicillin tablets 350 mg and 43 women metronidazole tablets 400 mg, given 1 h before and 4 and 8 h after the abortion. In the pivampicillin group 5 women (13.1%) and in the metronidazole group 8 women (18.6%) developed post-abortal PID, a non-significant difference (P greater than 0.05). The number of hospital days and amounts of antibiotics were not significantly different in the two treatment groups (all P-values greater than 0.05). Women with a history of PID were found to be at risk of contracting postabortal PID.

Preventing febrile complications of suction curettage abortion

To identify risk factors for febrile complications after suction curettage abortion, we analyzed the data of 26,332 women who underwent suction curettage abortion at five participating centers in the Joint Program for the Study of Abortion, Part III, from 1975 to 1978. We defined febrile morbidity as an oral temperature of greater than or equal to 38 degrees C for 2 days or longer. The febrile morbidity rate was 0.34 per 100 abortions. We performed a multivariate analysis using a linear logistic regression model. Prophylactic antibiotics proved to be the most protective factor, reducing the rate of febrile complications to about one third that of women who received no prophylactic antibiotics (relative risk 0.36; 95% confidence interval 0.18 to 0.70). Patients who had had one or more previous births also had a significantly lower risk of febrile morbidity (relative risk 0.54; 95% confidence interval 0.33 to 0.88). Other factors did not significantly affect the febrile complication rate.