The effect of antibiotic prophylaxis for acute pelvic inflammatory disease after hysterosalpingography: a retrospective cohort study

Pelvic inflammatory disease in the adolescent and young adult: An update

Pelvic inflammatory disease (PID) is an infection of the female upper genital tract that is typically polymicrobial with classic core involvement of Neisseria gonorrhoeae and/or Chlamydia trachomatis, though other endogenous flora from the vagino-cervical areas can be involved as well. It is often a sexually transmitted disease but other etiologic routes are also noted. A variety of risk factors have been identified including adolescence, young adulthood, adolescent cervical ectropion, multiple sexual partners, immature immune system, history of previous PID, risky contraceptive practices and others. An early diagnosis and prompt treatment are necessary to reduce risks of PID complications such as chronic pelvic pain, ectopic pregnancy and infertility. Current management principles of PID are also reviewed. It is important for clinicians to screen sexually active females for common sexually transmitted infections such as Chlamydia trachomatis and provide safer sex education to their adolescent and young adult patients. Clinicians should provide comprehensive management to persons with PID and utilize established guidelines such as those from the US Centers for Disease Control and Prevention (CDC).

Safety of oil-based contrast medium for hysterosalpingography: a systematic review

Recent meta-analyses have shown that a hysterosalpingography (HSG) with oil-based contrast increases pregnancy rates in subfertile women. However, the frequency of complications during or after an HSG with oil-based contrast in subfertile women and/or their offspring is still unclear. This systematic review and meta-analysis, without restrictions on language, publication date or study design, was performed to fill this knowledge gap. The results show that the most frequently reported complication was intravasation of contrast, which occurred in 2.7% with the use of oil-based contrast (31 cohort studies and randomized controlled trials [RCT], 95% CI 1.7-3.8, absolute event rate 664/19,339), compared with 2.0% with the use of water-based contrast (8 cohort studies and RCT, 95% CI 1.2-3.0, absolute event rate 18/1006). In the cohort studies and RCT there were 18 women with an oil embolism (18/19,339 HSG), all without serious lasting consequences. Four cases with serious consequences of an oil embolism were described (retinal oil embolism [n = 1] and cerebral complaints [n = 3]); these reports did not describe the use of adequate fluoroscopy guidance during HSG. In conclusion, the most frequently reported complication after an HSG with oil-based contrast is intravasation occurring in 2.7%. In total four cases with serious consequences of oil embolisms in subfertile women were published.

Complications after hysterosalpingography with oil- or water-based contrast: results of a nationwide survey

STUDY QUESTION

What is the incidence of complications after hysterosalpingography (HSG) using oil-based contrast versus water-based contrast?

SUMMARY ANSWER

Among 5165 women undergoing HSG, the most frequently reported complication after HSG with oil- and water-based contrast was intravasation of contrast medium (4.8% versus 1.3%, respectively), which was without further consequences, and pulmonary embolization or death did not occur.

WHAT IS KNOWN ALREADY

An HSG with oil-based contrast increases pregnancy rates in women with unexplained infertility. However, there have been some concerns regarding complications, including the risks of intravasation of the contrast medium, oil embolism and infection. Here, we present the incidence of complications after HSG with different types of contrast media used in the Netherlands in the year 2017.

STUDY DESIGN SIZE DURATION

In January 2018, an electronic survey was sent to all 73 clinics in the Netherlands that perform HSG. The survey consisted of 12 questions addressing the number of HSGs performed in 2017, the amount and type of contrast medium used, the occurrence of post-procedural complications and what their clinical consequences were. Non-responding clinics were sent multiple reminders.

PARTICIPANTS/MATERIALS SETTING METHODS

We calculated the incidence of the complications and reported on their clinical consequences. Furthermore, we examined the average amount of contrast used as well as the administration of prophylactic antibiotics.

MAIN RESULTS AND THE ROLE OF CHANCE

The response rate was 96% (67/70) (during the study, one site closed and was not included while two clinics no longer performed HSGs). In the 67 clinics, 3289 HSGs with oil-based contrast and 1876 HSGs with water-based contrast were performed in 2017. The median amount of contrast used was 8.0 ml (interquartile range (IQR) 7.0-10.0) for oil-based contrast and 10.0 ml for water-based contrast (IQR 10.0-10.0). Antibiotic prophylaxis was administered in 61% (41/67) of the clinics. Intravasation occurred in 4.8% of the HSGs performed with oil-based contrast and in 1.3% of the HSGs with water-based contrast (relative risk (RR), 3.6; CI, 2.4-5.4). Pulmonary embolism or death was not reported. Pelvic inflammatory disease (PID) occurred in 0.3% of the HSGs performed with oil-based contrast versus 0.4% with water-based contrast. PID occurred in 0.3% of the HSGs in clinics using antibiotic prophylaxis and 0.2% in clinics not using antibiotic prophylaxis. Allergic reactions were reported in one HSG performed with oil-based contrast (0.03%) compared with two HSGs performed with water-based contrast (0.1%). Anaphylactic reactions did not occur. The overall complication rate was 5.1% in the clinics that used oil-based contrast versus 1.8% in the clinics that used water-based contrast (RR, 2.8; CI, 1.9-4.0; P-value, <0.0001).

LIMITATIONS REASONS FOR CAUTION

Half of the clinics did not routinely register complications, and the incidence of the complications in their clinic was based on the recall of the clinician. Estimated complication rates in the clinics with and without systematic registration did not significantly differ. The survey asked about the frequency of intravasation but no classification system is being used in daily practice, which may create differences in reporting. There was no standard screening of post-HSG thyroid function for the mother and the foetus.

WIDER IMPLICATIONS OF THE FINDINGS

In this nationwide cohort study, the complication rates after HSG were low. Intravasation occurred more frequently with the use of oil-based contrast compared with water-based contrast but did not lead to any problems or symptoms in any of the women. We therefore conclude that safety concerns should not be a reason to deny the use of oil-based contrast in women with unexplained infertility. The data also support that fluoroscopy appears to be an essential safety measure during HSG.

STUDY FUNDING/COMPETING INTERESTS

This work was partly funded by Guerbet, France. I.R. reports receiving travel fee for presenting at the Congress of the American Society for Reproductive Medicine 2019 from Guerbet. V.M. reports receiving travel and speaker's fee as well as research grants from Guerbet. K.D. reports receiving travel and speaker's fee from Guerbet. B.W.M. is supported by an National Health and Medical Research Council (NHMRC) Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for ObsEva, Merck KGaA and Guerbet and travel and research grants from Merck KGaA and Guerbet. The other authors do not report conflicts of interest.

TRIAL REGISTRATION NUMBER

N19.056.

Epilepsy is associated with higher subsequent mortality risk in patients after stroke: a population-based cohort study in Taiwan

Objective: To use the National Health Insurance Research Database (NHIRD) of Taiwan to determine whether patients with poststroke epilepsy (PSE) in Taiwan have an increased risk of mortality.

Methods: We analyzed the data from the NHIRD of patients (≥40 years) who had received stroke diagnoses between 2000 and 2012. The patients with stroke were divided into PSE and poststroke non-epilepsy (PSN) cohorts and compared against a sex-, age-, comorbidity-, and index-date-matched cohort from normal population. We calculated adjusted HRs (aHRs) and 95% CIs of all-cause mortality risk in these cohorts after adjustment for age, sex, and comorbidities.

Results: Among the poststroke patients, 12.14% constituted the PSE cohort. The cumulative mortality rate was considerably higher in the PSE than in the PSN cohort. The PSE (aHR=4.18, 95% CI=3.91–4.48) and PSN (aHR=1.90, 95% CI=1.83–1.98) cohorts were associated with higher risks of mortality than the comparison cohort. Furthermore, advanced age (≥65 years), male sex, alcohol-related illness, chronic obstructive pulmonary disease, coronary artery disease, diabetes, hypertension, asthma, and cancer would further increase the risk of mortality after a stroke event.

Conclusion: The mortality risk in poststroke patients is approximately two times the likelihood in those with PSE than in those without, and approximately four times higher than that in the normal population. Our findings provide crucial information for clinicians and the government to improve survival after stroke.