Chlamydial and Gonococcal Infections and Adverse Reproductive Health Conditions Among Patients Assigned Female at Birth in the Veterans Health Administration.

BACKGROUND: Reproductive age female individuals comprise the fastest-growing segment of Veterans Health Administration patients, but little is known about rates of reproductive health outcomes among those with chlamydia or gonorrhea infections. Our aim was to estimate the risk of pelvic inflammatory disease, ectopic pregnancy, infertility, and pelvic pain in female veterans tested for chlamydia or gonorrhea. METHODS: We performed a retrospective cohort analysis of female veterans tested for chlamydia or gonorrhea between January 1, 2010, and December 31, 2020. We calculated rates of pelvic inflammatory disease, ectopic pregnancy, infertility, and pelvic pain per 100,000 person-years and used Cox proportional hazards regression models to estimate the risk of these reproductive health conditions according to infection status after adjustment for age, race, ethnicity, military sexual trauma, mental health diagnoses, and substance use disorder. RESULTS: Of female veterans, 232,614 were tested at least once for chlamydia or gonorrhea, with a total of 1,665,786 person-years of follow-up. Of these, 12,971 had positive chlamydia or gonorrhea results (5.8%, 796 cases per 100,000 person-years). Compared with people who tested negative, those testing positive had double the risk of pelvic inflammatory disease (adjusted hazard ratio [aHR], 1.94; 95% confidence interval [CI], 1.81-2.07), 11% increased risk of infertility (aHR, 1.11; 95% CI, 1.04-1.18), 12% increased risk of pelvic pain (aHR, 1.12; 95% CI, 1.08-1.17), and 21% increased risk of any of these conditions (aHR, 1.21; 95% CI, 1.17-1.25). People with positive chlamydia or gonorrhea testing tended to have an increased risk of ectopic pregnancy (aHR, 1.14; 95% CI, 1.0-1.30). Among those with a positive test result, 2218 people (17.1%) had 1 or more additional positive test results. Compared with those with 1 positive test result, people with more than 1 positive test result had a significantly increased risk of pelvic inflammatory disease (aHR, 1.37; 95% CI, 1.18-1.58), infertility (aHR, 1.20; 95% CI, 1.04-1.39), and pelvic pain (aHR1.16; 95% CI, 1.05-1.28), but not ectopic pregnancy (aHR, 1.09; 95% CI, 0.80-1.47). CONCLUSIONS: Female veterans with positive chlamydia or gonorrhea results experience a significantly higher risk of pelvic inflammatory disease, infertility, and pelvic pain, especially among those with repeat infection.

Association Between Pelvic Inflammatory Disease and Risk of Endometriosis: A Systematic Review and Meta-Analysis.

Background: Endometriosis is a common chronic disorder, which leads to dysmenorrhea, dyspareunia, pelvic chronic pain, and infertility. It affects ∼6% to 10% of the general female population. However, the etiology of endometriosis remained unclear. We aimed to systematically assess the association between pelvic inflammatory disease (PID) and the risk of endometriosis. Materials and Methods: Eligible studies published until May 21, 2022, were retrieved from the PubMed, EMBASE, and Web of Science databases. The studies were included based on the following criteria: (1) original articles on the association between PID and risk of endometriosis; (2) randomized controlled trials and cross-sectional, case-control, and cohort studies; and (3) studies involving humans. The Newcastle-Ottawa Quality Assessment Scale was used to assess the quality of the studies included in this systematic review. The association between PID and risk of endometriosis was evaluated using the overall odds ratio (OR) and correlative 95% confidence interval (CI). Results: The meta-analysis included 14 studies with 747,733 patients. The mean prevalence of PID in women with endometriosis was 33.80%. Our quantitative synthesis revealed that endometritis was associated with a significantly increased risk of endometriosis (OR: 1.63, 95% CI: 1.53-1.74, I2 = 59%). Conclusion: We study a statistically significant association between PID and the risk of endometriosis. In particular, endometritis might play an important role in endometriosis, based on the lower heterogeneity of the subgroup analysis. This finding suggests that reducing the incidence of endometritis might aid in the prevention and treatment of endometriosis.

Pelvic inflammatory disease and risk of epithelial ovarian cancer: a national population-based case-control study in Sweden.

BACKGROUND: Epithelial ovarian cancer is an insidious disease, and women are often diagnosed when the disease is beyond curative treatment. Accordingly, identifying modifiable risk factors is of paramount importance. Inflammation predisposes an individual to cancer in various organs, but whether pelvic inflammatory disease is associated with an increased risk of epithelial ovarian cancer has not been fully determined. OBJECTIVE: This study aimed to investigate a possible association between clinically verified pelvic inflammatory disease and the risk of epithelial ovarian cancer. STUDY DESIGN: In this national population-based case-control study, all women in Sweden diagnosed with epithelial ovarian cancer between 1999 and 2020 and 10 controls for each were identified, matched for age and residential district. Using several Swedish nationwide registers, data on previous pelvic inflammatory disease and potential confounding factors (age, parity, educational level, and previous gynecologic surgery) were retrieved. Adjusted odds ratios and 95% confidence intervals were estimated using conditional logistic regression. Histotype-specific analyses were performed for the subgroup of women diagnosed with epithelial ovarian cancer between 2015 and 2020. Moreover, hormonal contraceptives and menopausal hormone therapy were adjusted in addition to the aforementioned confounders. RESULTS: This study included 15,072 women with epithelial ovarian cancer and 141,322 controls. Most women (9102 [60.4%]) had serous carcinoma. In a subgroup of cases diagnosed between 2015 and 2020, high-grade serous carcinoma (2319 [60.0%]) was identified. A total of 168 cases (1.1%) and 1270 controls (0.9%) were diagnosed with pelvic inflammatory disease. Previous pelvic inflammatory disease was associated with an increased risk of epithelial ovarian cancer (adjusted odds ratio, 1.39; 95% confidence interval, 1.17-1.66) and serous carcinoma (adjusted odds ratio, 1.46; 95% confidence interval, 1.18-1.80) for the entire study population. For the subgroup of women diagnosed in 2015-2020, pelvic inflammatory disease was associated with high-grade serous carcinoma (adjusted odds ratio, 1.43; 95% confidence interval, 1.01-2.04). The odds ratios of the other histotypes were as follows: endometrioid (adjusted odds ratio, 0.13; 95% confidence interval, 0.02-1.06), mucinous (adjusted odds ratio, 1.55; 95% confidence interval, 0.56-4.29), and clear cell carcinoma (adjusted odds ratio, 2.30; 95% confidence interval, 0.90-5.86). A dose-response relationship was observed between the number of pelvic inflammatory disease episodes and the risk of epithelial ovarian cancer (Ptrend<.001). CONCLUSION: A history of pelvic inflammatory disease is associated with an increased risk of epithelial ovarian cancer and a dose-response relationship is evident. Histotype-specific analyses show an association with increased risk of serous epithelial ovarian cancer and high-grade serous carcinoma and potentially also with clear cell carcinoma, but there is no significant association with other histotypes. Infection and inflammation of the upper reproductive tract might have serious long-term consequences, including epithelial ovarian cancer.

Global burden of pelvic inflammatory disease and ectopic pregnancy from 1990 to 2019.

BACKGROUND: Pelvic inflammatory disease (PID) is a widespread female public problem worldwide. And it could lead to infertility, preterm labor, chronic pelvic pain, and ectopic pregnancy (EP) among reproductive-aged women. This study aimed to assess the global burden and trends as well as the chaning correlation between PID and EP in reproductive-aged women from 1990 to 2019. METHODS: The data of PID and EP among reproductive-aged women (15 to 49 years old) were extracted from the Global Burden of Disease study 2019. The disease burden was assessed by calculating the case numbers and age-standardized rates (ASR). The changing trends and correlation were evaluated by calculating the estimated annual percentage changes (EAPC) and Pearson's correlation coefficient. RESULTS: In 2019, the ASR of PID prevalence was 53.19 per 100,000 population with a decreasing trend from 1990 (EAPC: - 0.50), while the ASR of EP incidence was 342.44 per 100,000 population with a decreasing trend from 1990 (EAPC: - 1.15). Globally, PID and EP burdens changed with a strong positive correlation (Cor = 0.89) globally from 1990 to 2019. In 2019, Western Sub-Saharan Africa, Australasia, and Central Sub-Saharan Africa had the highest ASR of PID prevalence, and Oceania, Eastern Europe, and Southern Latin America had the highest ASR of EP incidence. Only Western Europe saw significant increasing PID trends, while Eastern Europe and Western Europe saw increasing EP trends. The highest correlations between PID and EP burden were observed in Burkina Faso, Laos, and Bhutan. General negative correlations between the socio-demographic index and the ASR of PID prevalence and the ASR of EP incidence were observed at the national levels. CONCLUSION: PID and EP continue to be public health burdens with a strong correlation despite slightly decreasing trends detected in ASRs globally. Effective interventions and strategies should be established according to the local situation by policymakers.

Gynecologists and pelvic inflammatory disease: do we actually know what to do?: A cross-sectional study in Jordan.

Pelvic inflammatory disease (PID) is an upper genital tract infection caused by a variety of aerobic and anaerobic microorganisms ascending from the cervix or vagina. Though PID is mainly a sexually transmitted disease; 15% are non-sexually transmitted.[1] In our study, we aim to assess gynecologists' understanding and awareness of PID; as it presents an important health issue affecting the Jordanian community and similar communities with the same cultural and religious backgrounds. A cross-sectional study was conducted using an online questionnaire that received responses from 172 gynecologists in Jordan. The questionnaire aimed at testing gynecologists' knowledge of different aspects of PID starting with diagnosis and ending with management. 68.6% of gynecologists acknowledged that PID is a problem in Jordan. However, obvious confusion was observed in the scopes of clinical presentation, choosing the most reliable PID investigations, and treatment. PID is not being addressed properly in a sexually conservative community that has low rates of sexually transmitted diseases like Jordan, which is misleading and dangerous. In addition, we think there is a lack of certain standards on how to define PID and acknowledge its effect on the community as well as the disappointing level of knowledge about different aspects of PID gynecologists show, starting with its prevalence and ending with treatment policy. Clearer guidelines for the diagnosis, management, and prevention of PID should be adopted. These findings should be acknowledged by all doctors from neighboring countries as well as those within similar communities to Jordan.

Association of Neighborhood Economic Status and Race With Developing Pelvic Inflammatory Disease After Sexually Transmitted Infections.

OBJECTIVE: To explore the association of neighborhood-level socioeconomic status (SES) and race with developing pelvic inflammatory disease (PID) after sexually transmitted infection (STI) among female adolescents and young adults in Maryland. METHODS: We used Maryland statewide hospital claims data (outpatient and inpatient visits) for this retrospective cohort study. Female adolescents and young adults aged 15-24 years who had at least one STI from July 1, 2013, to March 31, 2015, were included. A participant entered the cohort on the date of the first STI diagnosis and was followed up until PID occurrence or 3 years after the first STI. Median household income of the participant's residential ZIP code tabulation area was used as the neighborhood-level SES. Discrete-time hazard models were used to estimate the hazard of PID. RESULTS: Of the 2,873 participants, 88.5% were of Black race, and 67.2% were aged 20-24 years. The hazard of PID after an STI among Black women was 1.40 times that of White women (95% CI 1.06-1.85). After adjustment for age, insurance type, and number of STI events, the hazard ratio (HR) did not change. However, adding neighborhood-level SES to the model attenuated the disparity in PID after STI between Black and White women (HR 1.25, 95% CI 0.94-1.67). CONCLUSION: Racial disparities in PID diagnosis are mitigated by neighborhood-level SES.

Prevalence and Factors Associated With Mycoplasma genitalium Infection in At-Risk Female Adolescents in Bronx County, New York.

BACKGROUND: Mycoplasma genitalium infection can adversely affect female reproductive health, but data are limited about prevalence and characteristics of the infection in female adolescents. We employed a sensitive assay to detect M. genitalium infection, and we describe its characteristics in a clinical sample of women younger than 21 years. METHODS: We recruited females aged 13 to 20 years in children's hospital clinics whose clinicians were testing for chlamydia/gonorrhea. Participants completed a questionnaire providing demographics, sexual history, and current symptoms. Urine/endocervical samples were tested for chlamydia/gonorrhea and partitioned for M. genitalium testing using Aptima M. genitalium assay. We reviewed records for the clinic visit to document examination, diagnosis, and results of sexually transmitted infection (STI) testing. We compared prevalence of M. genitalium infection by demographics, sexual history, symptoms, and signs. RESULTS: Of 153 participants mean age 18.07 ± 1.68 years, 58% self-identified as Hispanic, 27% Black, 64% straight/heterosexual, 27% bisexual, 1% gay/lesbian, 29% reported a prior STI diagnosis. Prevalence of M. genitalium was 11.1% (17/153), 13 of 17 were asymptomatic, 2 of 17 had pelvic inflammatory disease (PID), 3 of 17 coinfected with chlamydia or gonorrhea. Prevalence of chlamydia was 6.6% and of gonorrhea 2.6%. A logistic regression model indicated independent associations of bisexual orientation versus all other orientations (adjusted odds ratio [aOR], 4.80; 95% confidence interval [CI], 1.38-16.67), self-reported prior STI (aOR, 3.83; 95% CI, 1.10-13.37), and self-reported prior PID (aOR, 9.12; 95% CI, 1.02-81.72) with higher odds of M. genitalium infection. CONCLUSIONS: Findings suggest that in at-risk female populations younger than 21 years, M. genitalium is a prevalent STI and symptomatic adolescents may warrant testing and treatment. Further study of harms and benefits of testing asymptomatic bisexual female adolescents or those with prior STI/PID is needed.

Update on the Epidemiology, Screening, and Management of Chlamydia trachomatis Infection.

Chlamydia trachomatis infection ("chlamydia") is the most commonly diagnosed bacterial sexually transmitted infection globally, occurring in the genitals (urethra or vagina/cervix), rectum, or pharynx. If left untreated in women, genital chlamydia can ascend into the upper genital tract causing pelvic inflammatory disease, increasing their risk for ectopic pregnancy, infertility, and chronic pelvic pain. In men, chlamydia can cause epididymitis and proctitis. However, chlamydia is asymptomatic in over 80% of cases. This article provides an update on the epidemiology, natural history, and clinical manifestations of chlamydia in adults and discusses the current approaches to its management and control policy.

Genital tract infection and pelvic surgery contribute to the development of endometriosis.

Endometriosis is a multifactorial disease, and inflammation is considered a core pathology. Inflammation related to genital tract infection (GTI) and surgical injury may cause endometriosis. Therefore, we investigated the incidence of endometriosis in women with a recent history of GTI, pelvic surgery, or both. Using the Korean National Health Insurance Service-National Sample Cohort, 20- to 49-year-old women diagnosed with GTI or who underwent pelvic surgeries between 2002 and 2008 were collected and followed up for five years. After excluding women who had already been diagnosed with endometriosis or diseases that may affect endometriosis, a total of 30,336 women were diagnosed with GTI (Study 1), 2894 women who underwent pelvic surgery (Study 2), and 788 women who underwent GTI and pelvic surgery, both (Study 3) were enrolled for each study. The comparison groups in which sociodemographic factors matched for each group were collected. The incidence of endometriosis per 1000 person-year was 5.37, 5.17, and 20.81 in each case group and was significantly higher than each comparison group. A recent history of GTI increased an adjusted hazard ratio (aHR) of 2.29 (1.99-2.63, 95% confidence interval) for the development of endometriosis. The aHRs of pelvic surgery history and the history of both GTI and pelvic surgery were 2.10 and 7.82, respectively. In conclusion, the pelvic inflammation resulting from genital infection and pelvic surgical injury may play a role in developing endometriosis. Active treatment of genital infections and careful surgical procedures to minimize tissue injury may reduce the incidence of pelvic endometriosis.

Pelvic inflammatory disease hospitalizations in Brazil: time trend from 2000 to 2019 / Internações por doença inflamatória pélvica no Brasil: tendência temporal de 2000 a 2019

Abstract Objectives: to evaluate the temporal trend of hospitalizations for pelvic infammatory disease in Brazil and its regions between 2000 and 2019. Methods: longitudinal ecological study with data from the Hospital Information System. The analysis of temporal trends in hospitalization rates by age group was performed using segmented linear regression (joinpoint regression). Both annual percent change total and by age groups were estimated for Brazil and each region. Results: Brazil had an average reduction of 5.2% per year in the period and the age groups most affected were 20 to 29 and 30 to 39 years. North region had the highest rates and South and Southeast regions, the lowest. Midwest region had the largest annual average reduction (8.1%), followed by the Northeast (5.7%), Southeast (5.0%), North (4.6%) and South (4.3 %). The only age group that showed a significant increase was that of 10 to 19 years in the Southeast in the period from 2008 to 2019 (0.9%) and in the Northeast in the period from 2014 to 2019 (3.3%). Conclusions: hospitalization due to pelvic infammatory disease has significantly decreased in Brazil. The increase observed for adolescents in the Southeast and Northeast in the most recent period points to problems in the prevention and control of sexually transmitted infections in this age group.

Resumo Objetivos: avaliar a tendência temporal de internações por doença infamatória pélvica no Brasil e regiões entre 2000 e 2019. Métodos: estudo ecológico longitudinal com dados do Sistema de Informações Hospitalares. A análise das tendências temporais das taxas de internação hospitalar por faixas etárias foi feita por regressão linear segmentada (joinpoint regression). Foram estimadas variações percentuais anuais gerais e por faixas etárias para o Brasil e cada região. Resultados: o Brasil teve uma redução média de 5,2% ao ano no período e as faixas etárias mais afetadas foram 20 a 29 e 30 a 39 anos. A região Norte apresentou as maiores taxas e as regiões Sul e Sudeste as menores. A região Centro-Oeste teve a maior redução média anual (8,1%), seguida das regiões Nordeste (5,7%), Sudeste (5,0%), Norte (4,6%) e Sul (4,3%). A única faixa etária que apresentou um aumento significativo foi a de 10 a 19 anos nas regiões Sudeste no período de 2008 a 2019 (0,9%) e no Nordeste no período de 2014 a 2019 (3,3%). Conclusões: a internação hospitalar por doença infamatória pélvica reduziu no Brasil de forma importante. O aumento verificado para adolescentes no Sudeste e Nordeste no período mais recente aponta para problemas na prevenção e controle das infecções sexualmente transmissíveis nesta faixa etária.

Performance of a rapid molecular test to detect Chlamydia trachomatis and Neisseria gonorrhoeae in women with pelvic inflammatory disease / Realización de una prueba molecular rápida para detectar Chlamydia trachomatis y Neisseria gonorrhoeae en mujeres con enfermedad inflamatoria pélvica

Objective: The aim of this study was to investigate the prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) in women with pelvic inflammatory disease (PID) and the usefulness and cost-effectiveness of a rapid molecular test for the diagnosis and clinical management of PID. Methods: This observational study included 75 patients with mild-to-moderate PID (n=33), severe PID (n=29) and non-specific lower abdominal pain (NSAP) (n=13). CT/NG infections were analyzed using a standard and a rapid test. A cost analysis was carried out. Results: Samples of 19 patients (25.3%) were CT/NG positive. Concordance between rapid and standard tests was 100%. No significant differences were observed in the incidence of CT/NG in mild-to-moderate compared to severe PID. Costs differed according only to disease severity. Conclusions: Rapid molecular tests could help with the diagnosis of PID in sexually active women in clinical settings in which a standard technique is not available.(AU)

Objetivo: El objetivo de este estudio fue investigar la prevalencia de Chlamydia trachomatis (CT) y Neisseria gonorrhoeae (NG) en mujeres con enfermedad inflamatoria pélvica (EIP) y la utilidad y costo-efectividad de una prueba molecular rápida para el diagnóstico y manejo clínico de la EIP. Métodos: Este estudio observacional incluyó a 75 pacientes con EIP leve a moderada (n=33), EIP grave (n=29) y dolor abdominal bajo inespecífico (n=13). Las infecciones por CT/NG se detectaron mediante una prueba estándar y una prueba rápida. Se realizó un análisis de costes. Resultados: Las muestras de 19 pacientes (25,3%) fueron positivas para CT/NG. La concordancia entre las pruebas rápida y estándar fue del 100%. No se observaron diferencias significativas en la incidencia de CT/NG en la EIP leve a moderada en comparación con la grave. Los costes difirieron solo según la gravedad de la enfermedad. Conclusiones: Las pruebas moleculares rápidas podrían ayudar en el diagnóstico de la EIP en mujeres sexualmente activas en entornos clínicos en los que no se dispone de una técnica estándar.(AU)

Performance of a rapid molecular test to detect Chlamydia trachomatis and Neisseria gonorrhoeae in women with pelvic inflammatory disease.

OBJECTIVE: The aim of this study was to investigate the prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) in women with pelvic inflammatory disease (PID) and the usefulness and cost-effectiveness of a rapid molecular test for the diagnosis and clinical management of PID. METHODS: This observational study included 75 patients with mild-to-moderate PID (n=33), severe PID (n=29) and non-specific lower abdominal pain (NSAP) (n=13). CT/NG infections were analyzed using a standard and a rapid test. A cost analysis was carried out. RESULTS: Samples of 19 patients (25.3%) were CT/NG positive. Concordance between rapid and standard tests was 100%. No significant differences were observed in the incidence of CT/NG in mild-to-moderate compared to severe PID. Costs differed according only to disease severity. CONCLUSIONS: Rapid molecular tests could help with the diagnosis of PID in sexually active women in clinical settings in which a standard technique is not available.

Chlamydia infection, PID, and infertility: further evidence from a case-control study in China.

BACKGROUND: Chlamydia trachomatis infection and pelvic inflammatory disease (PID) are well-known risk factors for female infertility. But there is limited evidence from China. This study aimed to further explore the associations between previous/current chlamydial infection, PID, and infertility in China. METHODS: We performed a 1:2 matched case-control study with two control groups: pregnant controls and non-pregnant controls in China in 2019. Women diagnosed with infertility were selected as cases (n = 255). Controls were selected based on the following criteria: Pregnant women who were documented in the selected hospitals were chosen as Pregnant controls (n = 510), and people who sought health care in Obstetric/Gynecologic clinics, Family Planning clinics, Dermatology and STD Department or Urological department were selected as Non-pregnant controls (n = 510). Infertility induced by male factors and people who used antibiotics in the vagina within two weeks were excluded. The first-stream specimen of urine samples was tested for chlamydia by nucleic acid amplification testing (NAAT). Conditional logistic regression was used to estimate the association. RESULTS: The prevalence of previous chlamydial infection and PID were significantly higher in cases (2.4%, 17.3%) than in controls (Non-pregnancy: 0.4%, 3.0%; Pregnancy: 0.4%, 9.0%). The current chlamydial infection rates were 5.9%, 7.3%, and 7.1% in infertile, pregnant, and non-pregnant women, respectively. After adjusting for confounders, PID largely elevated the risk of infertility (using non-pregnant controls: adjusted OR = 2.57, 95% CI 1.51, 4.39; using pregnant controls: adjusted OR = 6.83, 95% CI 3.47, 13.43). And the positive association between PID and tubal infertility was more obvious for both groups. For current chlamydial infection, none of the odds ratios were significant at the 0.05 level, while small sample size limited the evaluation of an association between prior chlamydial infection with infertility. CONCLUSIONS: Previous PID was indicated to largely increase the risk of infertility, especially tubal infertility. And there should be continuing emphasis on highly sensitive and specific biomarker for prior chlamydial infection.

Factors associated with pelvic inflammatory disease: A case series analysis of family planning clinic data.

BACKGROUND: We aimed to better understand factors associated with pelvic inflammatory disease in an outpatient setting. METHODS: We analysed the characteristics of pelvic inflammatory disease cases diagnosed in an outpatient setting during 2018. There were 72 cases included in the final analysis. RESULTS: Of the pelvic inflammatory disease cases analysed, 55% were idiopathic, 22.2% were related to a sexually transmitted infection, and 22.2% had onset of symptoms within 6 weeks of a gynaecological procedure. Of the sexually transmitted infection-positive pelvic inflammatory disease cases, Chlamydia trachomatis was present in 56%, Mycoplasma genitalium was present in 38%, and Neisseria gonorrhoeae was present in 12.5% of cases. Many pelvic inflammatory disease cases had evidence of vaginal dysbiosis or features associated with vaginal flora disruption (recent antibiotic usage and/or vulvovaginal candidiasis). CONCLUSION: This case series highlights the burden of Mycoplasma genitalium pelvic inflammatory disease, and clinicians should be aware to include testing for this when diagnosing pelvic inflammatory disease. Our findings also support the hypothesis that host dysbiotic microbiota may contribute to pelvic inflammatory disease pathogenesis, with further research required to explore this proposition.

Pelvic inflammatory disease in pregnancy: a systematic review focusing on perinatal outcomes.

BACKGROUND: Pelvic inflammatory disease during pregnancy is a rare and an understudied occurrence with potential negative outcomes. OBJECTIVE: This study aimed to evaluate the outcomes of pregnant women with pelvic inflammatory disease with or without pelvic abscesses. DATA SOURCES: We performed a systematic review of the literature using Ovid MEDLINE, Scopus, CINAHL, and PubMed (including Cochrane) with no time limitations. STUDY ELIGIBILITY CRITERIA: Relevant studies on pelvic inflammatory disease during pregnancy were identified and considered eligible if they described at least 1 case of pelvic inflammatory disease after conception, defined as infection in one or more of the following: uterus, fallopian tubes, and ovaries; based on clinical findings, physical examination, and imaging with or without pelvic abscesses present. Only studies on pelvic inflammatory disease with or without tubo-ovarian abscesses during pregnancy that evaluated perinatal outcomes were included. Data on the risk factors, delivery methods, and maternal, fetal, and neonatal outcomes were collected. METHODS: Reviewers screened all relevant titles using the inclusion/exclusion criteria and selected relevant articles for appraisal. A total of 49 cases with reported pelvic inflammatory disease, pelvic abscesses, or both were included. RESULTS: After exclusion of articles that did not meet the inclusion criteria, 34 manuscripts describing the occurrence of pelvic inflammatory disease in 49 pregnancies were analyzed, focusing primarily on cases reported after 1971. The mean age of patients was 25±6.3 years, the mean gestational age at diagnosis was 19.0±10.3 weeks, and 67.6% of patients were multiparous. Of all included patients, 27 (62.8%) underwent exploratory laparotomies, 14 (32.6%) underwent unilateral salpingo-oophorectomies, and 11 (25.6%) underwent appendectomies. Of all the deliveries, 13 (50%) pregnancies were full term, 14 (53.8%) were cesarean deliveries, 10 (38.5%) were spontaneous vaginal deliveries, and 2 (7.7%) were cesarean hysterectomies. There were 26 (60.5%) cases of viable births (mean gestational age at delivery, 33.8±5.1 weeks) and 17 (39.5%) cases of nonviable births. Sepsis was a complication in 3 (7.0%) cases and caused 3 neonatal deaths. CONCLUSION: Although rare, pelvic inflammatory disease can have severe health consequences. Risk factors for pelvic inflammatory disease development include maternal pelvic structural anomalies, a history of sexually transmitted infections, recent pelvic surgery, and in vitro fertilization or oocyte retrieval. Pelvic inflammatory disease can coincide with pregnancy and can occur in the second trimester. Making a prompt diagnosis can help to improve the outcomes; therefore, if a high enough suspicion exists, treatment should not be delayed.

Vaginal microbiota in ethnically diverse young women who did or did not develop pelvic inflammatory disease: community-based prospective study.

OBJECTIVES: A lactobacilli-dominated vaginal microbiome may protect against pelvic inflammatory disease (PID), but one dominated by Gardnerella species might increase susceptibility. Not all lactobacilli are equally protective. Recent research suggests that D(-) isomer lactic acid producing lactobacilli (Lactobacillus crispatus, Lactobacillus jensenii and Lactobacillus gasseri) may protect against infection with Chlamydia trachomatis, an important cause of PID. Lactobacillus iners , which produces L(+) isomer lactic acid, may be less protective. We investigated the microbiome in stored vaginal samples from participants who did or did not develop PID during the prevention of pelvic infection (POPI) chlamydia screening trial. METHODS: Long-read 16S rRNA gene nanopore sequencing was used on baseline vaginal samples (one per participant) from all 37 women who subsequently developed clinically diagnosed PID during 12-month follow-up, and 111 frequency matched controls who did not, matched on four possible risk factors for PID: age <20 versus ≥20, black ethnicity versus other ethnicity, chlamydia positive versus negative at baseline and ≥2 sexual partners in the previous year versus 0-1 partners. RESULTS: Samples from 106 women (median age 19 years, 40% black ethnicity, 22% chlamydia positive, 54% reporting multiple partners) were suitable for analysis. Three main taxonomic clusters were identified dominated by L. iners, L. crispatus and Gardnerella vaginalis. There was no association between a more diverse, G. vaginalis dominated microbiome and subsequent PID, although increased Shannon diversity was associated with black ethnicity (p=0.002) and bacterial vaginosis (diagnosed by Gram stain p<0.0001). Women who developed PID had similar relative abundance of protective D(-) isomer lactic acid producing lactobacilli to women without PID, but numbers of PID cases were small. CONCLUSIONS: In the first-ever community-based prospective study of PID, there was no clear association between the vaginal microbiome and subsequent development of PID. Future studies using serial samples may identify vaginal microbial communities that may predispose to PID.

Hospitalisations for pelvic inflammatory disease in young Aboriginal women living in remote Australia: the role of chlamydia and gonorrhoea.

OBJECTIVE: Aboriginal women living in remote Australia experience a high burden of both chlamydia and gonorrhoea infections and disproportionately high rates of pelvic inflammatory disease (PID). We estimated for the first time the fraction of PID attributable to these infections in young Aboriginal women living in these settings. METHODS: Using published data from two large Australian studies (2002-2013; 2010-2014), we calculated the fraction of emergency department presentations and hospitalisations for PID attributable to chlamydia and/or gonorrhoea infection in Aboriginal women aged 16-29 years living in remote Australia. We used a Monte Carlo simulation to estimate the mean and 95% CIs for the assumed prevalence and population attributable fractions for PID for infection stratifications (chlamydia only, gonorrhoea only and dual infection) as well as for any infection (chlamydia and/or gonorrhoea). Additional outputs were calculated for chlamydia infection with/without gonorrhoea coinfection, and vice versa. RESULTS: The prevalence of chlamydia only was 12.9% (95% CI: 11.6% to 14.2%), gonorrhoea only was 7.8% (95% CI: 6.6% to 8.9%) and dual infection was 6.5% (95% CI: 5.8% to 7.2%); rate ratios of PID were 1.9 (95% CI: 1.5 to 2.3), 5.2 (95% CI: 4.3 to 6.4) and 4.6 (95% CI: 3.8 to 5.5), respectively. The overall fraction of PID attributable to chlamydia and/or gonorrhoea was 40.2% (95% CI: 36.0% to 44.4%); any gonorrhoea was 33.4% (95% CI: 29.2% to 37.8%) and any chlamydia was 20.6% (95% CI: 16.9% to 24.6%). CONCLUSION: Our study demonstrates the importance of calculating the fraction of PID related to chlamydia and gonorrhoea in the local context, demonstrating the major contribution gonorrhoea makes to PID hospitalisations among Australian Aboriginal women living in remote settings. To significantly and sustainably reduce the unacceptable rate of PID in this population, strategies are urgently needed to improve timely testing and treatment and recognition and management of PID in primary care.

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).

Pelvic Inflammatory Disease Trends Among Emergency Department Visits in North Carolina, 2008 to 2017.

BACKGROUND: Pelvic inflammatory disease (PID) is an infection of the upper female reproductive organs that can lead to infertility and ectopic pregnancies. It is a reportable condition in North Carolina (NC) but is likely underreported. We aimed to quantify PID diagnoses in NC emergency department (ED) visits. METHODS: The NC Disease Event Tracking and Epidemiology Collection Tool tracks all ED visits in NC. We identified PID diagnoses among women of reproductive age (15-44 years) between 2008 and 2017 using International Classification of Diseases, Ninth/Tenth Revision, Clinical Modification codes, and calculated the yearly proportion with PID diagnoses. We assessed the number of PID visits per patient each year, and the proportion of ED visits with a PID diagnosis by age, proportion of the patient's ZIP code living below the poverty line, insurance coverage, and NC provider region. RESULTS: The percent of women with PID decreased from 6189 (1.0%) in 2008 to 4337 (0.58%) in 2016 before increasing slightly to 4371 (0.61%) in 2017. We identified 54,502 (0.45%) ED visits among 51,847 (0.76%) women with ≥1 PID diagnosis code. Most (95.5%) women with PID had one ED visit during the calendar year. Each year, the proportion with PID was highest among women aged 20 to 24 years, covered under public insurance, from the most impoverished areas, and whose provider was in the Coastal region of NC. CONCLUSIONS: The percent with PID among women visiting EDs decreased between 2008 and 2017 in NC. Although this decline was observed across all demographics, disparities associated with PID continued to persist over time.

Pelvic inflammatory disease is associated with ovarian cancer development in women with endometriosis: A cohort study in Taiwan.

OBJECTIVE: Endometriosis and pelvic inflammatory disease are considered to be risk factors for ovarian cancer, as dysbiosis probably contributes to ovarian cancer development via chronic inflammation and immune response alteration. Therefore, we hypothesized that pelvic inflammatory disease predisposes to ovarian cancer development in women with endometriosis. METHODS: We selected patients who were diagnosed with endometriosis or pelvic inflammatory disease between January 1, 2000 and December 31, 2015, in a 2 million longitudinal health and welfare database in Taiwan with cancer and death registries. Patients were divided into five groups: (1) those with endometriosis, (2) those with pelvic inflammatory disease, (3) those with endometriosis diagnosed before pelvic inflammatory disease, (4) those with pelvic inflammatory disease diagnosed before endometriosis, and (5) healthy women. Propensity score matching with inverse probability of treatment weighting was used to adjust for covariates across the study groups. RESULTS: The risk of ovarian cancer was significantly higher in women with endometriosis and subsequent pelvic inflammatory disease than in those with endometriosis alone (hazard ratio 8.07; 95% confidence interval 4.53-14.37; P < 0.001). The same result was found for ovarian cancer incidence per 1000 person-years. CONCLUSION: Our data show that pelvic inflammatory disease is associated with cancer development in women with pre-existing endometriosis.