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Directed to the health care professional, this review covers the current concepts of pelvic inflammatory disease (PID) affecting adolescent and young adult women. It defines PID and discusses the magnitude of the problem, risk factors (sexual activity, age, method of contraception, history of previous PID, history of gonococcal of chlamydial lower genital tract infection, and uterine instrumentation), etiologic agents (N. gonorrhea, aerobic and anaerobic bacteria, chlamydia trachomatis, genital mycoplasmas, and other pathogens), pathogenesis, clinical and laboratory features, diagnostic evaluation, differential diagnosis, treatment, and sequelae. The Centers for Disease Control define acute PID as "the acute clinical syndrome (unrelated to pregnancy or surgery) attributed to the ascent of microorganisms from the vagina and endocervix to the endometrium, fallopian tubes, and/or contiguous structures." The true incidence and prevalence of PID in women is uncertain. Recent data show an increase to 267,200 in the average annual number of hospitalizations for PID during the 1975-81 period for women 15-44 years of age. PID occurs rarely in sexually inactive women. The large number of PID cases among adolescents reflects in part the high proportion of sexually active females in that group. The risk of developing PID in sexually active females is inversely related to age; 1/3 of all patients in Westrom's series were 19 years of age or younger at the time of their 1st PID episode, and 69% of all women with PID were younger than 25 years. Women who have had 1 episode of PID have a 20-25% chance of developing subsequent episodes. A large series of PID cases verified by laparoscopy has shown that only a small proportion of patients (3%) present with a severe clinical illness. Low abdominal pain is the most common symptom and may be present for variable periods of time prior to diagnosis. Other common symptoms include vaginal discharge (55%), irregular vaginal bleeding (36%), urinary symptoms (19%), nausea and vomiting (10%), and proctitis symptoms (7%). The major goals of therapy in PID are to prevent infertility and other long-term sequelae. About 15% of patients fail to respond to initial antibiotic therapy, 20% experience recurrences, 20% develop involuntary infertility, and 8% of post-PID patients who conceive have an ectopic pregnancy. Early diagnosis and treatment reduces the risk of residual tubal damage.
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PMID:Acute pelvic inflammatory disease. 360 34

A disproportionately high percentage of adolescents are contracting sexually transmitted diseases. Factors that predispose teenagers to these diseases include the "sexual revolution," the psychosocial development of the adolescent and physiologic factors such as the vulnerability of the female cervical epithelium to infection. Long-term complications of sexually transmitted diseases include chronic abdominal pain and infertility.
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PMID:Adolescents and sexually transmitted disease. 361 49

The clinical presentation of ectopic pregnancy is explored in this study along with the most constant predisposing factors among Saudi women. The medical records of 68 cases of suspected ectopic pregnancies were reviewed. Only 45 of the 68 cases, those that were finally diagnosed as ectopic pregnancies, constitute the basis of this study. The incidence of ectopic pregnancy was 1:742 pregnancies. 39 of the 45 patients with ectopic pregnancies were para 1-5; only 1 and 5 patients were reported to be nulliparous and grandmultipara, respectively. 27 of the 45 cases were 20-30 years of age. Between 40% and 45% of the 45 patients had positive histories of pelvic infection, abdominal or pelvic surgery, or infertility. 1 case each of an IUD in situ and of a recurrent ectopic pregnancy were reported. Amenorrhea with lower abdominal pain and tenderness were the most constant features of ectopic pregnancy. Vaginal bleeding was present in about 51% of the cases; fainting attacks and shoulder tip pains were late manifestations. Duration of amenorrhea was 6-8 weeks in about 63% of the cases; 36% had amenorrhea lasting 12-16 weeks. Only 1 patient presented with amenorrhea of longer duration (20 weeks), and she proved to have a cervical pregnancy. Laparoscopy was the only reliable diagnostic procedure. In all cases of clinically suspected hemoperitoneum, laparotomy was performed as a mandatory procedure. Pelvic examinations performed with the patient under anesthesia and also culdocentesis were both unreliable and inconclusive as diagnostic measures. Of the 40 cases of tubal ectopic pregnancy seen at laparotomy, 21 had already ruptured, 15 were still intact and 4 were cases of tubal abortion. The incidence of ectopic pregnancy is modified by age, parity, race, socioeconomic factors, sexual habits, contraceptive used and pelvic infection. The part played by 1 or more of those factors is unknown but definitely variable. In this study there were 40 tubal (88.8%), 1 cervical (2.2%), and 2 ovarian pregnancies (4.4%).
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PMID:A study of 45 cases of ectopic pregnancy. 610 59

Inflammatory bowel disease (IBD) commonly affects women of childbearing age, leading to concerns about the effects of the disease on fertility and pregnancy, the effect of pregnancy on the disease, and the diagnosis and treatment of IBD in the pregnancy women. The literature regarding these issues is reviewed, and a representative case report is discussed. Ulcerative colitis has no effect on fertility. Crohn's disease appears to be associated with an increased risk of infertility. "Subfertility," a temporary inability to conceive associated with chronic disease activity, is perhaps a more suitable description. There have been no studies regarding infertility and males with IBD, although sulfasalazine has recently been reported to cause reversible infertility in men. Ulcerative colitis is not associated with a higher spontaneous abortion rate than the general population, although it is not clear whether certain subgroups of patients have a higher rate of abortion. A similar conclusion has been reached for Crohn's disease, although reported abortion rates of 10-25% are somewhat higher than the general population. Approximately 30-50% of pregnant women with ulcerative colitis have exacerbations during their pregnancy or postpartum, a figure that is applicable to Crohn's disease as well, and which is no different than a control population of nonpregnant women with IBD. Patients with active ulcerative colitis at conception have a higher incidence of disease exacerbation than those with quiescent disease. Postpartum recurrences are more frequent in Crohn's disease, occurring in up to 40% of patients, but respond to standard medical therapy. Women who have had an ileostomy for ulcerative colitis consistently and successfully carry pregnancy to term. There is no data regarding women who have had an ileostomy for Crohn's disease. The approach to the women with abdominal pain during pregnancy is reviewed, including the use of radiographic procedures. No amount of radiation exposure can be considered safe, but the judicious use of standard radiographic tests when considered necessary for the health of the mother appear to be associated with little risk for the fetus. The medial treatment of IBD during pregnancy is the same as that for the nonpregnant patient. Despite animal data to the contrary, the bulk of human data suggests that steroids, when used to treat a variety of conditions including IBD, pose little risk to the human fetus. Similarly, despite the theoretical risk of kernicterus, sulfasalazine appears to be a safe drug even when used during the third trimester of pregnancy.U
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PMID:Inflammatory bowel disease and pregnancy. 612 70

This article examines causal factors of ectopic pregnancy, discusses management with emphasis on tubal conservation, and updates information on diagnosis, fertility maximization, and minimization of risks of recurrent ectopic gestations. The common factor in ectopic gestations appears to be a delay in the transport of the fertilized ovum to the uterus, allowing the embryo to develop invasive trophoblast. Factors that appear to have increased the incidence of ectopic pregnancy over the past include increased sexual exposure, more effective theraphy for pelvic inflammatory disease, IUDs, tubal surgery, and surgical sterilization reversals. 77% of extrauterine gestations occur in the middle and distal thirds of the fallopian tube, with clinical manifestations largely determined by the site of implantation. Abdominal pain, amenorrhea/vaginal bleeding, and a pelvic mass are the classic signs of an ectopic pregnancy. Newer diagnostic procedures including serum human chorionic gonadotropin-beta subunit assay pregnancy testing supported by ultrasonography and laparoscopy have allowed the vast majority of tubal pregnancies to be diagnoses before rupture, permitting surgery to be undertaken more for the purpose of preserving fertility than for saving the mother's life. Factors in selecting candidates for conservative surgery include medical stability of the patient, parity, desire for future pregnancy, age under 35, mid or distal tubal gestation, prior ectopic gestation or tubal surgery. Considerations influencing the surgical approach for appropriate candidates include location of the pregnancy, condition of the involved and contralateral tube and ovary, pelvic anomalies, previous surgery, and need for ancillary procedures. If the ectopic gestation is located in the mid to distal segment of the fallopian tube, a segmental resection or salpingostomy using microsurgery should give a good anatomic and functional result. A review of the literature indicates that, contrary to prevailing opinion, recurrent etopic gestations are not more common in patients undergoing tubal conservation than in those undergoing more radical procedures. Recent data have shown term pregnancy rates of 40-55% and recurrent ectopic pregnancy rates of 5% in patients with conservative procedures, the improved rate being attributed to availability of microsurgical techniques, finer suture and minimal surgical trauma, which lead to less adhesions and scarring. tudies have indicated that use of Dextran minimizes pelvic adhesion formation, decreasing anatomic distortion leading to subsquent infertility or ectopic pregnancy.
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PMID:Tubal conservation with ectopic gestations. A reappraisal. 623 72

This discussion of acute pelvic inflammatory disease (PID) -- usually a spontaneous infection that occurs among sexually active, menstruating, nonpregnant women -- covers: pathophysiology; microbial etiology (gonorrhea, chlamydia, genital mycoplasmas, and aerobic and anerobic bacteria); epidemiology (number of sexual partners, age, IUDs, previous PID, previous gonorrhea, untreated male sexual contacts, and perihepatitis associated with PID); diagnosis (physical examination, laboratory examination, culdocentesis, examination of the male partner, cultures, and ultrasonography); treatment; and sequelae (recurrent PID, infertility, ectopic pregnancy, and pain). The majority of infections are caused by bacteria and a polymicrobial bacterial infection is common. Neisseria gonorrhea, Chlamydia trachomatis, and a wide variety of aerobic and anerobic bacteria are most frequently isolated from women with PID. Primary PID is usually and acute infection in which organisms ascend into the uterus and fallopian tubes from the cervix. Chronic active infections are unusual except in neglected cases and in Actinomyces infection, but sterile chronic inflammatory adhesions are common residuals of acute infection. Except for women who have an IUD in place or the 15% who have had uterine instrumentation, spontaneous PID is almost totally confined to women who are sexually active. There is a much higher PID rate among younger than older women. Women who use an IUD for contraception are at least 2-4 times more likely to develop PID than nonusers. Women who have had PID are twice as likely to develop the infection as those who have never had it. A history of a prior uncomplicated gonococcal infection is more common among women with PID than among women without disease. Untreated males with urethral N. gonorrhea and possibly with C. trachomatis infection are an important source of infection both for the initial and for recurrent episodes of PID. Abdominal pain is the most common symptom although the pain may be mild or even absent in at least 5% of patients with PID verified by laparoscopy. In patients who have overt PID, it is possible to establish the diagnosis with reasonable certainty by a combination of history, physical examination, Gram stain of cervical secretions, culdocentesis, and examination of the male sexual partner. Adequate treatment of salpingitis includes an assessment of the severity of the infection, administration of appropriate antibiotics, employment of other health measures, close patient follow-up, and treatment of the male sexual patner. 25% of women with 1 episode of salpingitis develop a subsequent episode.
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PMID:Acute pelvic inflammatory disease. 636 7

Ectopic pregnancy is a serious complication of pregnancy accounting for 6-13% of all maternal deaths in the U.S. Early diagnosis and treatment is absolutely necessary to ensure a successful outcome. In the period from January 1, 1965-December 31, 1979, 556 consecutive cases of ectopic pregnancy were treated at The Brookdale Hospital Medical Center in Brooklyn, accounting for less than 1% of all pregnancies handled in that period. 3 of these cases had an ovarian pregnancy, 8 had an abdominal, and 545 a tubal pregnancy. Relevant personal characteristics and aspects of obstetric history of these cases were studied. 85% of them had used no contraception prior to the ectopic pregnancy. Maternal age was not a factor in the occurrence of the ectopic pregnancy. The following factors in the clinical history were found to put the patient in a high-risk category: 1) primary or secondary infertility; 2) previous abortion or ectopic pregnancy; 3) previous tubal operation, either reconstructive or sterilizing; 4) recent uterine evacuation; and 5) the use of an IUD or its recent removal due to abdominal pain and/or bleeding. Major symptoms were found to be abdominal pain, common symptoms or early pregnancy, abdominal tenderness, adnexal mass, and tenderness on motion of the cervix. Culdocentesis and laparoscopy are effective diagnostic aids. Procrastination by observation should not be followed.
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PMID:A fifteen year experience with ectopic pregnancy. 645 44

One hundred and eighty cases of uterine fibroids out of the two hundred treated in a gynaecological unit in a 7-year period are reviewed. The incidence of uterine fibroids among gynaecological conditions was 3.2% and it accounted for 3.6% of the operations. The peak age incidence was at 31-40 years (46%). Twenty per cent of those affected were grand multiparae. The commonest clinical features were abdominal swelling, infertility, abdominal pain, menorrhagia and dysmenorrhoea. Most of the patients were treated surgically with myomectomy (68%), mainly on account of the low parity and age. There was increased morbidity among those who had hysterectomy; 2 deaths occurred in this group. We have advocated liberal use of myomectomy , with its preservation of menstrual and reproductive function.
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PMID:Management of uterine fibroids at the University of Benin Teaching Hospital. 672 79

Despite the advent of improved methods of diagnosis and therapy, ectopic pregnancy remains a significant cause of morbidity and mortality worldwide. The diagnosis is often difficult to make clinically, but should be included in the differential of any woman of gestational age presenting with lower abdominal pain, even with a normal menstrual history. With a high index of suspicion, improving methods of diagnosis such as the immunoassays for B-hCG and ultrasonography may lower mortality rates by enabling more diagnoses to be made before rupture. The significant infertility rate following ectopic pregnancy remains a problem despite newer, more conservative approaches to surgical therapy.
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PMID:Ectopic pregnancy--a brief review. 675 Nov 72

Acute salpingitis is an important complication of sexually transmitted disease in young women and should be considered in the differential diagnosis of abdominal pain in all young women. Many organisms, in addition to N. gonorrhoeae, have been associated with this tubal infection giving support to polymicrobial etiology. However, the exact pathophysiologic role of these organisms needs to be clearly defined. The microbiology of acute salpingitis, through direct culture from the site of infection, the fallopian tubes, needs to be clearly elucidated. Early recognition and treatment of acute salpingitis is essential in preventing the major long-term problem, involuntary infertility. Curran has estimated the reproductive outcome for a cohort of adolescent women reaching reproductive age in 1970. By the year 2000, there will have been one episode of salpingitis for every two women; 15% will be hospitalized for salpingitis with over half of these women requiring major gynecologic surgery; 10% will be rendered nonsurgically sterile; and 3% will have experienced an ectopic pregnancy. Adolescent females may be more susceptible to upper genital tract infection than older women due to possible unique biologic characteristics and sexual behaviors. Prospective microbiologically controlled studies of women with salpingitis using laparoscopy need to be developed to evaluate treatment regimens. Until such studies are undertaken, diagnosis, treatment, and fertility in women with acute salpingitis will remain unsatisfactory.
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PMID:Acute salpingitis in the adolescent female. 703 72


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