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In a previous article (3 May, p. 1127), the British Medical Journal attempted to assess the demography of ectopic pregnancy and noted that a rise in incidence might lead to a better diagnosis of the condition. Cited as possible causes of ectopic pregnancy are pelvic sepsis and IUD usage. There is clinical confirmation of the relationship between pelvic sepsis and IUD usage. A review of the records of 325 consecutive patients diagnosed as having ectopic pregnancy in 4 large London Hospitals during the period 1967-79 revealed that PID (Pelvic Inflammatory Disease) was uncommon (11%). 12% of the remaining patients had IUDs and a further 2% were progestogen-only contraceptive failures. As regards the role of IUDs in ectopic pregnancy, failed intrauterine contraception is hypothesized to result in pregnancy, but with an incidence of ectopic, mainly tubal, implantation by reasons of disturbed ovum migration along the oviduct. The physiology of the human oviduct is not well known. Further research should be done on the many common aberations of human reproduction, iatrogenic and spontaneous.
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PMID:Unanswered questions on ectopic pregnancy. 740 28

The incidence of pelvic inflammatory disease (PID), which can lead to serious reproductive impairment, infertility, or ectopic pregnancy, is increasing worldwide. About 500,000 women in their childbearing years contract PID for the first time each year in the U.S., and the incidence among young women appears to be increasing. Sexually transmitted diseases are responsible for many PID cases worldwide, while in developing countries postpartum and postabortion sepsis and endemic diseases such as filariasis and schistosomiasis may also be implicated. Some increase of PID is associated with legal abortion and IUD insertion, while pill use appears to protect women from PID. A worldwide review of medical literature indicates that the risk of PID is 3.5 times greater for IUD users than for nonusers, although several variables other than IUD use affect PID risk, such as age, race, socioeconomic status, and sexual activity. The risk for never pregnant IUD users in a Swedish study was 11.8 per 100 woman years, compared to 3.4 for ever-pregnant IUD users. There was no difference in relative risk for users of the pill or barrier methods, or for non-contraceptors. Another study reported a higher relative risk of PID related to duration of IUD use.
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PMID:IUD users may have higher risk of contracting PID, studies find; pill may have protective effect. 743 43

According to a 3-year collaborative study estimating maternal mortality rates from 41 hospitals affiliated with teaching centers in India, maternal mortality was 721 per 100,000 live births. Community studies in rural areas of Sirur, Pachod, and Ambula reported maternal mortality as 210-253 per 100,000. Cohort studies conducted by the Indian Council of Medical Research reported maternal mortality as 530 per 100,000 based on data from rural areas of Varanasi, 460 per 100,000 in urban Delhi, and 450 per 100,000 in urban Madras. The Ministry of Health gave the rate as 460 per 100,000 in 1984, while UNICEF gave a figure of 400 per 100,000 for 1980-91. India has 1 out of 4 of the world's maternal deaths, or 1 every 6 minutes. The risk of maternal death has been calculated to be one in 64. Risk is unevenly distributed geographically. Risk is low in Kerala compared to Uttar Pradesh or Madya Pradesh. In 1992 maternal mortality was calculated to be 1320 per 100,000 births based on 5 district hospitals. The cause of maternal deaths was anemia in 25% of cases. 75% of cases were accounted for by eclampsia, sepsis, hemorrhage, and abortion. Anemia (pre-existing the pregnancy) is acerbated by the demands of pregnancy and causes congestive heart failure and death. Blood losses of greater than 150 ml (due to hemorrhages of pregnancy and labor) can be fatal. During 1982-89 anemia was responsible for 17-24% of all maternal deaths in rural areas. Morbidity from pregnancy-related causes included obstetric fistulae, pelvic inflammatory disease, anemia, genital prolapse, and urinary incontinence. Quality of maternal care is an important factor in reducing maternal mortality and morbidity. Societal factors such as illiteracy and malnutrition, early marriage, poorly supervised pregnancies, and lack of transportation during emergencies are other determinants of mortality and morbidity. About 10% of maternal deaths are attributed to unsafe abortion. The government aim for the year 2000 of 100% prenatal care and care during delivery will require professional commitment and thousands more midwives in rural areas.
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PMID:How safe motherhood in India is. 765 33

During 1992, 53 women were admitted to Lady Hardinge Medical College and Smt Sucheta Kriplani Hospital in New Delhi, India, for septic induced abortion and 1855 were admitted for medical termination of pregnancy (MTP). Most septic induced abortion cases lived in semi-urban/urban slums (64.15%), were Hindus (98.11%) and married (94.34%), and had a parity of less than 2 (56.6%). The leading reason for abortion was unwanted pregnancy among septic abortion cases (81%) and contraceptive failure among MTP cases (98.3%). No septic abortion case had used contraception. Among septic abortion cases, termination methods included instrumentation by untrained midwives (62%), foreign body insertion (7.5%), and dilatation and curettage or suction by unqualified personnel (7.5%). About 33% of septic abortion cases presented with generalized peritonitis, septicemia, septic shock, acute renal failure, or disseminated intravascular coagulation (DIC). All septic abortion cases had pelvic inflammatory disease compared to 3.55% among MTP cases. 94.35% had anemia. About 34% needed a blood transfusion compared to 0.16% among MTP cases. MTP cases were significantly less likely to suffer uterine perforation than septic abortion cases. None of the MTP cases had septicemia. The need for laparotomy was more common among septic abortion cases than MTP cases (26.4% vs. 0.43%). A hospital stay of more than one week was also more common (72% vs. 0.43%). On discharge, MTP cases were more likely to be in satisfactory condition than septic abortion cases (100% vs. 75.7%). No one in the MTP group died, while 13.2% died in the septic abortion group. The causes of death were septic shock (7 cases), hepato-renal failure (2 cases), and DIC (1 case). The abortion ratio was 312/1000 births. The abortion mortality ratio was 1.7/1000 abortions. Illegally induced abortions were responsible for 20% of all maternal deaths at this institution in 1992. These findings suggest that family planning education, contraceptive use, and safe pregnancy termination facilities would prevent abortion-related morbidity and mortality.
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PMID:Maternal mortality and morbidity associated with clandestine abortions. 765 45

The diagnosis of abdominal infections and inflammations often presents considerable difficulty, and various imaging techniques may be required to localize them accurately. At present, radiolabelled leucocytes offer the most widely accepted radionuclide method for imaging inflammation. Because of the many advantages of technetium-99m (99mTc) over indium-111 (111In), 99mTc-HMPAO-leucocyte scintigraphy is preferred for the investigation of acute abdominal sepsis and inflammatory bowel disease, and 111In-leucocyte scintigraphy for more chronic infections and renal sepsis. The 99mTc-HMPAO-labelled leucocytes technique is highly accurate within the first few hours postinjection, and is therefore useful also in acutely ill patients. It is sensitive in detecting abdominal abscesses in all locations except the liver and spleen. By whole body imaging, unsuspected sites and types of infection can be found. 99mTc-HMPAO-leucocyte scan is valuable also in the investigation of acute cholecystitis in problematic situations in which ultrasound is known to give misleading results, especially in acute acalculous cholecystitis. In inflammatory bowel disease it can reliably assess disease activity, but a normal scintigraphy does not exclude mild inflammation. Leucocyte scan is useful also in suspected acute appendicitis, acute diverticulitis, pelvic inflammatory disease, aortic graft infection, etc. But infection and inflammation cannot reliably be differentiated, which may cause misinterpretations in the early postoperative period. Radionuclide techniques have an important role to play in the investigation of abdominal sepsis if the nuclear medicine department can offer instant investigations when the clinical problem is acute.
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PMID:Investigation of suspected intra-abdominal sepsis: the contribution of nuclear medicine. 797 41

Enterovesical fistula is a rare complication of pelvic radiotherapy. Recurrent disease is the cause of fistulization in most patients. We identified 14 patients who developed enterovesical fistula in the absence of tumor recurrence. These women were at high risk for radiation morbidity due to prior surgery, pelvic inflammatory disease, adjuvant hyperbaric oxygen, or locally high doses of radiotherapy caused by suboptimal geometry and technique. All patients underwent radiographic imaging including barium enema, intravenous pyelogram, and upper gastrointestinal study with small bowel follow-through. The range of radiation morbidity was great: some patients had small fistulae, others had extensive fistulization and radionecrosis. Six patients had colovesical fistulae, five had enterovesical fistulae, and three had fistulae involving both the small and large bowel. Twelve patients underwent 13 surgical procedures. Healing or successful repair of the fistula was achieved in 1 of 3 patients treated with diversion (loop colostomy), 2 of 4 patients treated with isolation of the fistulized bowel loop and urinary conduit, and 5 or 6 treated with bowel resection with or without urinary conduit. Two of three perioperative deaths occurred in the isolation group managed without urinary conduit and were related to ongoing sepsis. Surgical procedures which resect necrotic fistulized bowel and result in complete separation of the gastrointestinal and genitourinary tracts provided the best results in patients with radiation-induced enterovesical fistulae. CT scan of the abdomen and pelvis is recommended in the evaluation of the majority of patients with suspected enterovesical fistula.
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PMID:Enterovesical fistula following radiotherapy for gynecologic cancer. 815 86

A number of different organisms can be isolated from intraabdominal infection. The most common are aerobic Gram-negative bacilli. Anaerobes are not unusual. From June 1989 to January 1990, Cefmetazole was administered to 23 patients with intraabdominal infection at Veterans General Hospital-Taipei. There were six patients with spontaneous bacterial peritonitis, five biliary tract infection, five liver abscesses, five with pelvic inflammatory disease, one acute ruptured appendicitis and another intraabdominal abscess. In addition, ten patients had sepsis. Clinical response was satisfactory in 21 (91.3%) of 23 patients, and the microbiological eradication rate was 90% (36/40). One patient with Streptococcus and Bacteroides oralis liver abscess relapsed after organism eradication. Therapy failed in a case with Pseudomonas aeruginosa and Bacteroides fragilis infection. This study showed Cefmetazole to be an effective and safe antibiotic for treatment of intraabdominal infection.
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PMID:[Clinical efficacy of cefmetazole in intraabdominal infection]. 828 91

In the Netherlands a 34-year old pregnant women presented at the obstetrics and gynecology department of OLVG Hospital in Amsterdam with uterine bleeding. She was at 11 weeks gestation and had an IUD in situ. A vaginal ultrasound revealed that the pregnancy was intact so the physicians could not remove the IUD. She returned 12 days later because she was suffering from an incomplete spontaneous abortion. The physicians removed the IUD and performed an aspiration curettage. They did not administer antibiotics. 10 days after the operation the woman suffered worsening pain in the right thigh and leg and had difficulty walking, a fever, and general sickness. She was breathing very rapidly. Repeated vaginal ultrasounds revealed that she had retained the conceptus. The physicians prescribed respiratory support and antibiotics (claforan, gentamicin, and metronidazole). Blood culture indicated Staphylococcus aureus. Computer tomography revealed a retroperitoneal abscess at the level of the right iliopsoas muscle near the os ilium and the sacro-iliac joint. The physicians performed an extraperitoneal incision and drainage of the abscess and a repeat aspiration curettage. Staphylococcus aureus was isolated from all abscess samples, the conceptus, the cervix, the vagina, the urine, and the sputum. The physicians continued gentamicin and metronidazole treatment. They dismissed her after a complete recovery 16 days after the 2nd aspiration curettage. Possible complications of psoas abscess are sepsis, pulmonary embolism, hemorrhage, and bowel obstruction. Antibiotic prophylaxis in abortion curettage may prevent late sequelae, such as psoas abscess and pelvic inflammatory disease.
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PMID:Psoas abscess related to spontaneous abortion, intra-uterine contraceptive device and curettage. 838 62

In a 6-month prospective study conducted at Sidamo Regional Hospital (Yirgalem, Ethiopia) from April 1 to September 30, 1991, 185 cases of abortion were admitted. 64 (35%) of these abortions were illegally induced and 121 (65%) were spontaneous. During the study period, there were 443 gynecological admissions; thus, illegal abortion comprised 14% of total cases treated. There were 2 deaths in the induced abortion group (0.8% case fatality). 50 (78%) women with illegal abortions were under 25 years of age and 42 (66%) were unmarried. Instruments most often used to induce abortion were plastic catheters (56%) and metallic objects (32%); the procedure was performed by health workers in 55% of cases and friends in 39%. 122 (66%) of women admitted with induced abortion required evacuation and curettage. Complications of illegal abortion included septicemia (36 cases), hemorrhagic shock (12 cases), pelvic abscess (11 cases), and cervical trauma (22 cases). The mean hospital stay for induced abortion was 6.3 days compared with 2.1 days for spontaneous abortion. 83% of women in the induced abortion group were using no form of contraception prior to the unwanted pregnancy, 11% were using a method incorrectly, and 6% were considered to be proper users. Since 41% of women in the spontaneous abortion group reported that their pregnancy was unwanted, it is possible that some may have in fact undergone an illegal abortion. Unable to be measured were the long-term effects of illegal abortion, including chronic pelvic inflammatory disease and infertility. Overall, these findings document the magnitude of the problem of illegal abortion in Ethiopia and indicate an urgent need for contraceptive education among young women.
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PMID:A six month prospective study on different aspects of abortion. 840 81

Mycoplasma hominis and Ureaplasma urealyticum are common inhabitants of the human genital tract. Evidence for an aetiological role in pyelonephritis, pelvic inflammatory disease, post-abortion and post-partum fever has been presented. There are sporadic reports of Mycoplasma causing serious extragenital infection such as septicemia, septic arthritis, neonatal meningitis and encephalitis. We review 38 cases of surgical infections with Mycoplasma.
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PMID:Surgical infections with Mycoplasma: a brief review. 911 82


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