Fecundity and morbidity following acute pelvic inflammatory disease treated with doxycycline and metronidazole

We studied fecundity and late sequelae of 39 women who had laparoscopic and microbiological sampling-proven acute pelvic inflammatory disease (PID) treated with the same antimicrobial regimen. The grade and etiology of index PID were classified using laparoscopy, endometrial biopsy and microbiological cultures from the cervix, endometrium and tubes: 20 had mild and 19 severe PID. The mean (SD) follow-up period after the index PID was 125 (44) [range 8–204] months. The primary end-point was pregnancy. All other or recurrent infections or other diseases related to the infection, including infertility, were evaluated. Twenty (51%) women had laparotomy or second laparoscopy during follow-up and findings were evaluated. Chlamydia trachomatis was isolated in 38% of all cases. Eleven (28%) of 39 women avoided conception or it was no longer possible. Twenty-eight women had tried to conceive after the index PID and 25 (89%) of them had at least one pregnancy. Twenty-five women had 56 pregnancies, 33 (59%) of which ended in delivery, 9 (16%) miscarried, 13 (23%) were induced abortion and only one (1.8%) tubal pregnancy occurred. Etiologic factors or severity of PID made no difference to the conception rate. Patients with mild or moderate salpingitis had a high conception rate. Endometriosis was found in 6 (30%) out of 20 women with second laparoscopy or laparotomy. Hysterectomy had been performed in 4 cases. Precise diagnosis of acute PID is the cornerstone for the treatment of the condition. Combination regimens, including drugs against the most common factors underlying acute PID against both aerobic and anaerobic microbes, prevent late sequelae in cases with mild or moderate salpingitis but not in cases with tubal or pelvic abscess.     

Salpingitis; aspects of diagnosis and etiology: a 4-year study from a Swedish capital hospital

359 patients underwent laparoscopy to verify the diagnosis of salpingitis. Pelvic inflammatory disease (PID) was found in 187 (52%) cases. Laparoscopy revealed normal conditions in 136 (37%) cases. Other diseases were diagnosed in 36 (10%) cases. Bacteriological cultures from the fimbrial lumen were positive in 24% of the PID cases. Chlamydia trachomatis (CT) was detected in 12%, Bacteroides species (BS) in 5%, Actinomyces israelii (AI) in 3%, Gardnerella vaginalis (GV) in 2%, Neisseria gonorrhoeae (NG) in 1%, and Ureaplasma urealyticum (UU) in 1%. Cervical cultures were positive for NG and/or CT in 71% of the PID cases but only in 19% of the non-PID cases. From these no positive intra-abdominal cultures were detected. Serological tests for CT were carried out. A positive acute titre of greater than or equal to 1/64 was noted in 37%, a seroconversion (X4) 2-3 weeks later was found in 14%. Positive serology despite a negative culture was registered in 19%.     

子宫颈淋球菌解脲支原体人型支原体和沙眼衣原体感染1866例分析

目的：探讨子宫颈淋球菌（NG）,解脲支原体（UU）,人型支原体（MH）和沙眼衣原体（CT）感染情况。方法：应用病原体培养及免疫荧光检测等方法,对我科性病专科门诊初诊的1866例女性患者,取宫颈拭子进行NG,UU,MH和CT四种主要性传播疾病（STD）病原体检测。结果：病原体检出率分别为NG 3．16％（59／1866）,UU49．62％（926／1866）,MH 11．58％（216／1866）和CT17．58％（328／1866）,总的病原体检出率为60．29％（1125／1866）,其中单一病原体感染率为41．00％（765／1866）,混合感染率为19．29％（360／1866）,结论：UU,CT,MH和NG是宫颈感染的主要病原体,其感染率UU＞CT＞MH＞NG,且混感染已是一个越来越严重的问题。     

In situ hybridization study on the localization of HPV DNA in the precancerous lesions of uterine cervix

Human papillomavirus (HPV) types 16 and 18 have been found closely associated with cervical cancer. In order to investigate the relationship between HPV DNA and cervical precancerous lesions, we examined the formalin fixed specimens obtained from 22 cases of mild dysplasia, 33 cases of moderate dysplasia and 31 cases of severe dysplasia of the uterine cervix for the presence of HPV 6/11, 16 and 18 DNAs by in situ hybridization using the biotinylated HPV DNA probes. We also followed some HPV DNA positive cases of cervical dysplasia for more than 6 months prospectively. The results of in situ hybridization analysis revealed that HPV DNA was detected in the nuclei of koilocytosis, dysplastic cells and metaplastic cells. HPV 6/11 was positive in 27.3% (6/22) of mild dysplasia and 21.2% (7/33) of moderate dysplasia. On the other hand, HPV 16 positive rate increased with the grade of dysplasia and 36.4% (12/33) of moderate dysplasia, 61.3% (19/31) of severe dysplasia were positive for HPV 16 DNA. Some of the follow-up cases which were positive for HPV 16 DNA were later found to have carcinoma in situ. Our results suggest that HPV type 16 might play an important role in cervical carcinogenesis.     

Clinical utility of CA125 levels in predicting laparoscopically confirmed salpingitis in patients with clinically diagnosed pelvic inflammatory disease.

OBJECTIVE: The purpose of this study was to determine the utility of serum CA125 determinations in diagnosing acute salpingitis. METHODS: CA125 levels were determined for 34 women with the clinical diagnosis of pelvic inflammatory disease (PID). Acute salpingitis was confirmed laparoscopically in 28 women (82.3%). RESULTS: Twenty patients (71.4%) with laparoscopically confirmed acute salpingitis had CA125 levels greater than 7.5 units, compared with no patients (0/6) with laparoscopically normal tubes (P = 0.002). The degree of elevation of CA125 levels correlated with the severity of tubal inflammation noted at laparoscopy. All patients with levels above 16 units had laparoscopically severe salpingitis. CONCLUSIONS: We conclude that while CA125 levels above 7.5 units may modestly improve the ability of the clinical diagnosis of PID to accurately reflect visually confirmed acute salpingitis, limitations of the test make its clinical utility questionable.     

Effect of human immunodeficiency virus-1 infection on treatment outcome of acute salpingitis

OBJECTIVE: To examine the effect of human immunodeficiency virus (HIV)-1 infection on treatment outcome of laparoscopically verified acute salpingitis. METHODS: Women aged 18-40 years with laparoscopically verified acute salpingitis received antibiotic therapy that included cefotetan 2 g intravenously and doxycycline 100 mg orally every 12 hours and laparoscopically guided drainage of tuboovarian abscesses of 4 cm or more. Clinical investigators blinded to HIV-1 serostatus used predetermined clinical criteria, including calculation of a clinical severity score and a standard treatment protocol to assess response to therapy. RESULTS: Of the 140 women with laparoscopically confirmed acute salpingitis, 61 (44%) women had mild, 38 (27%) had moderate, and 41 (29%) had severe disease (ie, pyosalpinx, tuboovarian abscesses, or both). Fifty-three (38%) were HIV-1-infected. Severe disease was more common in HIV-1-infected in comparison with HIV-1-uninfected women (20 [38%] compared with 21 [24%], P = .02). Defined as time of hospital discharge or 75% or more reduction in baseline clinical severity score, HIV-1-infected women with severe (6 days [4-16] compared with 5 days [3-9], P = .09) but not those with either mild (4 days [2-6] compared with 4 days [2-6] P = .4) or moderate salpingitis (4 days [3-7] compared with 4 days [3-6] P = .32) tended to take longer to meet criteria for clinical improvement. The need for intravenous clindamycin or additional surgery was not different in HIV-1-infected and uninfected cases (15 [28%] compared with 18 [21%], P = .3). CONCLUSION: Although HIV-1 infection may prolong hospitalization in women with severe salpingitis, all women hospitalized with acute salpingitis responded promptly to antibiotic therapy and surgical drainage regardless of HIV-1 infection status. LEVEL OF EVIDENCE: II-2.     

Diagnostic laparoscopy in infertile women with normal hysterosalpingograms

OBJECTIVE: To assess the value of laparoscopy in infertile women with normal hysterosalpingograms, with and without risk factors suggesting pelvic disease. STUDY DESIGN: We retrospectively reviewed 1,022 consecutive charts from a tertiary infertility practice. In 265 women, laparoscopies were performed after normal hysterosalpingograms. RESULTS: Laparoscopies were normal in 136 (51%) women, whereas 129 (49%) had one or more abnormal laparoscopic findings, including minimal or mild endometriosis (n = 85), moderate or severe endometriosis (n = 11), adnexal adhesions (n = 27), subserosal myomas (n = 17), ovarian neoplasms (n = 5), distal phimosis (n = 1) and salpingitis isthmica nodosa (n = 1). Only 7% of cases had findings that might require standard operative laparoscopy or laparotomy, although not all were causally related to infertility. A history of dysmenorrhea or dyspareunia increased the likelihood of detecting endometriosis from 41% to 64% and 69%, respectively. The presence of both symptoms increased the likelihood to 83%. CONCLUSION: In the presence of a normal hysterosalpingogram, laparoscopy identified other pelvic disease in about half of patients. Because most abnormalities were mild, this knowledge can be used to plan a micro-laparoscopic approach for many women, reserving traditional or operative laparoscopy for women with an abnormal hysterosalpingogram or extensive disease following micro-laparoscopy. Alternately, knowledge of the nature and severity of the expected laparoscopic findings might lead to bypassing laparoscopy in favor of assisted reproduction when the perceived benefit of surgical intervention is small.     

A study of second-look laparoscopy after acute salpingitis

Acute salpingitis (AS) has a major impact on the reproductive health of women. In this study second-look laparoscopy was assessed for its ability to predict reproductive function after AS. We questioned 158 women who had had a second-look laparoscopy with tubal dye insufflation after laparoscopically proven AS between September 1984 and August 1989. The answers of 69 women with at least two years of involuntary infertility were analyzed. The mean follow-up period was 76 months (range 53–108 months). Second-look laparoscopy revealed bilateral tubal occlusion in 21.7% (15/69). Bilateral tubal occlusion was found in 9.5% (2/21) after mild stage, 20% (4/20) after moderate stage and 32.1% (9/28) after severe stage AS. The rate of infertility during follow-up was 9.5% (stage I), 35% (stage II) and 39.9% (stage III). Eighty per cent (12/15) of women with proven bilateral tubal occlusion after treated AS had involuntary infertility, and 14.8% (8/54; P=0.000001) of women with one or both tubes patent also had infertility. Specificity, sensitivity and positive predictive value for subsequent infertility were 85.2%, 80% and 84.1%, respectively. Pelvic adhesions (21/69) were strongly correlated with bilateral tubal occlusion (8/21; 38.1%; P=0.029), a history of chronic pelvic pain (14/21; 66.7%; P=0.00024), as well as failure to achieve an intrauterine pregnancy (10/21; 47.6%; P=0.024). Recurrent pelvic infections occurred in 16% (12/69) and ectopic pregnancies in 7.3% (5/69). Operations for infertility and pelvic pain (excluding ectopic pregnancy), were carried out in 11.6% (8/69). We conclude that second-look laparoscopy after treated AS have accurate evaluation of reproductive function. Received: 10 January 1996 / Accepted: 29 April 1996     

C-reactive protein in assessing antimicrobial treatment of acute pelvic inflammatory disease

Serial serum C-reactive protein (CRP) determinations were used in the evaluation of antimicrobial treatment of acute pelvic inflammatory disease (PID) as proven by laparoscopy and endometrial biopsy or microbiologic findings in the upper genital tract in 36 women. Sixteen patients were treated with ciprofloxacin and 20 with doxycycline plus metronidazole. The mean CRP levels did not differ significantly in patients with severe and moderate salpingitis in comparison with mild salpingitis on admission or during treatment, nor was there any significant difference between the mean CRP levels in patients with acute chlamydial/gonococcal and nonchlamydial/nongonococcal PID. The mean CRP levels decreased by the third day of treatment in all treatment groups, and the decrease by the sixth day of treatment was significant (P less than .05), reflecting the clinical response to therapy faster than did serial ESR determinations. After the documentation of acute PID, serial serum CRP determinations were a useful predictor of the short-term response to antimicrobial therapy.     

Doxycycline in human oviduct mucosa and plasma 24-30 hours after an oral dose of 100 mg

Oviductal and peripheral plasma concentrations 24 hours after the last dose of Doxycycline (DC) were studied in 17 patients. The concentration of DC in healthy oviduct mucosa was 1.3 micrograms/g (range 0.6-1.7) and 1.1 micrograms/ml (range 0.6-1.7) in plasma. One patient with severe chronic salpingitis in acute exacerbation showed 3.6 micrograms/g in tissue and 2.4 micrograms/ml in plasma in proliferative phase.     

Comparison of endometrial biopsy and peritoneal fluid cytologic testing with laparoscopy in the diagnosis of acute pelvic inflammatory disease

Twenty-seven women with suspected acute pelvic inflammatory disease were studied by laparoscopy and endometrial biopsy. Overall, 67% (18 of 27) of the women had acute salpingitis at laparoscopy, 70% (19 of 27) had plasma cell endometritis, and 67% (10 of 15) had an inflammatory cytologic pattern of the peritoneal fluid. In comparison to laparoscopically detected salpingitis, endometritis detected with biopsy had a sensitivity of 89%, a specificity of 67%, a positive predictive value of 84%, and a false negative rate of 22% in the diagnosis of pelvic inflammatory disease. The corresponding figures for inflammation of the peritoneal fluid were 75%, 67%, 90%, and 25%. This study demonstrates that nonpuerperal endometritis is an entity associated with pelvic inflammatory disease, most likely representing an intermediate stage between cervicitis and salpingitis. Endometrial biopsy as an office procedure is a good alternative to laparoscopy in the diagnosis of acute pelvic inflammatory disease and may in fact detect early cases not yet visible at laparoscopy.     

Incidence of the luteinized unruptured follicle syndrome in fertile women and in women with endometriosis

One-hundred normal fertile women with normal luteal phase and 118 women with endometriosis underwent luteal phase laparoscopy before day 22. The luteal phase was ascertained by the presence of secretory endometrium and serum progesterone levels higher than 3 ng/ml. The ovaries were carefully inspected for the presence or absence of an ovulation ostium. The percentage of ostii that was observed in fertile women (91%) was similar to that observed in women with mild endometriosis (85%). However, in women with moderate and severe endometriosis, significantly less ostii were noted, respectively 72 and 51%. It is therefore argued that the absence of an ovulation ostium (so-called luteinized unrupted follicle syndrome, LUF) is more frequent in women with moderate and severe endometriosis and may contribute to infertility in this group of women.     

Physiopathologie,diagnostic et prise en charge des infections génitales hautes

Pelvic inflammatory diseases (PID) include salpingitis and endometritis. They usually result from the infection of upper genital tract by pathogens ascending from the cervix or the vagina. Since the clinical signs of uncomplicated forms are frequently mild or misleading, diagnosis require other exams such as microbiology (samples from the cervix and, if applicable, from the pelvis) and laparoscopy. Acute complications (pelvic abscesses, peritonitis) can occur, that call for both surgical drainage and antibiotics. Pelvic sequelae with permanent tubal alterations due to immuno-allergic reactions can also happen, that lead to chronic pelvic pain and infertility. Treatment consists in broad-spectrum antibiotics by oral route, combined with non steroid anti-inflammatory drugs. Atraumatic laparoscopic procedure can also be performed.     

Postabortal pelvic infection associated with Chlamydia trachomatis and the influence of humoral immunity

Among 1101 women undergoing legal abortion by vacuum aspiration within 14 weeks of gestation, 69 (6.3%) harboured Chlamydia trachomatis in the cervix and/or urethra. Of the chlamydia-positive women, 16 (23.2%) developed endometritis and 10 (14.5%) developed salpingitis during the first postoperative month. The corresponding figures among the chlamydia-negative women were 59 (5.7%) and 5 (0.6%). These differences are highly significant (p less than 0.001). To study the significance of systemic and local humoral immunity to C. trachomatis in these complications, chlamydial antibodies were determined in serum and cervical secretions. No difference in frequency of local IgA antibodies in chlamydia-positive women was observed between those with and those without complications. On the other hand, there was a strong indication that chlamydia-positive women who developed salpingitis had a lower mean titer (17) of serum IgG chlamydial antibodies than carriers without symptoms (82, p less than 0.02). The group of endometritis patients did not differ in this respect from chlamydia-positive women who were free of infectious complications. These results suggest that C. trachomatis may be an etiologic agent in postabortal salpingitis and probably also in endometritis. Serum antibodies seemed to offer some protection against salpingitis in chlamydia-positive cases, whereas local antibodies did not.     

A study of plasma progesterone, oestradiol-17beta, prolactin and LH levels, and of the luteal phase appearance of the ovaries in patients with endometriosis and infertility

Thirty-four infertile patients with regular cycles and endometriosis were studied and compared to a control group of 28 women. The endometriosis was classified as mild (n = 16), moderate (n = 9) and severe (n = 9) according to Acosta et al (1973). The interval between the LH peak and the onset of subsequent menstruation was shorter (P = 0.024) in patients with endometriosis than in the control group. In mild endometriosis, oestradiol-17beta levels fell on the day after the LH peak, but this was not the case in moderate and severe endometriosis. In mild, moderate and severe endometriosis the plasma progesterone concentration did not rise on the first day following the LH peak, and at laparoscopy significantly (P less than 0.005) less ovulation stigmata were present. We conclude that endometriosis is associated with luteinization in situ and that this may explain the associated infertility.     

Transvaginal Ultrasound Can Accurately Predict the American Society of Reproductive Medicine Stage of Endometriosis Assigned at Laparoscopy

Study ObjectiveTo evaluate the diagnostic accuracy of transvaginal ultrasound in predicting a laparoscopic, surgically assigned, revised American Society of Reproductive Medicine (ASRM) endometriosis stage.DesignA multicenter, retrospective, diagnostic accuracy study.SettingThe patients visited 1 of 2 academic gynecologic ultrasound units and underwent laparoscopy led by 1 of 6 surgeons in metropolitan Sydney, Australia, between 2016 and 2018.PatientsPatients with suspected endometriosis (n = 204).InterventionsUltrasound followed by laparoscopy.Measurements and Main ResultsSurgical cases were identified. The preoperative ultrasound report and surgical operative notes were each used to retrospectively assign an ASRM score and stage. The breakdown of surgical findings was as follows: ASRM 0 (i.e., no endometriosis), 24/204 (11.8%); ASRM 1, 110/204 (53.9%); ASRM 2, 22/204 (10.8%); ASRM 3, 16/204 (7.8%); ASRM 4, 32 204 (15.7%). The overall accuracy of ultrasound in predicting the surgical ASRM stage was as follows: ASRM 1, 53.4%; ASRM 2, 93.8%; ASRM 3, 89.7%; ASRM 4, 93.1%; grouped ASRM 0, 1, and 2, 94.6%; and grouped ASRM 3 and 4 of 94.6%. Ultrasound had better test performance in higher disease stages. When the ASRM stages were dichotomized, ultrasound had sensitivity and specificity of 94.9% and 93.8%, respectively, for ASRM 0, 1, and 2 and of 93.8% and 94.9%, respectively, for ASRM 3 and 4.ConclusionUltrasound has high accuracy in predicting the mild, moderate, and severe ASRM stages of endometriosis and can accurately differentiate between stages when ASRM stages are dichotomized (nil/minimal/mild vs moderate/severe). This can have major positive implications on patient triaging at centers of excellence in minimally invasive gynecology for advanced-stage endometriosis.     

Human papillomaviruses in women with a history of abnormal Papanicolaou smears and in their male partners

Human papillomavirus infection of the genital tract was identified by the filter in situ hybridization test. Exfoliated cervical cells were tested separately for the prevalence of human papillomavirus 6/11 and 16/18. Human papillomavirus deoxyribonucleic acid (DNA) was identified in 70 and 92% of specimens of U.S. and West German women, respectively, who showed concurrent cytologic and colposcopic abnormalities, and in 50 and 54% of women, respectively, who showed neither cytologic nor colposcopic abnormalities at the time of examination. In the cytologic categories of condyloma, mild to moderate dysplasia (cervical intraepithelial neoplasia I/II), and severe dysplasia-carcinoma in situ (cervical intraepithelial neoplasia III), the overall DNA detection rate of human papillomavirus 6/11 and 16/18 varied between 75 and 83%; but human papillomavirus 16/18 was recovered relatively more frequently from the more severe lesions. Forty-eight West German women were monitored cytologically over a period of three to 24 months; progression to carcinoma in situ (cervical intraepithelial neoplasia III) was correlated with initial isolation of human papillomavirus 16/18. The vagina and vestibule were found to be frequent sites of human papillomavirus infection with the same virus type as in the cervix. In an investigation of male partners of 40 human papillomavirus-positive women, human papillomavirus was identified in exfoliated cells from 26; in 19 instances, the males harbored the same human papillomavirus types as their female partners.     

Acute salpingitis in sterilized women

Previously sterilized women are generally considered protected against salpingitis. However, when we diagnosed salpingitis by laparoscopy in 48 patients during a 16-month period, we found four (8%) who had been previously sterilized. Therefore, contrary to generally stated belief, salpingitis may occur after interruption of tubal continuity.     

Anatomic sites of upper genital tract infection

The microbiologic correlates of upper genital tract infection were studied among 36 women with suspected upper genital tract infection and 11 control women undergoing tubal ligation. Laparoscopic evidence of confirmed salpingitis was seen in 25 (69%) of the 36 women. Pathologic evidence of endometritis was present in 26 women (72%), and 22 (85%) of them had salpingitis as well. Thus, four women had endometritis but no salpingitis, three women had salpingitis but no endometritis, and seven women had neither. Among the 25 women with salpingitis, one or more organisms were isolated from the fallopian tubes of nine women (36%) and from the cul-de-sac of six women (24%), versus none and one (9%), respectively, among the 11 cases without salpingitis, and one (9%) and none among the 11 control women. Among the 26 cases with endometritis, one or more organisms were isolated from the endometrium of 19 women (73%) versus 12 (67%) among the 18 women without endometritis. Chlamydia trachomatis was isolated from the uterine cavity of nine women and from the fallopian tubes of three women with upper genital tract infection. The corresponding figures for Neisseria gonorrhoeae were three and two. Other nongonococcal nonchlamydial organisms were commonly isolated from the fallopian tubes and/or culde-sac of women with salpingitis. Bacteria frequently were isolated from the endometrium of both study cases and control subjects, but the latter were more likely to have nonpathogens of low virulence.     

Glassy cell carcinoma of the cervix revisited

OBJECTIVE: Glassy cell carcinoma (GCC) of the cervix has traditionally been characterized as an aggressive histologic subtype with poor outcomes. An earlier series from our institution supported a grim prognostic outlook, demonstrating a survival rate of only 55% in women with stage I disease. We present a comparison of a contemporary series of patients with GCC. METHODS: All cases of GCC treated from 1993 to 1999 identified by our tumor registry were reviewed for a variety of clinicopathologic features, treatment strategies, and outcome. RESULTS: A total of 403 cases of invasive cancer of the cervix were identified. There were 22 patients with histologically confirmed GCC, representing only 5.4% of all cervical cancer diagnoses. Patients with GCC had an overall survival of 73% (16/22) and a disease-free survival of 64% (14/22). The incidence of stage I lesions was 64% (14/22). Overall survival of patients with stage I disease was 86% (12/14), with a disease-free survival of 71% (10/14) at a median follow-up of 28.5 months. Seven stage IB lesions were treated with surgery alone, whereas six received adjuvant radiation or chemoradiation following surgery. Two patients in each treatment group recurred, yielding an overall recurrence rate of 29% (4/14). However, of those who recurred with stage I disease, all 4 patients had two or more intermediate risk factors (lymph-vascular space invasion [LVSI], deep tumor invasion, or tumor size greater than 3 cm). CONCLUSIONS: Glassy cell carcinoma of the cervix appears to have a better prognosis than previously reported. We observed that intermediate risk histopathologic features identified in squamous cell cohorts are also predictive of a poorer outcome in patients with GCC. Thus, patients with LVSI, deep stromal invasion, and large tumor size are at the highest risk for pelvic relapse and should be candidates for adjuvant treatment.