The value of screening and universal antibiotic prophylaxis in
the periabortal period
The Royal Oldham Hospital, Obstetrics/Gynaecology,
Oldham, North West, UK
Introduction Each year 210 million
pregnancies occur worldwide, of which an estimated 46 million end in an induced
abortion [WHO 2003]. There were 185,375 legal abortions carried out in England
and Wales in 2000, a rise of 2,125 (1.2%) compared with 1999. Pelvic infection
complicates up to 12% of induced abortions and has an adverse effect on future
reproductive outcome. The presence in the lower genital tract of Neisseria
gonorrhoeae, Chlamydia trachomatis or the anaerobic organisms characterising
bacterial vaginosis is associated with an increased risk of post-abortion
infective morbidity. Meta-analysis of randomized trials has shown that
prophylaxis with antibiotics effective against either Chlamydia trachomatis or
bacterial vaginosis reduces the risk of post-abortion infective morbidity by
around a half. Other strategies that have been advocated for minimizing the risk
of infective morbidity are screening for lower genital tract infections, with
treatment of positive cases only, and a combined strategy where women are
screened for sexually transmitted infections as well as receiving prophylaxis.
Objectives To review the strategy for prevention of post-abortal infection at a
Fertility Awareness Clinic.
Method A retrospective analysis of patients
attending a Fertility Awareness Clinic for TOP from November 2000 to December
2004. Data was extracted from a Microsoft Access TOP database and calculations
were done with Microsoft Excel.
Results A total of 1600 patients attended the
clinic, during the study period, requesting TOP. Only 1475 (92.2%) eventually
had TOP. Majority of the patients (83.9%) had a surgical induced abortion while
a medical method was used in 16.1%. About 68.1% accepted screening for infection
prior to the procedure. The prevalence of bacteria vaginosis, Chlamydia
trachomatis and Neisseria gonorrhoeae was 9.9%, 5.3%, and 1.0% respectively.
Majority of the patients (99.0%) had prophylactic antibiotics regardless of
acceptance of screening. Post-abortal contraceptive uptake was 77.0%. The most
common methods used were: Implanon (32.7%), IUCD (13.7%), COC (12.5%) and DMPA
(10.1%). Only 42.2% of patients attended the TOP clinic for follow up. About
2.4% of these were managed for post-abortal sepsis.
Conclusion Our study
confirms that a combined strategy of screening for sexually transmitted
infections as well as universal antibiotic prophylaxis is effective in reducing
post-abortal pelvic infection. An advantage of this strategy over the screen and
treat policy is that it allows for better coverage of the population at risk
since compliance with follow up visits cannot always be guaranteed. Furthermore
post-abortal pelvic infection can still occur due to false negative screening
tests or infections not screened for. Although this strategy appears costly at
the outset than the screen and treat policy, there are potential health and
economic benefits from preventing the sequelae of post-abortal sepsis.