19 Prior pelvic inflammatory disease, endometriosis and ectopic pregnancy Joyanto Choudhury and Saikat Banerjee The aim of pre-pregnancy counseling is to PRIOR PELVIC INFLAMMATORY address issues regarding women’s concerns DISEASE about their ability to fall pregnant and to give birth to a healthy baby at the end of pregnancy. PID is defined as an infection of the endo- Pelvic inflammatory disease (PID)1 and metrium, fallopian tubes and/or contiguous endometriosis2 are both risk factors associated structures caused by the ascent of microorgan- with subfertility and thus could potentially isms from the lower genital tract1. The major- lead to failure to become pregnant. In the ity of cases in young women are associated event of a successful conception, tubal dam- with sexually transmitted infections (STIs), age secondary to these pre-existing disease the most prevalent being Chlamydia trachoma- processes increases the risk of an ectopic preg- tis and Neisseria gonorrhoeae. These organisms nancy. Of great importance, a prior history of often initiate an inflammatory process and an ectopic pregnancy is a possible indicator of then are replaced by opportunistic bacteria existing tubal damage and hence a strong risk including aerobes, anaerobes and Mycoplasma factor for reoccurrence3. Such an event will not sp8. Special consideration should be given to only be associated with an unsuccessful preg- tuberculosis which is discussed separately in nancy, but also with maternal morbidity at the this book. very least, if not mortality. Even in the pres- The Department of Health and Human Ser- ence of first-world medical facilities, ectopic vices in the USA9 and the Department of Health pregnancy still remains the leading cause of in the UK10 have expressed concerns that with maternal mortality in the first trimester, with changes in lifestyle, STIs represent a growing three women dying in the UK4 and 45 in USA every year5. problem with nearly 333 million curable cases 9 With the development of early pregnancy occurring worldwide annually . This concern assessment units, screening for risk of ectopic is not only based on increasing numbers of pregnancy, one of WHO’s primary objectives6, new STIs diagnosed in genitourinary clinics, not only is possible, but also has been shown but also on the fact that these rates are highest to be cost effective7. It is therefore imperative in women who are young and in the reproduc- to use the opportunity, when meeting a poten- tive age range. Young women aged 16–25 years tial mother to be, to identify risk factors for account for nearly half of all STIs diagnosed in ectopic pregnancy and to decide upon a man- genitourinary clinics, and it is this same group agement plan in advance for possible compli- that will potentially be considering a preg- cations that may arise. nancy post-infection. Of further concern is the 251 PRECONCEPTIONAL MEDICINE fact that 15% of women rarely or never use a infection in pregnancy are identical to those condom with a new sexual partner9. outside pregnancy, with development of repeat Prior infection (symptomatic or asymp- PID, increased risks of subfertility and ecto- tomatic) is a risk factor for current infection, pic pregnancy. Approximately 70% of preg- which may be associated with vaginal dis- nant and non-pregnant women infected with charge, irregular vaginal bleeding or pelvic chlamydia are asymptomatic; a small propor- pain, all of which direct women to seek medi- tion may present with non-specific symptoms cal advice. Unfortunately, such infections can including vaginal discharge, dysuria, lower also be asymptomatic and thus undetected abdominal pain, postcoital bleeding or arthri- at the time of consultation in the absence of tis. The vaginal discharge may be mild, irritat- routine screening procedures. Pre-pregnancy ing, usually yellow, and often goes unnoticed. counseling sessions may provide one of the Therefore, in the presence of these symptoms, few times that an otherwise healthy woman women in the clinic should be offered a test voluntarily accesses medical attention, and, as to exclude the possibility, with appropriate such, becomes an ideal chance to opportunisti- treatment and counseling if the result proves cally screen for STIs. positive. For women with no prior history of infec- Asymptomatic chlamydia infection during tion, the current UK national antenatal care pregnancy is associated with adverse preg- guidelines published by the National Institute nancy outcomes (low birth weight, preterm of Clinical Excellence (NICE)11 state that there delivery and preterm rupture of membranes) is no good evidence to suggest that routine as well as with postpartum endometritis and antenatal screening for STIs (other than HIV, neonatal morbidity, including respiratory tract syphilis and hepatitis B) is indicated. Previ- infection and conjunctivitis15. Up to two-thirds ously, however, with the advent of the National of women affected with chlamydia during Chlamydia Screening Programme12, NICE had labor may transmit the organism to the infant envisaged that based on current expert opin- during vaginal delivery. The infection clearly is ion, women who are pregnant or seeking pre- treatable and therefore is not an indication for pregnancy counseling at the age of 25 years or cesarean section; no evidence links chlamydia younger, should be advised on the availability with chorioamnionitis. of the screening program and that screening Microbiological detection is by vaginal, urine could be undertaken as part of this program. In or blood tests (Tables 1 and 2). Nucleic acid the USA routine antenatal screening is recom- amplification tests (NAAT) have a higher sen- mended for chlamydia along with gonorrhea, sitivity (90–95%) than enzyme immunoassays the latter if the pregnant woman comes from (40–70%) and therefore are the recommended an area of high prevalence13. Referral screen- laboratory test for diagnosing chlamydia ing programs also have the additional benefit infection from endocervical and vulvovaginal of contact tracing. swabs16. The vulvovaginal swabs have a sen- sitivity similar to endocervical swabs (90– 95%) and can be taken by either the patient Chlamydia or health-care worker. Variable sensitivities (65–100%) have been reported using the first Chlamydia trachomatis is currently the most catch urine (FCU) specimen. Cell culture common curable STI in the western world. In can be used on all specimen types, but has current screening programs, 8.5% of women low sensitivity (60–80%); because it requires below 25 years of age test positive for chla- expertise and is costly, it is not recommended mydia14. The clinical implications of chlamydia for routine purposes. On the other hand, the 252 Prior pelvic inflammatory disease, endometriosis and ectopic pregnancy Table 1 Tests in asymptomatic women. (Modified from UK National Screening and Testing Guidelines, 200616) Site or specimen Gonorrhea Chlamydia Syphilis HIV Urethra Cervix Culture NAAT Vagina NAAT Rectum Oropharynx Urine NAAT Blood EIA/TPPA/TPHA+VDRL EIA NAAT, nucleic acid amplification test; EIA, enzyme immunoassay; TPPA, Treponema pallidum particle assay; TPHA, Treponema pallidum hemagglutination assay; VDRL, Venereal Disease Research Laboratory Table 2 Tests in symptomatic women. (Modified from UK National Screening and Testing Guidelines, 200616) Site or specimen Gonorrhea Chlamydia Syphilis HIV Urethra M+C DGM Cervix M+C NAAT Vagina NAAT NAAT Rectum Culture Tissue culture Oropharynx Culture Tissue culture PCR Urine NAAT Blood EIA IgM EIA/LIA M+C, microscopy + culture; DGM, dark ground microscopy; PCR, polymerase chain reaction; EIA, enzyme immunoassay; LIA, line immunoassay direct fluorescent antibody test is applicable to can be identified on transvaginal ultrasonog- all specimens, including rectal and pharyngeal raphy appearing as elongated paraovarian swabs, but its widespread use is hampered by a cysts containing multiple partial septae and an low sensitivity (80%) and the need for techni- irregular inner luminal wall giving an appear- cal expertise; it is therefore not recommended ance described as ‘cog wheeling’. The cog for routine diagnosis. wheels are a result of aggregation of the tubal Diagnosis may also be made at surgical luminal cilia (Figure 2). The fallopian tubes inspection of the pelvic and abdominal cavities are usually bilaterally affected. At laparoscopy, with the demonstration of classical peritubular the pathognomonic feature of prior chlamydial adhesions (Figure 1a) as compared to the cen- tral midline adhesive disease more commonly pelvic infection is that of perihepatic adhesions associated with endometriosis (Figure 1b). named Fitz-Hugh-Curtis syndrome which is The tubal fimbrial ends are often damaged, also seen with prior gonorrheal infection and giving rise to distal occlusion with clubbing less commonly with tuberculosis associated and mild hydrosalpinx. Such hydrosalpinges PID. 253 PRECONCEPTIONAL MEDICINE a b Figure 1 (a) Fine filmy peritubular adhesions associated with pelvic inflammatory disease. (b) Dense central adhesions of the posterior cul de sac associated with endometriosis (note the tubal sparing) re-exposure is suspected. It should be deferred for 5 weeks (6 weeks if azithromycin is given) after treatment is completed in order to avoid false positive results16. Pre-pregnancy treatment of the tubal damage is by surgery to divide adhesions and possibly open up the distal blocked end of the fallopian tube by a cuff salpingostomy. An anti-adhesive barrier may