The value of screening and universal antibiotic prophylaxis in the periabortal period

A.O. Bale

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.