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  • Title: A randomised comparison of strategies for reducing infective complications of induced abortion.
    Author: Penney GC, Thomson M, Norman J, McKenzie H, Vale L, Smith R, Imrie M.
    Journal: Br J Obstet Gynaecol; 1998 Jun; 105(6):599-604. PubMed ID: 9647149.
    Abstract:
    OBJECTIVES: To determine lower genital tract carriage rates of C. trachomatis, N. gonorrhoeae and bacterial vaginosis among women seeking termination of pregnancy. To compare two clinical management strategies for minimising the risks of infective morbidity after induced abortion. DESIGN: Prevalence of infections was assessed by screening women undergoing abortion. Clinical management strategies were compared by a randomised trial. SETTING: The gynaecology departments of four hospitals in Scotland. PARTICIPANTS: 1672 women undergoing induced abortion. INTERVENTIONS: Women randomised to prophylaxis received metronidazole 1 g rectally before abortion plus doxycycline 100 mg twice daily for seven days. Women randomised to screen-and-treat received appropriate antibiotics only if screening proved positive for one or more infection. MAIN OUTCOME MEASURES: Prevalences of infections; morbidity in the eight weeks following abortion as assessed by reported symptoms, general practitioner consultation and prescription rates and hospital re-attendances; costs to the NHS of alternative managements. RESULTS: Prevalence rates: C. trachomatis 5.6%; N gonorrhoeae 0.19%; bacterial vaginosis 17.5%. Overall, women allocated to receive prophylaxis had lower rates of measures of short term infective morbidity than those allocated to screen-and-treat. These differences only reached statistical significance for women who were reported negative on screening. The direct costs to the NHS of prophylaxis and screen-and-treat were calculated to be 8.17 and 18.34 per woman, respectively. CONCLUSIONS: Prevalences of lower genital tract infections which have been implicated in increased rates of infective morbidity after abortion are similar to those reported elsewhere. Universal antibiotic prophylaxis is at least as effective as a policy of screen-and-treat in minimising the risk of short term infective morbidity and is far more cost efficient. The presence of infection in the lower genital tract at the time of induced abortion has been associated with an increased risk of postabortion pelvic inflammatory disease (PID). The present study investigated the prevalences of Neisseria gonorrhoeae, Chlamydia trachomatis, and bacterial vaginosis among 1672 women undergoing induced abortion at four Scottish hospitals in 1995-96. It further compared the effectiveness of two clinical management strategies for minimizing the risk of postabortion infection. Women were randomly assigned to receive either 1 g of metronidazole rectally before abortion and 100 mg/day of doxycycline for 7 days (n = 826) or treatment only if screening was positive for infection (n = 846). Preabortion lower genital tract screening indicated 3 women (0.2%) were positive for N. gonorrhoeae, 91 (5.6%) for C. trachomatis, and 282 (17.5%) for bacterial vaginosis. A review of the rates of general practitioner consultations, antibiotic prescriptions, and hospital readmissions in the 8 weeks postabortion showed that symptoms were minor and similar in duration and intensity among women in both treatment groups. The postabortion PID/endometriosis rate was 4.6% among women in the prophylaxis group and 6.8% in the screen-and-treat group. Women in these two groups who were initially positive for 1 or more infection had significantly higher rates of postabortion PID/endometriosis (7.7% and 7.4%, respectively) than those who were initially negative (3.1% and 5.7%, respectively). Antibiotics had to be prescribed postabortion to 13.1% of women initially positive for 1 or more infection compared with 7.8% of those initially negative. The cost of universal prophylaxis (8.17 pounds) was less than half that of screening with treatment and follow up of positive cases.
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