Pelvic Inflammatory Disease

This case describes how a relatively safe gynaecological intervention gave rise to a complication that increased patient’s morbidity significantly. Although majority of studies suggest Insertion of IUS to be a safe procedure with little or no effect on PID and use of prophylactic antibiotic being unnecessary, this case is a clear example of the need for modifying this practice according to risk factors. Considering our patient, she had a few risk factors rendering her slightly more immunosuppressed. She had Ankylosing spondylitis and had been on adalimumab injection (although withheld once PID diagnosed). She was also obese with type 2 Diabetes Mellitus which again were potentially affecting her immune response. Although in this case her sexual history was not significant nor was she previously diagnosed with Sexually transmitted infections. Since this case, we’ve had two more cases of tubo-ovarian abcess developed after IUS insertion in obese women with other medical conditions that could affect their immune response. Reconsidering the protocol for women based on their past medical history and administering antibiotics might reduce the incidence of these life-threatening Tubo-ovarian abcesses reducing patient Morbidity significantly. To make it cost-effective, a criteria can be designed for women who should or should not receive prophylactic antibiotics. Table 1 suggests some risk factors that could lead to consideration of prophylactic antibiotics. Table 1: Suggests some risk factors that could lead to consideration of prophylactic antibiotics. Risk Factors for PID that might need consideration of prophylactic antibiotics BMI Presence of medical conditions that can effect immunity e.g Diabetes, Use of immunosuppressants (6), HIV (10) etc. Endometrial biopsy obtained at the same time as IUS insertion. Previous history of treated Sexually transmitted Infection The table also suggests antibiotics for women who previously had STIs based on studies that compared the incidence of PID with IUS insertion in women with STIs to women without previous/ current STI [8]. It is, however, important to mention here that IUS is altogether contraindicated in women with purulent cervicitis or active cervical chlamydial infection or gonorrhoea. There have been suggestions about pre IUS insertion screening for chlamydia and Gonorrhoea, however no significant difference has been identified in the incidence of PID among screened and unscreened women [7]. Although there have been small studies on some immunosuppressed condition where IUS was shown not to increase the risk of PID, author is still of the opinion that larger trial are needed to assess the effect of IUS in the immunosuppressed as well as the need for prophylactic antibiotic.

Although there is strong evidence against the use of prophylactic antibiotics before IUS insertion, there is a need for studies focused on immunosuppressed patients. Until then, considering antibiotics for high risk women might prevent significant morbidity in this group of patients.

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