Infection Associated With Abortion

Thomas W. Strahan Memorial Library
Index
Standard of Care for Abortion
Abortion Decision-Making
Psychological Effects of Abortion
Social Effects and Implications
Physical Effects of Abortion
Abortion and Maternal Mortality
Adolescents and Abortion
Definition of Terms
Women's Health After Abortion
Material Yet to be Cataloged
Strahan Summary Articles

Sub-Index
Physical Effects
Abortion Technique Risks
Short Term Complications
Immediate Complications
Pain in Women
Organ or System Failure
Infections Related Complications
Impact on Later Pregnancies
Cancer Risks

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Septic Abortion

Infections and Abortion, Sebastian Faro and Mark Pearlman (New York: Elsevier, 1992) 42

Acute complications from septic abortion include adult respiratory distress syndrome, septic shock, death of woman, renal failure, abscess formation, and septic emboli.

"Postabortion Infection, Bacteremia, and Septic Shock" in Infectious Diseases of the Female Genital Tract, 3rd Edition, Ed. Richard L Sweet and Ronald S Gibbs (Baltimore, Wilkins & Wilkins, 1995) 363-378

"Fatal Myocardial Infarction Resulting From Coronary Artery Septic Embolism After Abortion: Unusual Cause and Complications of Endocarditis," Victor Caraballo, Annals of Emergency Medicine 29(1): 175, Jan 1997.

"Emergency physicians often encounter patients who have undergone abortions. Such patients are at risk for many infectious and thromboembolic complications."

Acute Renal Failure from Septic Abortion

"S.R. v. City of Fairmont," 280 S.E. 2d 712 (W. Va. 1981)

A young woman underwent an induced abortion at a private abortion facility. The doctor noted on the medical record that fetal parts were seen following the abortion. It appeared that the woman was discharged without being so advised. She then developed cramps, vaginal bleeding and fever. She went to a local hospital but the personnel there were unsuccessful in diagnosing the exact nature of the problem. She went into shock. Ultimately, she was transferred to a larger medical center where the personnel there were able to save her life. However, before the undelivered fetal parts were removed, she developed acute renal failure arising from the septic abortion. In the absence of a kidney transplant, had to rely upon an ambulatory dialysis machine as a life support system.

Autoimmune Disease

"Pregnancy outcome and anti-Ro/SSA in autoimmune diseases. a retrospective cohort study," CP Mavragini et al, Br J Rhewmatol 37(7): 740-745, 1998.

A Greek study found that anti-Ro/SSA-positive women with systemic lupus erythematosus reported a significantly higher rate (18%) of therapeutic abortions compared to anti- Ro/SSA-negative women (5.6%) and healthy controls (4.6%).

"Etiological aspects of insulin dependent diabetes mellitus: an epidemiological perspective," G Dahlquist, Autoimmunity 15(1):61-65, 1993.

The mechanism of beta-cell destruction leading to insulin dependent diabetes is probably a cell mediated auto-immune process occurring in genetically susceptible individuals… Risk factors that may increase the peripheral need for insulin (infectious diseases, stressful life events, etc) may act as promoters of a beta-cell impairment and make the disease clinically overt.

"Stress and auto-immune endocrine diseases," J Leclere and G Weryha, Hom Res31(1-2): 90-93, 1989.

Auto-immunity may occur in all endocrine tissues, with a particular prevalence in thyroid and pancreatic islets… clinical observation registers frequent stressful life events just before the onset of these diseases… recent findings on the close relations between the immune system and central nervous system lead to conceive an actual psychoneuro- endrocine-immune axis.

"Fatal myocarditis associated with abortion in early pregnancy," DA Grimes, W Cates, Jr, Southern Medical Journal 73(2): 236-238, Feb 1980.

Four abortion-related deaths from 1975-78 are described which were attributed to myocarditis in the first trimester of pregnancy. The authors stated that, " the potential influence of pregnancy or abortion on the development or severity of cases of myocarditis is speculative. Since mild cases are usually undetected, the incidence of this condition among women of childbearing age is unkown. Only 59 women in the U.S. of childbearing age (15-44) were reported to have died from acute or subacute myocarditis in 1975." The authors noted that three of the four deaths were associated with conditions which have a presumed immunologic mechanism. Ed Note: myocarditis is inflammation of the muscular walls of the heart.

"Interplay between environmental factors, articular involvement, and HLA-B-27 in patients with psoriatic arthritis," R Scarpa et al, Annals of Rheumatic Diseases 51:78-79, 1992.

An Italian study of the medical records of patients with psoriatic arthritis and rheumatoid arthritis were reviewed. 9% of the patients with psoriatic arthritis had an acute disorder, which included abortion, immediately preceding the onset of the arthritis. In contrast, only 1% of the patients with rheumatoid arthritis recorded an acute event prior to the onset of their arthritis.

Endometritis

Endometritis is an infection in the inner uterine wall. It sometimes may be called febrile reactions. If not promptly treated, endometritis can require hostipalization and can impair future fertility. Endometritis is a major cause of maternal mortality.

"Postabortal Endometritis and Isolation of Chlamydia trachomatis," MB Barbacci et al, Obstet Gynecol 68:686, 1986.

A Johns Hopkins University study found that 10% of chlamydia positive women who underwent a first or second trimester abortion developed endometritis compared to 3.5% for chlamydia negative women.

"Morbidity Risk Among Young Adolescents Undergoing Elective Abortion," RT Burkman et al, Contraception 30(2): 99, 1984.

A Johns Hopkins University study found that teenagers age 17 or younger were more likely to develop postabortion endometritis (7.0%) compared to women age 20-29 (2.7%).

"Postabortal pelvic infection associated with Chlamydia trachomatis infection and the influence of humoral immunity," S Osser and K Persson, Am J Obstet Gynecol 150:699, 1984.

A Swedish study found that chlamydia positive women age 13-19 were more likely to develop postabortion endometritis (28%) compared to chlamydia positive women age 20- 24 (22.7%) or chlamydia positive women age 25-29 (20%). The same study found that chlamydia negative women aged 13-19 were also more likely to develop postabortion endometritis (9.3%) compared to chlamydia negative women age 20-24 (4.8%) or chlamydia negative women age 25-29 (4.7%).

"Preventing febrile complications of suction curettage abortion," T-K Park et al, Am J Obstet Gynecol 152:252-255, 1985.

A study of 26,332 women undergoing abortion at five abortion facilities during 1975-1978, found that post-abortion infections as measured by an oral temperature of 38 degrees centigrade for two or more days were significantly lower (relative risk 0.54) among women with one or more previous births compared to women with no previous births.

"Postabortal Endometritis in Chlamydia-Negative Women- Association with Preoperative Clinical Signs of Infection," B Hamark and L Forssman, Gynecol Obstet Invest31:102-105, 1991.

Women with clue cells constitute a group at risk for postabortal endometritis.

Genital Tract Infection

"Trichomonas Vaginalis: A Re-emerging Pathogen," P. Heine, J.A. McGregor, Clinical Obstetrics and Gynecology 36(1): 137, March 1993.

Trichomoniasis is the most prevelent non-viral sexually transmitted disease. Worldwide, there are approximately 180 million cases and 2.5 to 3 million infections occurring annually in the United States. There is an association between postabortal infection and trichomonal colonization. Improved understanding of the natural history, pathobiology, diagnosis and treatment of this common protozoa is urgently needed. Practitioners should consider routinely screening and treating women for trichomoniasis before any reproductive tract surgery (chorionic villi sampling, hysterectomy, cesarean section, dilation and curettage and therapeutic abortion).

"Pre-operative Cervical Microbial Flora and Post-Abortion Infection." P.T. Moberg, P. Eneroth, J. Harlin, A. Liung, and C.E. Nord, Acta Obstet. Gynecol. Scand 57:415-419. (1978).

One of the important complications of first-trimester abortion by vacuum aspiration is pelvic infection. The incidence of this complication varies widely [0.3-18 percent] due to differences in [1] definition of post-abortion infection; [2] use of prophylactic antibiotic treatment; [3] time of observation. Of 104 women who underwent first-trimester abortions, no patients showed any sign of lower genital tract infection prior to the operation. Nevertheless, 14 percent required postoperative treatment with antibiotics because of mild or severe infection of the upper genital tract. Patients were studied after two months.

"Genital Tract Infection," Ob. Gyn. News 20(3):42 February 1-41 1985 (quoting Kenneth Schulz, Division of Sexually Transmitted Disease, Center for Disease Control, Atlanta, Georgia).

An estimated 13,000 women develop postabortal upper genital tract infection which is associated not only with long-term morbidity but also, occasionally, with long-term sequelae such as infertility and ectopic pregnancy.

"Preventing Febrile Complications of Suction Curettage Abortion," F.K. Park, M. Flock, K. Schulz, and D. Grimes, American Journal of Obstetrics and Gynecology, 152:252-255, June 1,1985.

Despite the clinical and public health importance of infection, the risk factors for postabortal infection are not well understood. Because of the lack of uniform definitions and diagnostic criteria, rates of infectious complications, including endometritis, salpingitis or peritonitis, are difficult to interpret. Fever can provide a more objective estimate of the incidence of infectious morbidity, yet it is not an ideal indicator of infection. Little information has been published on the effect of parity on abortion complications. In the study, febrile morbidity rate was 0.34 per 100 abortions, with oral temperature greater than 38°C. for two days.

"Observations on Patients Two Years After Legal Abortion," P. Jouppila, A. Kauppila and L. Punto, International Journal Fertility, 19:233-239(1974).

Five hundred sixty-two Finnish patients who underwent legal abortions [69 percent by vacuum aspiration] were invited to a follow-up exam two years later. Only 25 percent came to a detailed gynecological exam. The rest either had an unknown address or were unwilling to take part in the discussion of an experience with "negative personal associations." Of the 143 patients examined, 14 percent had some early complications associated with the abortion. There were six cases of endometritis, six cases of heavy bleeding, one cervical rupture and one uterine perforation. A gynecological exam gave rise to suspected cervical insufficiency in 15 women, of which 10 had abortions by vacuum aspiration. Hysterosalpingography suggested tubal pathology in 18 percent. Laparoscopy revealed a normal tubal finding in 50 percent, although the HSG finding had been pathologic. Patients with pathologic tubal findings in laparoscopy [adhesions, nodules and sactoaalpinx formations] had not had early complications on abortion. The author concluded, "The need of new follow-up examination following induced abortion is obvious." This is one of the few studies on longer term effects.

"Morbidity after termination of pregnancy in first-trimester," S. Duthrie, D. Hobson, I.A. Tait, B. Pratt, N. Lowe, P. Sequeira and C. Hargreaves, Genitourinary Medicine 63(3): 182- 187, June 1987.

Pre-abortion clinical and microbiological tests were undertaken. Post-abortion morbidity was measured in 167 women in Liverpool, England during 1984. Twelve percent had major upper genital tract infection 8-17 days after their abortion. Another 10% later showed clinical signs that suggested minor upper genital tract infection. Abnormal cervical cytology (mostly inflammation) was found in 52% of the overall sample and 79% of the women with chlamydial infection had abnormal cervical cytology. Neither the medical history nor clinical examination before the abortion would have indicated that post- abortion complications were likely to occur. Ed. Note - The findings strongly suggest that it was the abortion procedure that was the primary cause of the post-abortion morbidity.

"Postabortal pelvic infection associated with chlamydia trachomatis infection and the influence of humoral immunity," S. Osser and K. Perrson, Am. J. Obstetrics and Gynecology150:699-703 (1984)

Chlamydia positive women aged 13-19 were more likely to develop post-abortion endometritis (28%) compared to women aged 20-24(22.7%) or women aged 25-29(20%). Chlamydia positive women aged 13-19 were more likely to develop post-abortion salpingitis (21.9%) compared to women aged 20-24 (13.6%).

Pelvic Inflammatory Disease (PID)

====General Background Studies for PID===="

About 1 out of 10 women cannot become pregnant after having PID once. After having PID three or more times, as many as 7 out of 10 women become infertile.

"Factors Related to Infertility in the U.S.. 1965-1976," William D. Mosher and Sevgi 0. Aral, Sexually Transmitted Diseases, 12(3): 117-123, July/September 1985.

The longer sexually active women postpone having their first baby, the greater is their risk of pelvic inflammatory disease and hence primary infertility.

"Chlamydia Trachomatis in Acute Salpingitis," J. Paavonen, E. Vesterinen and K. Aho, British Journal Venereal Diseases, 55: 203-206 (1979).

Acute salpingitis is a common disease and seems to be increasing. The clinical diagnosis of acute salpingitis was based on common criteria: pelvic pain of short duration, tender adnexal masses, increased erythrocyte sedimentation rate, and usually fever. The late sequelae of salpingitis are well known: infertility, increased frequency of ectopic pregnancies, and chronic abdominal pain. The risk of spread of cervical infection to the fallopian tubes must be considered in the treatment of cervical chlamydia.

"Chlamydial Infection in Infertile Women," T.R. Moss (letter). Fertility and Sterility,44(4): 559, October 1985.

Chlamydial pelvic inflammatory disease (PID) is an important cause of lost fertility. The challenge must be to prevent the tubal damage by early diagnosis, effective chemotherapy and prevention of reinfection. Fifteen percent of male patients attending this clinic were found to be asymptomatic with chlamydia trachomatis. It is considered a serious clinical omission in the investigation of PID to fail to take specimen from the anterior urethra of the male partner of the female patient.

"Chlamydia Trachomatis Infection in Women," Farq, Journal of Reproductive Medicine 30(3):273-278 (Supp), March 1985.

Infants of women with cervical chlamydial colonization have a 60-70 percent risk of being colonized during birth. Approximately 25-50 percent of them develop conjunctivitis, and 10-20 percent develop pneumonia. The patophysiology of Chlamydia trachomatis genital tract infection is not well understood. However, the principal focus of infection appears to be the cervix. Sequelae to acute salpingitis include chronic pelvic pain, hydrosalpinx pyhosalpinx, ectopic pregnancy, infertility, tuboovarian abscess and the Fitz-Hugh-Curtis syndrome.

"Effect of Acute Pelvic Inflammatory Disease on Fertility," L. Westrom, American Journal of Obstetrics and Gynecology, 12(5); 707-713, March 1,1975.

Obstruction of the fallopian tube is the most common cause of sterility in women. The only unequivocal proof of preserved tubal function after PID is an intrauterine pregnancy. Reinfection was found to have the strongest effect on fertility after PID. One out of five previously healthy women who fell ill with acute PID had a second infection. The relatively low frequency of sterility (12.8 percent) after one infection increased nearly threefold (to 35.5 percent) after two infections, and six fold (18 out of 24 cases) after three or more infections.

"Pelvic Inflammatory Disease: Etiology. Diagnosis and Treatment," Richard L. Sweet, Sexually Transmitted Diseases, 8(4): 308-315 (Supp.) December 1981.

PID caused by sexually transmitted pathogens results in infertility in more than 20 percent of the cases, and the risk of ectopic pregnancy increases six- to tenfold after PID. It is crucial to prevent reinfection by seeking out the sexual partners of women with PID and treating them for sexually transmitted diseases. In this way, the recurrent infections which lead to poor prognosis for fertility can be circumvented.

"Economic Consequences of PID in the U.S," James Curran, American Journal of Obstetrics Gynecology, 138 (7): 848 (1980).

In 1978, nearly one million women in the United States suffered from PID and its sequelae. They accounted for more than 2.5 million physician visits, 250,000 hospital admissions and nearly 150,000 surgical procedures. PID associated with sexually transmitted disease often begins in young, single women; manifestations of recurrent disease, sterility, ectopic pregnancy and major surgery occur five to ten years later. It was estimated that the direct annual cost is greater than $600 million, and the total cost for this disease is upwards of $3 billion.

"The Economic Cost of Pelvic Inflammatory Disease," A.E. Washington, P.S. Arno, M.A. Brooks, Journal of the American Medical Association, 255(13): 1735-1738, April 4,1986.

This study concluded that the total cost of PID and PID-associated ectopic pregnancy and infertility in the U.S. exceeded $2.6 billion in 1984. By 1990, the estimated cost of PID and its sequelae will total $3.5 billion per year, assuming an annual medical care inflation rate of 5 percent and the constant rate of incidence of PID during this six-year period. The study concludes that these estimated costs of PID and its associated sequelae emphasize the urgent need for effective programs to prevent Pm.

"Incidence, Prevalence and Trends of Acute Pelvic Inflammatory Disease and Its Consequences in Industrialized Countries," L. Westrom, American Journal Obstetrics Gynecology, 138: 880-892 (1980).

Despite antibiotic therapy, patients who have had at least one episode of salpingitis have a 21 percent rate of involuntary infertility, as compared with the rate of 3% among the control population.

"Introductory Address: Treatment of Pelvic Inflammatory Disease in View of Etiology and Risk Factors," L. Westrom, Sexually Transmitted Diseases, October-December 1984, pp. 437-440.

Clinically, PID can vary from an almost symptom-free disease to a life threatening condition. Sequelae to the disease are common. Ever since the first reports on PID in the literature, a strong correlation has been observed between sexually transmitted disease and PID. In recent studies, up to 75 percent of cases of PID in women less than 25 years of age have been associated with cultural and/or serologic evidence of infection with n. gonorrhea, chlamydia trachomatis, or m. hominis. For any sexually active woman, the risk of acquiring a sexually transmitted disease (STD), and hence of running this high risk of acquiring PID, is proportional to the regional prevalence of the corresponding STD and to the number of sexual partners.

Abortion Related Pelvic Inflammatory Disease

"Induced Abortion: Microbiological Screening and Medical Complications," B. Stray- Pederson et. al.. Infection 19: 305,1991.

A Scandinavian study found that Pelvic Inflammatory Disease developed significantly more often in untreated chlamydia-positive women (22.7%), mycolpasma hominis-positive women (8.1%) and Group B streptococci-positive women (6.1%) than in women without these microbes (0.5%).

"Bacterial Vaginosis and Anaerobes in Obstetric-Gynecologic Infection," D.A. Eschenbach, Clinical Infectious Diseases 16 (Suppl. 4): S282, 1993

Bacterial vaginosis has an important role in the development of postabortion pelvic inflammatory disease.

"Early and Late Onset Pelvic Inflammatory Disease among Women with Cervical Chlamydia trachomatis Infection at the Time of Induced Abortion- A Follow-up Study," J.L. Sorensen et al.. Infection 22(4): 242,1994.

A Danish study found that untreated women with chlamydia trachomatis infection at the time of induced abortion had a cumulative risk of 72% of developing early or late pelvic inflammatory disease, if observed for 24 months.

"Delayed Care of Pelvic Inflammatory Disease as a Risk Factor for Impaired Fertility," S.D. Hillis et. al.. Am. J. Obstet. Gynecol. 168:1503-1509,1993.

A Centers for Disease Control study found that women who delayed care for pelvic inflammatory disease after onset of symptoms had nearly a threefold increase risk of fertility impairment. Among women who delayed seeking care were women who had a history of a recent induced abortion.

"A Randomized Trial of Prophylactic Doxycycline for Curettage in Incomplete Abortion," J.A. Preito et. al., Obstet. Gynecol. 85: 692-696,1995.

Several epidemiologic studies have examined risk factors associated with postabortal pelvic infection. These include: patient less than 20, nulliparity, multiple sex partners, previous PID or gonorrhea, and untreated lower genital tract infections.

"Pelvic Inflammatory Disease Following Induced First-Trimester Abortion. Risk Groups. Prophylaxis and Sequelae," L. Heisterberg, Danish Medical Bulletin 35(1): 64-75, February, 1988.

Little is known about the costs of abortion complications and the true incidences of their sequelae. Long term prospective studies with follow-up of women who had abortions are most needed to assess the rate of sequelae after post aborted complications.

"Mobiluncus and Clue cells as Predictors of PID After First-Trimester Abortion," P.G. Larsson, B. Bergman, V. Forsum, J. Platz-Christenson and C. Pahlson, Acta Obstet Gynaecol Scand. 68:217-220, (1989).

In a Swedish study of 531 women in 1985-86 a correlation was found between the presence of mobiluncus and clue cells in vaginal discharge and the incidence of PID. Where women had clue cells the incidence of post-abortion PID was 11.8% compared to 3.2% PID when women showed normal epithelium cells.

"Early Complications of Induced Abortion in Primigravidae," K. Dalaker, K. Sundfor and J. Skuland, Annes Chirurgiae et Gynaecologiae 70:331-336(1981).

A follow-up examination 4-6 weeks following abortion by vacuum aspiration found 4.8% with retained fetal parts: 11.1% had post-abortion bleeding greater than normal menstrual period, and 4.1 % had pelvic inflammatory disease.

"Therapeutic Abortion," F. Jerve and P. Fylling, Acta. Obstetric Gynecology Scand. 57:237 (1978).

Pelvic inflammatory disease is a major complication after therapeutic abortion; readmission rates to hospitals were 4 percent in this study, with pelvic infections and retained products being the main causes.

"Chlamydia Trachomatis in Relation to Infections Following First Trimester Abortions," T. Radberg and L. Hamberger, Acta. Obstetrida Gynecological (Supp. 93) 154:478 (1980). (abstract)

In a Swedish study, women with endocervical chlamydial infections were over five times more likely than uninfected women to develop PID within four weeks after a first-trimester induced abortion. (23.4% vs. 4.4%)

"Chlamydia Trachomatis Infections in the United States, What Are They Costing Us?" A. Eugene Washington, R. Johnson, and L. Sanders, Jr. Journal of the American Medical Association, 257(15):2070-2072 April 17,1987.

Approximately 30-50 percent of PID episodes are caused by chlamydia trachomatis infection. It is estimated that each year 402,200 episodes of chlamydial PID occur, leading to 1,005,400 outpatient visits 106,900 hospitalizations, 8,050 infertility consultations, 13,900 ectopic pregnancies, and 280 deaths. Other adverse health effects, and estimated direct and indirect costs are discussed. Ed. Note - This report is most significant to the issue of induced abortion as it is implicated in the onset of pelvic inflammatory disease.

"Therapeutic Abortion and Chlamydia Trachomatis Infection," E. Qvigstag, K. Skaug, F. Jerve, I. Vik and J. Ulstrup, British Journal of Venereal Disease, 58:182-183(1982).

In a study of 218 women admitted for legal termination of pregnancy in Oslo, Norway, 30 (13.8 percent) had chlamydia trachomatis in the cervix before abortion. Twenty-one of the 30 patients exhibiting chlamydia trachomatis were followed up three months after their abortions. Seven (23.3 percent) had developed PID, six (20 percent) had developed salpingitis, 17(81 percent) showed detectable chlamydial antibodies. Conclusion: Patients harboring chlamydia trachomatis in the cervix at termination of pregnancy are at high risk of developing post-operative infections. Routine screening in the cervix before surgery is essential.

"Chlamydial Serology in Infertile Women by Immunofluorescence, R," Punnonen, P. Terho, V. Nikkanen and O. Meurman, Fertility and Sterility, 31(6): 656-659(1979).

This study showed the distribution of chlamydial antibody titers among infertile women, pregnant women and women exposed to males with STD. Non-sexually promiscuous women have significantly lower percentages of chlamydial antibodies.

Sexually Transmitted Diseases, K.K. Holmes, P.A. Mardh, P.F. Sparling, P.J. Wiesner (McGraw-Hill, 1984) 623

Operative procedures such as cervical dilatation, curettage, tubal insufflations and IUD insertions carry a small risk of infectious complications. During the last few decades, the numbers of legal abortions and IUD insertions have reached such proportions that the immediate consequences have influenced the epidemiology of salpingitis.

"Acute Salpingitis: Aspects on aetiology, diagnosis and prognosis," L. Westrom and P-A Mardh in Genital Infections and their Complications, D. Danielsson et al. eds. (Stockholm: Almqvist & Wiksell International, 1975,) 157-165.

In some cases iatrogenic procedures, such as legal abortions and insertion of lUD's, can cause an unrecognized infection in the cervix to spread to the uterine tubes.

Bacterial Vaginosis

Bacterial vaginosis appears to be one of the serious consequences of the sexual revolution and is of considerable concern to public health officials as the following articles indicate. It also appears that a substantial number of women presenting for induced abortion would have bacterial vaginosis.

"Bacterial vaginosis: a threat to reproductive health? Historical perspectives, current knowledge, controversies and research demands," PA Mardh, Eur J Contracept Reprod Health Care 5(3): 208-219, Sept 2000.

Bacterial vaginosis is a change in flora, the cause of which is still unknown in the vast majority of instances. Bacterial vaginosis has generally been used to represent any change in vaginal flora resulting in an assumed loss of lactobacilli. However, whether or not such a flora represents the genetically normal state of some women is poorly defined. The present "crude" diagnosis of bacterial vaginosis ought to be refined… Although bacterial vaginosis is generally believed to be an endogenous condition, a number of behavioral factors are involved, such as the use of contraceptive and intimate hygiene products and smoking habits. Although bacterial vaginosis is not considered a true sexually transmitted infection, it is related to sexual activities.

"Association Between Bacterial Vaginosis and Preterm Delivery of a Low Birth Weight Infant," SL Hillier et al, New England Journal of Medicine 333:1737-1742, 1995.

Bacterial vaginosis is a condition in which the normal, lactobacillus- predominant vaginal flora is replaced with anaerobic bacteria, Gardnerella vaginalis, and Mycoplasma hominis. Bacteria vaginosis has been associated with preterm delivery, premature of the membranes, infection of the chorion and amnion, histologic chorioamnionitis, and infection of amniotic fluid.); see also "Bacterial Vaginosis and Anaerobes in Obstetric- Gynecologic Infection," DA Eschenbach, Clinical Infectious Diseases 16(Suppl 4): S282- S287, 1993.

"Bacterial Vaginosis in Pregnancy: An Approach for the 1990s," MC McCoy et al, Obstetrical and Gynecological Survey 50(6): 482, 1995.

Screening for it is suggested because 50% of bacterial vaginosis is asymptomatic. The diagnosis, which is rapid and inexpensive, remains defined by clus cells seen on wet prep, high vaginal pH, and amine odor of vaginal discharge.

"Is bacterial vaginosis a sexually transmitted infection?," MC Morris et al, Sex Transm Infect 77(1): 63-68, Feb 2001.

Bacterial vaginosis is associated with some factors related to the acquisition of gonorrhoea and chyamydia trachomatis, see also "Bacterial vaginosis: a public health review," M Morris et al, BJOC 108 (5): 439-450, May 2001.

"Vaginal infections in human immunodeficiency virus-infected women," A Helfgott et al, Am J Obstet Gynecol 183(2): 347-355, Aug 2000.

There were significant associations between human immunodeficiency virus infections and bacterial vaginosis.

"Preventing adverse sequelae of bacterial vaginosis: public health program and research agenda. CDC Bacterial Vaginosis Working Group," EH Koumans and JS Kendrick, Sex Transm Dis 28(5): 292-297, May 2001.

The cause of bacterial vagnosis remains poorly understood. Recent evidence strengthens the association between bacterial vaginosis and serious medical complications. Recent evidence shows that screening and treatment of bacterial vaginosis before abortion reduces pelvic inflammatory disease.

"Universal prophylaxis for chlamydia trachomatis and anaerobic (bacterial) vaginosis in women attending for suction termination of pregnancy: an audit of short-term health gains," AL Blackwell et al, Int J STD & AIDS 10(8): 508-513, 1999.

In a British study of 400 women who obtained abortions, 8% had cervical chlamydia trachomatis and 28% had bacterial vaginosis. 53% of the women with preoperative c. trachomatis also had bacterial vaginosis. Among the untreated women with c. trachomatis, 63% developed postabortion upper genital tract infection; When treated with metronidazole suppositories and oral oxytetracycline, 12% developed upper genital tract infection. Ed Note: The incidence of bacterial vaginosis (BV) was much higher than chlamydia trachomatis in this study. The presence of BV at the time of the abortion also appeared to substantially increase the incidence of post abortion upper genital tract infection.

"Mobiluncus and clue cells as predictors of PID after First Trimester Abortion," P-G Larsson et al, Acta Obstet Gynecol Scand 68:217, 1989.

A Swedish study found that the presence of bacterial vaginosis and the time of induced abortion increased the incidence of postabortion PID to 11.8% compared to 3.2% when bacterial vaginosis was not present.

"Antibiotic prophylaxis to prevent post-abortal upper genital tract infection with bacterial vagnosis: a randomized controlled trial," T Crowley et al, BJOG 108(4): 396-402, 2001

A British study of women undergoing first trimester suction abortion found that bacterial vaginosis was present in 29.3% of women. Treatment with metronidazole resulted in an incidence of 8.5% upper genital tract infection compared to 16% of women treated with a placebo.

"Can Fem Card use facilitate bacterial vaginosis diagnosis on day of abortion to prevent postabortion endometritis?," L Miller, Obstet Gynecol 97(4 Suppl 1): S58-S59, April 2001.

A self-collected vaginal swab FemExam test card result to Nugent Gram stain scoring of the same specimen was undertaken to test the hypothesis that bacterial vaginosis (BV) treatment begun on the day of an elective abortion would reduce postabortion endometritis. Of the women tested, 39% tested BV positive using the FemExam test card. Results of the study were incomplete.

Chlamydia Trachomatis Infection

Comparison of rates of adverse events in adolescent and adult women undergoing medical abortion: population register based studyBMJ 2011; 342:d2111

The rate of chlamydia infections was higher in the adolescents seeking an abortion (5.7% v 3.7%, P<0.001)than adults.

Advanced duration of gestation (9-12, 13-16, and 17-20 weeks) was associated with an increased risk of infections after abortion. Additionally, being married or cohabiting compared with being single was associated with an increased risk of infection.

"The Influence of Sexual and Social Factors on the Risk of Chlamydia Trachomatis Infections: A Population-Based Seriologic Study," M Jonsson et al, Sexually Transmitted Diseases229(355), Nov/ Dec, 1995.

A history of therapeutic abortion was a statistically significant risk factor for prevalence of antibodies to chlamydia trachomatis.

"Chlamydia Trachomatis in Relation to Infections Following First Trimester Abortions," T Radberg and L Hamberger, Acta Obstricia Gynecological (Supp. 93 )154:478, 1980. (Abstract)

In a Swedish study, women with endocervical chlamydial infections were over five times more likely than uninfected women to develop PID within four weeks after a first-trimester induced abortion (23.4% vs. 4.4%)

"Pelvic Infection After Elective Abortion Associated with Chlamydia Trachomatis," B Moller et al, Obstetrics and Gynecology 59(2): 210-213, Feb, 1982.

Women applying for abortion should be examined and treated for gonorrhea and infection with chlamydia trachomatis either before or, at the least, in conjunction with the abortion.

"Criteria for Selective Screening for Chlamydia Trachomatis Infection in Women Attending Family Planning Clinics," H Handsfield et al, Journal of the Medical Association 225(13): 1730-1734, April 4, 1986.

Selective screening of sexually active women for chlamydial infection is advocated as a necessary and cost effective measure.

"Significance of Cervical Chlamydia Trachomatis Infection in Post-Abortal Pelvic Inflammatory Disease," L Westergaard et al, Obstetrics and Gynecology 60(3): 322-325, Sept, 1982.

The presence of chlamydia in the cervical canal at the time of the abortion in asymptomatic women increases the risk of postabortal PID from 10% (without chlamydia) to 28% (with chlamydia)

"Chlamydia Trachomatis Infection in Sexually Active Adolescents: Prevalence and Risk Factors," Mariam R Chako and JC Lovchik, Pediatrics 73 (6), June, 1984.

The prevalence of chlamydial infection in 280 sexually active urban adolescents was 26%: 35% in male adolescents, 27% in pregnant female adolescents, and 23% in non-pregnant female adolescents. Chlamydia was almost three times as prevalent as gonorrhea in the same population. Age, past history of sexual transmitted disease, oral contraceptive use, and concomitant gonorrhea were not significantly associated with chlamydial infection. However, multiple current partners, contact with sexually transmitted disease, genitourinary symptoms, and cervical ectopy were significantly associated with chlamydial infection.

"Favors Barrier Methods Over OCs for Sexually Active Teenagers." Richard Brookman, Family Practice News 17, November 1-14, 1987.

About 20 percent of 4,000 patients at an adolescent health clinic in Richmond, Virginia were screened for sexually transmitted diseases. Thirty percent had at least one infection; the most common were gonorrhea and chlamydia. About 12 percent were pregnant/ one quarter of them also had an STD. One reason for the high incidence of infection among adolescents is that at puberty, and perhaps several years after, the squamocolumnar junction is on the outer portion of the cervix. The exposed columnar epithelium is particularly susceptible to gonorrhea and chlamydia if exposure occurs.

"Post-Abortal Endometritis and Isolation of Chlamydia Trachomatis," M. Barbacci, M. Spence, E. Kappus, R. Burkman, L. Rao and T. Quinn, Obstetrics and Gynecology 68(5):686- 90 November 1986.

In a Johns Hopkins study of 505 women who had an induced abortion, 17.6% had a chlamydia infection. Six of 17 patients with post-abortal endomhetritis were culture positive immediately prior to abortion. Some 10% of c. trachomatis-infected women vs. 3.5% of non-c.trachomatis-infected women had endometritis following induced abortion. The article stated: "It is believed that a factor in the development of endometritis is the induced abortion itself as it has been documented that dilation of the cervical canal and curettage of the uterine cavity can stimulate spread of an unrecognized cervical infection to the uterine cavity.") Citing "Culture and treatment results in endometritis following elective abortion," Burkman et al., American Journal of Obstetrics and Gynecology 128: 566 (1977). Ed. Note - Endometritis is inflammation of the uterine wall.

"Genital infections in women undergoing therapeutic abortion," D. Avonts and P. Piot, Europ. J. Obstet. Gynec. Reprod. Biol. 20: 53-59 (1985).

In a study of 170 women at the Institute of Tropical Medicine in Belgium, there was found to be a strong correlation between an infection with c. trachomatis before abortion and the appearance of infectious complications after the aspiration curettage. Post-abortion infections were stated to be caused by microorganisms introduced in the uterine cavity during the intervention. In addition, sexually transmitted micro-organisms such as n. gonorrhea and c. trachomatis can colonize the endocervix and cause endometritis or PID (pelvic inflammatory disease) after the aspiration curettage.

"Chlamydial and gonococcal infection in a defined population of women," L. Westrom et. al, Scand. J. Infect. Dis. 32: 157 (1982).

The risk of acquiring pelvic inflammatory disease (PID) appears to decrease with increasing age among sexually experienced women. The relative risk for PID in women who were culturally positive from the cervix for n. gonorrhea, c. trachomatis or both, assigning a relative risk of 1.0 in the 15-19 year old age group were 0.7 for women 20-24; 0.4 for women 25-29 and 0.2 for women 30-34. Cited in Sexually Transmitted Diseases K.K. Holmes, P-A Mardh et. al (McGraw-Hill, 1989) 598.

Gonnorhea

"Disseminated Gonococcal Infection," K.K. Kerle et. al., American Family Physician45(1): 209, Jan., 1992.

The most frequent systemic complication of acute, untreated gonorrhea is disseminated infection which develops in 0.5-3% of the more than 700,000 Americans infected with gonorrhea each year. Up to 80% of disseminated gonococcal infection occur in women.

"Untreated Endocervical Gonorrhea and Endometritis Following Elective Abortion," R.T. Burkman, J. Tonascia, M. Atienza and T. King, American Journal of Obstetrics and Gynecology, 126: 648-651(1976).

2.7 percent of 4,823 patients had gonorrhea; 14.7 percent of patients with gonorrhea developed endometritis over a two-year period. The authors concluded that there is a potential threefold increase for postabortal endometritis with untreated endocervical gonorrhea, which indicates a need to reevaluate approaches to some patients requesting pregnancy termination.

"Gonorrhea: Update on Diagnosis and Management," Steven D. Colby, Medical Aspects of Human Sexuality 22:15-24, Mar. 1988.

In 1986 approximately one million cases of gonorrhea were reported to public health officials in the U.S.; it is estimated that up to 3 million are infected annually. Strains of neisseria gonorrhea are becoming increasingly resistant to a variety of antibiotics. Attempts to develop a vaccine against gonorrhea have not been successful.

HIV/AIDS

"Deliveries, abortion and HIV-1 infection in Rome, 1989-1994," Damiano D. Abeni et al., European Journal of Epidemiology, 13:373-378, 1997.

Significantly higher prevalences of infection [HIV-1] were associated with induced abortion (0.49%) than with delivery (0.18%) (OR: .2.72; 95% CI: 2.29-3.22).

"HIV Infection at Outcome of Pregnancy in the Paris area, France," E. Couturier, Y. Brossard, C. Larsen, M. Larsen, Lancet 340:707-709,1992. 

A French study in the Paris area and 3 surrounding districts with 46% of the reported AIDS cases in France found that HIV seroprevalence rate in women having a elective abortion was twice that of women who delivered (0.54% v. 0.28%), 2% of women with ectopic pregnancy and 4.8% of women having a therapeutic abortion were HIV seropositive.

"Prevalence of HIV among childbearing women and women having termination of pregnancy: multidisciplinary steering group study," D.S. Goldberg, H. MacKinnon, R. Smith, N.B. Patel, British Medical Journal 304:1082-1088, April 25,1992.

A Scottish study in 1988-1990 found that 0.13% of women attending an antenatal clinic and 0.85% of women obtaining abortions had HIV infection.

"Chlamydia Is Getting No Respect," Medical Tribune 29(3):1,10-11/17, August 18,1988.

A history of Chlamydia is associated with an enhanced risk of human immunodeficiency infection (HIV). In a study presented at the recent Fourth International Conference on AIDS in Stockholm, researchers followed 500 prostitutes from Nairobi, Africa from 1984- 1987. During that time HIV seropositivity rose from 59% to 85% of the women. A sub- group of 124 women were questioned regarding sex practices, history of sexually transmitted diseases, etc. Eighty-three of the members of this sub-group sero-converted. For the sero-converted women, a history of Chlamydia was associated with almost a fourfold increased risk of HIV seroconversion independent of other factors. One reason for the possible relationship between HIV and Chlamydia is that Chlamydia causes an intense inflammation of the cervix. Another possible explanation is that Chlamydia may produce a focus of inflammatory cells that could be infected by the HIV virus.

"The Transmission of AIDS: The Case of the Infected Cell. Tay," A. Levy JAMA 259(20):3037-3038, May 27,1988.

In Africa, where heterosexual spread is prominent, transmission appears to be enhanced by concurrent venereal diseases, particularly those caused by Haemophilus ducreyi (chanceroid) and herpes virus, which produce ulceration's in both men and women. Citing several studies. Furthermore, the copious inflammatory genital fluid, containing potentially large numbers of virus-infected cells, may be an added factor increasing HIV transmission. (Resistance to HIV of an intact squamous epithelial lining of the vaginal canal most likely plays an important role in limiting HIV infection in women. (When lesions occur in the vagina or cervix secondary to venereal infections, women can become more susceptible to HIV. Citing three studies.

"Measures to Prevent Cervical Injury During Suction Curettage Abortion," K. Schulz, D. Grimes, W. Cates, The Lancet, May 28,1983, p. 1182.

In addition to overt injury to the cervix during suction curettage, covert trauma is also important. Microfractures of the cervix may occur during forceful dilatation of the cervix/which may lead to persistent structural changes, cervical incompetence, premature delivery and pregnancy complications. Citing several studies.

"Pelvic inflammatory disease following induced first-trimester abortion." Lars Heisterberg, Danish Medical Bulletin 35(1):64-75, February 1988.

Reviews the current status of studies on the subject. Notes that studies show evidence of elevated risk of post-abortal PID for women with history of PID or c. trachomatis. A recent episode of vaginitis may also be a risk factor.

"HIV/AIDS Prevention and Multiple Risk Behaviors of Gay Male and Runaway Adolescents," Clara Haignere, M. Rotheram-Borus, C. Koopman, P. Cristina, M. Burchfield and A. Morales, Paper presented to the Sixth International Conference on AIDS, San Francisco, June 1990. (Abstract)

In a study by researchers from the New York State Psychiatric Institute and Columbia University on 75 female adolescent runaways in New York City. Suicide attempts and suicide ideation were found to be significantly related to having had an abortion, (p .05). Female runaways who had been pregnant were also more likely to have been in trouble with the law, to use drugs, to engage in frequent unprotected sexual intercourse, and to have had sex with multiple partners in the previous three months. Ed. Note - This study indicates that abortion may increase sexual promiscuity, lessen the desire for self- preservation and increased self-destructive behavior, including the increased risk of HIV/AIDS.

"Impact of the HIV Epidemic on Mortality in Women of Reproductive Age. United States," S.Y. Chu, J.W. Buehler and R.L. Berkelman, JAMA 264(2):225-229, July 11,1990

In 1987 the leading cause of death in black women residing in New York and New Jersey was HIV / AIDS. Malignant neoplasms were second. Drug abuse was listed on 27% of the HIV/AIDS death certificates as an associated cause of death. Ed. Note - Laboratory tests at the University of Minnesota have found that HIV grew as much as three times faster in peripheral blood mono nuclear cells exposed to doses of cocaine compared to non- cocaine exposed controls.

"The Effects of Gender and Crack Use on High Risk Behaviors," E. Golden, M. Fullilove, R. Fullilove, R. Lennon,D. Porterfield, S. Schwarcz and G. Bolan, Paper presented at the 6th International Conference on AIDS: San Francisco, June, 1990

The Center for AIDS Prevention Studies in San Francisco found that among black sexually active teenagers (15-19 years) the practice of engaging in the exchanging of sexual favors for drugs and having sex under the influence of drugs or alcohol were significant predictors of pregnancy in female crack users. The total number of drugs used predicted the number of sexually transmitted diseases. It was concluded that crack use may be an important risk factor for HIV infection in young women.

"The Increasing Frequency of Hetero-sexually Acquired AIDS in the United States - 1983 -1988," K.K. Holmes, J. Karon and J. Kreiss, American Journal of Public Health 80(7):858- 863, July,1990

Drug use, exchange of sex for drugs or money and early onset of sexual activity are increasingly associated with heterosexually transmitted infections, particularly in inner-city populations. It was concluded that promotion of "safe-sex" practices would be especially difficult in this group.

"AIDS and behavioral risk factors in women in inner city Baltimore: A comparison of telephone and face to face surveys," M. Nebot et. al, J. Epidemiology & Community Health 48(4): 412-418, Aug. 1994.

A telephone survey found telephone surveys among women aged 17-35 were more likely to report HIV testing, live in subsidized housing, report a previous abortion or surgical sterilization compared to face to face counseling.

"Psychosocial correlates and predictors of AIDS risk behaviors, abortion, and drug use among a community sample of young adult women," J.A. Stein et. al. Health Psychology13(4): 308-318, July, 1994

Risky AIDS behavior was strongly associated with multiple drug use and less social conformity and modestly related to sexual experience and abortion.

"Psychosocial and behavioral factors associated with physical and sexual abuse among HIV infected women," LA Bedimo et al, Int Conf AIDS, 1998; 12:219 (abstract no. 14185)

Among women attending a HIV outpatient program in New Orleans, Louisiana, 45% reported ever experiencing sexual abuse, 82% acquired HIV through heterosexual contact. Among those sexually abused, 27% first experienced it before the age of 17. Factors associated with a history of sexual abuse included having a history of abortion (33% vs. 9%)

"HIV-1 infection and reproductive history: a retrospective study among pregnant women: Adidjan, Cote d'Iviire," A Desgrees et al, Int'l J STD & AIDS 9:452, 1998

A study of pregnant women in West Africa found that having had an abortion increased the likelihood of HIV-1 particularly among younger women.

Hepatitis

"Health issues associated with increasing use of "crack" cocaine among female sex workers in London," H Ward et al, Sex Transm Infect 76(4):292-293

Thirty-four percent of female sex workers reported using " crack" cocaine in 1995-1996. Crack use was associated with abortion and hepatitis C infection. It is possible that "crack" use facilitates hepatitis C transmission due to oral lesions from smoking.

"A study of the role of the family and other risk factors in HCV transmission," S Brusaferro et al, Eur J Epidemiol 15(2): 125-132, 1999

Surgical procedures such as abortion and/or uterine curettage significantly increased the risk of HCV transmission both with univariate and multivariate analysis.

"Risk factors of contamination by hepatitis C virus in the general population," V Merle et al, Gastroenterol Clin Biol 23(4): 439-446, 1999 (English Abstract)

Multiple deliveries or abortion significantly increased the risk of infection by hepatitis C virus.

"Hepatitis C virus, hepatitis B virus and human immune infection in pregnant women in North-East Italy: a case-control study," V Baldo et al, Eur J Epidemiol 16(1): 87-91, 2000

A history of a previous abortion increased the likelihood of HCV infection in pregnant women, Odds Ratio 2.8

Use of Antibiotics in Connection With Induced Abortion

"Antibiotic Prophylaxis for Gynecologic Procedures," ACOG Practice Bulletin, No. 23, January, 2001.

The optimal antibiotic and dosing regimens for induced abortion and dilation and curettage remain unclear. Both tetracyclines and nitro-imidazoles provide significant and comparable protection against postabortal pelvic inflammatory disease. Based on good and scientific evidence, it was recommended that " women undergoing surgically induced abortion are candidates for antibiotic prophylaxis."

"Tetracycline resistance determinants: mechanisms of action, regulation of expression, genetic mobility, and distribution," MC Roberts, FEMS Microbiol Rev 19(1): 1-24: 1996.

Tetracycline resistant bacteria are found in a wide variety of ecosystems. see also "Tetracycline resistant Chlamydia trachomatis in Toulouse, France," JC Lefevre et al, Pathol Biol (Paris) 45(5): 376-378, 1997.

"Antibiotics at the Time of Induced Abortion: The Case for Universal Prophylaxis Based on a Meta-Analysis," G.F. Sawaya, D. Grady, K. Kerlikowske, D.A. Grimes, Obstet. Gynecol. 87(5): 884, May, 1996.

A meta-analysis concluded that there is a potentially substantial protective effect in all subgroups of women, even women in low-risk groups if antibiotics are routinely used at the time of induced abortion. It was estimated that if this was done that up to half of all cases of postabortal infections could be prevented.

"Preventing Febrile Complications of Suction Curettage Abortion," T.K. Park, M. Flock, K. Schulz and D. Grimes, Am. J. Obstetrics and Gynecology 152:252-255(1985); JPSA-III (1975-1978).

This study evaluated the relative risk of antibiotics, previous deliveries, type of anesthesia, level of physician training and type of suction cannula on the frequency of febrile complications, i .e. 38c temp for 2 days or more. Despite the clinical and public health importance of infection, the risk factors for postabortal infections are not well understood. (Prophylactic antibiotics reduced the rate of febrile complications i.e. 38c temperature for 2 or more days by one-third.)

"Antibiotic prophylaxis to prevent post-abortal upper genital tract infection in women with bacterial vaginosis; randomized controlled trial," T Crowley et al, BJOG 108(4): 396-402, 2001.

A British study of women undergoing first trimester suction abortion found that bacterial vaginosis was present in 29.3% of the women. Treatment with metronidazole resulted in an incidence of 8.5% post-abortal upper genital tract infection compared to 16% for women treated with a placebo.

"Universal prophylaxis for chlamydia trachomatis and anaerobic (bacterial) vaginosis in women attending for suction termination of pregnancy: an audit of short-term health gains," AL Blackwell et al, Int J STD & AIDS 10(8): 508-513, 1999.

In a British study of 400 women who obtained abortions, 8% had cervical chlamydia trachomatis and 28% had bacterial vaginosis. 53% of the women with preoperative c. trachomatis also had bacterial vaginosis. Among untreated women with c trachomatis, 63% developed upper genital tract infection; when women were treated with metronidazole suppositories and oral oxytetracycline, only 12% developed upper genital tract infection.

"Prophylactic Antibiotics for Curettage Abortion," D. Grimes, K. Schulz and W. Cates, American Journal of Obstetrics and Gynecology 150(6):689-694, Nov. 15,1984.

Legal abortion is the most frequently performed gynecologic operation in the United States, with nearly 1.3 million procedures reported in 1980. Curettage procedures were used for 96 percent of these abortions. Opinion is divided as to the advisability of routine use of prophylactic antibiotics for curettage abortion. Nausea and vomiting caused by tetracyclines may preclude administration of these antibiotics before the abortion, but a short course of antibiotic could begin after the procedure. Prophylaxis may help prevent both short-term morbidity and potential late sequelae, such as ectopic pregnancy and infertility.

"A Clinical Double-Blind Study of the Effect of Tinidazole on the Occurrence of Endometritis after First Trimester Legal Abortion," L. Westrom, L. Svensson and P. Wolner- Hanssen, Scand. Journal Infect. Dis., Suppl. 26: 104-109 (1981).

Twelve percent of women who had undergone vacuum aspiration abortion had febrile reactions with rectal temperatures above 38° C. The author observed that a portion of the early febrile reactions after VA are not attributable to infection, at least not those covered by the study. He also observed that acute salpingitis, as confirmed by laparoscopy, is rarely diagnosed during the first week after VA.

"Pelvic Inflammatory Disease Following Induced First-Trimester Abortion Risk Groups, Prophylaxis and Sequelae," L. Heisterberg, Danish Medical Bulletin, 35(1): 64-75, February, 1988.

Reviews six studies on antibiotic prophylaxis in induced first trimester abortion; two were clinical controlled trials: 4 cohort studies could be undermined by bias including selection bias such as assigning women at risk to the treatment group. Also, knowing which women receive treatment can influence both the women and the physicians in their recognition of symptoms and diagnosis of infection. Concludes that antibiotic prophylaxis should be used.

"Survey Reveals Noncompliance with Guidelines on Treating PID," Family Practice News 17(21): 341 Nov 1-14,1987.

A 1983-84 Seattle survey of 520 physicians and nurses who treated ambulatory patients for PID found that only 23% fully conformed to the Centers for Disease Control guidelines for antibiotic treatment: 63% provided intermediate therapy and 14% provided consistently inadequate therapy.

"Inflammatory Disease and Its Consequences in Industrialized Countries," L. Westrom, American Journal Obstetrics Gynecology,138: 880-892 (1980).

Despite antibiotic therapy, patients who have had at least one episode of salpingitis have a 21 percent rate of involuntary infertility/ as compared with the rate of 3% among the control population.