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Three Part Question

Can [patients who are pregnant] [develop or have concomitantly] [pelvic inflammatory disease]?

Clinical Scenario

An 18 year old female presents to the emergency department with lower abdominal pain, vaginal discharge. She is currently 8 weeks pregnant by dates and ultrasound confirms a viable intrauterine gestation. You wonder if this patient could have pelvic inflammatory disease even though she is pregnant.

Search Strategy

Medline 1950-06/09 using OVID interface, Cochrane Library (2009), PubMed clinical queries
[("Pelvic Inflammatory Disease"/Diagnosis) AND (exp pregnancy)] Limit to human and English

Search Outcome

125 papers were found of which only one study was relevant to the three part question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Acquavella AP, Rubin A, D'Angelo LJ 1996 USA	Adolescents with pelvic inflammatory disease who are also pregnant	A retrospective chart review of all adolescents admitted to a single university medical center over a 10 year period with a diagnosis of PID and pregnancy. Charts were reviewed to evaluate if patients met the clinical criteria for a diagnosis of PID based on laboratory and physical exam findings, i.e. they fulfilled the three major criteria and at least one minor criterion.	Over a 10 year period, 1205 adolescents were admitted for PID. Of those, 67 subjects were also pregnant. 10 patients were excluded from analysis for insufficient documentation. Of the remaining 57 patients, 24 met clinical criteria for a diagnosis of PID during pregnancy.	Pregnancy and PID were coexistent in about 2% of adolescents admitted for PID	This is a retrospective chart review and thus is limited by the information available in the chart and the possibility of hindsight bias. As only hospitalized patients were considered, the overall incidence of the occurrence of PID during pregnancy could not be ascertained. Moreover, PID diagnoses could not be confirmed with endometrial biopsies or laparoscopy, as the subjects were pregnant. Finally, this paper only addresses PID in adolescents.

Comment(s)

Pelvic Inflammatory Disease represents an ascending infection of the female upper genital tract. Since during pregnancy the pathway for the spread of infection is theoretically obliterated, it has been a widely held belief that PID and Pregnancy rarely, if ever, coexist. The above paper represents the only large case series attempting to answer this question. Although no large case series has examined this question in adults, there have been several case reports in the literature of adult patients with PID during pregnancy. Given that PID is almost always a clinical diagnosis, it seems reasonable to rely on accepted clinical criteria to define PID infection in the pregnant population no differently than in the non-pregnant population. Based on the above study, the two conditions can indeed occur simultaneously.

Clinical Bottom Line

If the 18 year old pregnant patient above meets clinical criteria for pelvic inflammatory disease, she should be treated for it.

References

1. Acquavella AP, Rubin A, D'Angelo A The Coincident Diagnosis of Pelvic Inflammatory Disease and Pregnancy: Are They Compatible? The Journal of Pediatric and Adolescent Gynecology 1996; 129-132