|Year : 2016 | Volume
| Issue : 2 | Page : 100-104
Pattern of pelvic inflammatory disease in women who attended the tertiary care hospital among the rural population of North India
Seema Dayal1, Amit Singh2, Vineet Chaturvedi1, Mani Krishna1, Vivek Gupta3
1 Department of Pathology, Rural Institute of Medical Sciences and Research, Etawah, Uttar Pradesh, India
2 Department of Microbiology, Rural Institute of Medical Sciences and Research, Etawah, Uttar Pradesh, India
3 Department of Pathology, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
|Date of Web Publication||30-Jun-2016|
Department of Pathology, Rural Institute of Medical Sciences and Research, Safai, Etawah, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: The term "pelvic inflammatory" disease refers to any infection in the lower reproductive tract of women. Women living in rural areas are usually not aware of the symptoms. They go to health-care providers only after alarming symptoms develop. Aim: The aim of the present study is to find out frequency of pelvic inflammatory disease (PID), their clinical symptoms, microorganism isolation, and histopathological evaluation of these women who attended the tertiary care hospital. Setting and Design: Tertiary care hospital and retrospective study. Materials and Methods: A total of 247 women with clinical symptoms of PID was included in the study. The performa was filled that included relevant clinical details. Microbe culture and histopathology were the diagnostic tools used. Statistical Analysis: Percentage. Result: The frequency of PID was 15.38%. Maximum number of patients belonged to the age group of 31-40 years (41.29%). Abdominal pain (75.50%) was the chief clinical complaint. Leukocytosis (72.06%) and Gram's stain positivity (51.82%) was also seen. Staphylococcus aureus was most common microbe isolated (8.50%) in culture. Chronic cervicitis (11.33%) was common on histopathology, though endometritis (6.47%) is diagnostic for PID. Conclusion: PID is the most common disease causing morbidity and mortality in infected women. Therefore, measures should be taken regarding early diagnosis so as to provide treatment before the complications develop.
Keywords: Culture, histopathology, microbe isolation, PID
|How to cite this article:|
Dayal S, Singh A, Chaturvedi V, Krishna M, Gupta V. Pattern of pelvic inflammatory disease in women who attended the tertiary care hospital among the rural population of North India. Muller J Med Sci Res 2016;7:100-4
|How to cite this URL:|
Dayal S, Singh A, Chaturvedi V, Krishna M, Gupta V. Pattern of pelvic inflammatory disease in women who attended the tertiary care hospital among the rural population of North India. Muller J Med Sci Res [serial online] 2016 [cited 2017 Oct 20];7:100-4. Available from: http://www.mjmsr.net/text.asp?2016/7/2/100/185005
| Introduction|| |
Pelvic inflammatory disease (PID) has become a silent killer that devastates women's life. In rural population of India, women are generally not aware of symptoms of PID. They move for health care unless alarming symptoms develop.
PID is defined as the inflammation of the upper genital tract including the uterus, Fallopian tube More Details, ovaries, and the pelvic peritoneum. , If the disease is left untreated, it could result in serious consequences such as infertility, ectopic pregnancies, chronic abdominal pain, and internal pelvic scarring.
The natural protective mechanism is impaired during menstruation and after abortion and delivery. In addition to these factors, intrauterine manipulations such as curettage for evaluation in abortion and manual removal of placenta favor the entry and spread of pathogenic organism. Intrauterine contraceptive device is also a source of infection, particularly when it is not introduced under aseptic conditions. Inflammation observed in PID patients result from infection mostly bacterial.  The microorganism responsible that can be sexually transmitted are Chlamydia trachomatis, Neisseria More Details gonorrhea, , or Streptococcus sp. Enterococcus faecalis, Escherichia More Details coli, Klebsiella sp., Staphylococcus sp. , Histopathology is a diagnostic investigation done in patients with PID. Endometrial biopsy has been studied extensively in the diagnosis of PID. According to the CDC criteria Endometritis on histopathology is definitive criteria for the diagnosis of PID.  Endometritis is common and myometritis is uncommon, occurs in continuation with endometrium infections. Cervicitis is comparatively common and even some degree of cervix inflammation is present in virtually all parous women.
Salpingitis is common, its incidence keeps increasing. It may follow invasive procedure (such as curettage or insertion of IUCD). Oophoritis usually spread from endometrium and always associated with tubal involvement.
The incidence of PID in developing world is difficult to assess due to poor availability of data but cases are increasing in developing countries, such as India, especially among rural population, so this study was planned to know clinical characters, microorganism isolation and histopathological evaluation of PID.
Therefore, In all the suspicious patients of PID, cervicovaginal swab should be taken and cultured to isolate organism followed by histopathology must be done in rural population to reduce morbidity and mortality in infected females.
| Materials and Methods|| |
This is a retrospective study carried out in the Department of Pathology and Microbiology in Rural Institute of Medical Science and Research Saifai Etawah (UP). Samples received in Pathology and Microbiology department were included. For microorganism examination, Endocervical and endometrial samples biopsy were taken. Sample from peritoneum was also taken when PID was suspected. Saline wet preparation was carried to rule out Trichomonas vaginalis. Gram's stain was done on the smears for the morphological identification of organism. Giemsa stain was also applied to rule the presence of Chlamydia trachomatis specially Donovan bodies.
Culture for microbe isolation was done on Blood agar, McConkey agar media, and incubated aerobically at 37°c for 24 h. Identification was based on macroscopic examination of growth on cultured plates, microscopic studies of isolates on account of Gram's stain and biochemical characteristic coupled with test for motility. Polymerase chain reaction (PCR) was also done for the diagnosis for tuberculosis and Chlamydia trachomatis in those cases in which diagnosis was suspicious and not made by other investigations. Samples, such as leucocyte count, erythrocyte sedimentation rate, C-reactive protein, were taken for hematological investigations, whereas for histopathological examination received specimens were formalin fixed, sectioned at 4 microns, and stained with hematoxylin and eosin (H&E). Additional section if required were also taken.
Predesigned proforma was filled which included relevant information regarding patient's age, age of marriage, parity, no of living children, abortion, contraceptive use and clinical complaints. Pregnant women were excluded.
Statistical analysis was done by percentage. Pattern of pelvic inflammatory disease was analyzed using demographic factors and laboratory investigations which included hematology, microbiology and histopathology.
Ethical clearance was obtained from the Institutional Research Committee.
| Result|| |
During this study period (1 st January 2008 to 31 July 2015) 247 patients clinically suspicious of PID were included in present study. Centre for Disease Control and Preventation criteria were included in study for the diagnosis of PID. The frequency of PID was 15.38%. The maximum cases was seen in the age group of 31-40 years (41.29%). Most of the females were multiparous (80.97%) though 24.69% cases of abortion were also seen [Table 1]. Abdominal pain (75.70%) was chief clinical complaint of patients followed with abnormal discharge (73.27%) and others [Table 2]. Supplementary investigation, such as leukocytosis (72.06%), raised erythrocyte sedimentation rate (ESR) (72.06%), raised CRP (71.25 %), leukocytosis on vaginal discharge (67.61%), Gram's stain positive (51.82%), wet preparation (2.02%), were also included [Table 3].
|Table 1: Table showing demographic complaints of patients presenting with PID|
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|Table 2: Table showing clinical complaints of patients presenting with PID|
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|Table 3: Table showing adjutant investigations done in patients presenting with PID|
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In PID specimens, microbe isolation was seen only in 34% cases. Staphylococcus aureus was predominant (8.50%). Streptococcus pyogenes (7.28 %), Neisseria gonorrhoeae More Details (6.47%) were less common. However, mixed infection was found in 3% [Table 4].Histopathological examination is confirmatory for the diagnosis of PID. Chronic cervicitis was common in 11.33%, chronic endometritis was common in 4.8%, acute was common endometritis in 1.6% [Table 5].
|Table 4: Table showing microorganism isolated among the patients presenting with PID|
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|Table 5: Table showing inflammatory pathology of patients presenting with PID on histopathological examination|
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| Discussion|| |
PID is one of the common clinical complaints in gynecologic practice and frequently vexes both patients and clinician. PID implies inflammation of the upper genital tract involving fallopian tube as well as ovaries because most of PID are due to ascending or blood borne infection, the lesion is often bilateral though one tube may be affected than the other. It is estimated that about 40-50% of all PID cases in the developing countries are caused by abortion and puerperal sepsis, 5% by intra uterine contraceptive device. The complications of PID are about 15% suffer from infertility lastly 8% of those who conceive will have an ectopic pregnancy.  We have received less cases of PID in comparison to Nkwabong  reason behind that may be less registration of patients and most of cases were of acute PID which were treated by physician. So biopsy was not required.
The factors associated with PID are young age, multiparity, abortion, and reduced socioeconomic status.  The present study also justifies this because multiparity (80.97%) was associated demographic factor seen in majority with PID followed by low socioeconomic status (74.49%), history of abortion (24.69%), but maximum number of cases were seen in the age group of 31-40 years (41.29%) [Table 1] that was little above the younger age.
Several million women worldwide have symptomatic PID each year and similar number probably have symptom less PID.  Clinically, PID may be asymptomatic or may present with abdominal pain, abnormal vaginal discharge, menstrual disorders, backache, postcoital bleed, and other clinical features.
In the present study, abdominal pain was the chief complaint (75.70%), followed by abnormal vaginal discharge (73.27%) [Table 2], whereas Nkwabong detected abnormal vaginal discharge (100%) and pelvic tenderness (97.1%) as the chief complaint in his study.
A confirmed diagnosis of PID is made by culture and histopathology. But additive investigations, such as total leucocyte count, differential leucocyte count, erythrocyte sedimentation rate, C-reactive protien, are always significant though their specificity and sensitivity is less. They are raised in inflammatory and infective conditions. Quan M  and Jaiyeoba O  also justified the importance of these investigations. In the present study, leukocytosis (72.06%), raised ESR (72.06%), and increased CRP (71.25%) were seen in vaginal discharge (67.61%) [Table 3]. Microscopy for vaginal secretion should be performed in suspicious cases of PID, one leucocyte/epithelial cell is significant.  Gram's stain was originally devised by Christian Gram in 1884 as a method of staining bacteria in tissues. The Gram's stain differentiates Gram's positive and Gram's negative bacteria on the basis of retaining the primary stain.  On Gram's staining (51.82%), cases were Gram's positive. Wet preparation was found positive for Trichomonas vaginitis in (2.02%,) cases. Wet mount is the most widely used method for the detection of Trichomonas vaginitis with a sensitivity of 51-66% and specificity of 100%.  Tuberculosis is caused by Mycobacterium bacilli. Tuberculosis bacilli is diagnosed by Ziehl-Neelson stain, LJ media culture, PCR.  In this study, two cases were diagnosed by Ziehl-Neelson stain, one more on culture, and two more by PCR aggregating (2.02%). PCR is a rapid, sensitive, and specific molecular biological method applied, which is useful in the diagnosis of pulmonary and extrapulmonary tuberculosis. 
There are several natural barriers to the ascent of pathogenic organism from vagina to fallopian tube. The natural protective mechanism is impaired during menstruation and after abortion and delivery because the cervical canal becomes dilated, protecting epithelium of endometrium shed, vagina PH raises, causing genital tract more venerable to infections. In addition, intrauterine manipulation, such as curettage for evacuation in abortion and manual removal of placenta, favor the entry and spread of pathogenic organism. 
The inflammation observed in PID result from infection mostly bacterial. In the present study, microbe isolation was seen in (34%) cases. S. Aureus was (8.50%) predominant microbe followed by Streptococcus pyogenes (7.28%) and Neiserria gonococcus (6.47%) [Table 4] and mix infection was found (3%). Our result were similar with Spencer et al.  who found mix culture (2%), sterile culture in (55%). S. Aureus (14%), S. pyogenes (3%) in their study. Chlamydia trichomatis is common organism found in pelvic inflammatory disease. But in present study it was (2.42%). On the basis of Giemsa's stain, three cases of Chlamydia trichomatis and three more cases were identified by PCR. Chlamydia trichomatis by PCR assay performed on endo cervix swab specimens provide highest sensitivity, there by leading to early diagnosis which minimizes the risk of disease sequel and continued transmission of infections. 
The histopathological examination is confirmatory investigation in the diagnosis of PID. On histopathology examination of PID, chronic cervicitis (11.33%) was common. Cervix is gateway for reproduction and sexual intercourse. Hence, it can be prone to STI and UTI's during intercourse, conception, pregnancy, delivery and post-partum.
Chronic cervicitis is very common and it is seen in about 80% of women with any gynecological complaints. Chronic cervicitis is an extremely common condition in female. It is an important because it may lead to endometritis, salpingitis, and PID through ascending intraluminal spread, chorioamnionitis, or other complications acute cervicitis was aggregating (0.80%). The reason for less no. of cases of acute cervicitis was because it is treated by physician on medical treatment. So biopsy and culture was not required.
The rate of incidence of acute endometritis was 1.61%. Chronic endometritis on histopathology was more common (4.8%) compared to PID [Table 5].
Myometritis (0.80%) was found in association with endometritis. Myometritis is seen less frequently than endometritis and it occurs in continuation with endometrium infections.
Endometrium is the second most commonly infected site in female genital tract after fallopian tube. Tubercular endometritis is a form of chronic endometritis though it is uncommon in the Western countries unlike in the developing countries. In this study endometrial tuberculosis was (2.02%).
Salpingitis of the fallopian tube is a common disease and the rate of its incidence keeps increasing. It may follow invasive procedures such as curettage or the insertion of IUCD, but in most of the cases it occurs due to an ascending infection, often sexually transmitted. Complications of salpingitis can leads to infertility. 
Here, the rate of incidence of chronic salpingitis was 1.21%. It was secondary to ascending infection.
Oophoritis are uncommon. It usually spread from the endometrium and is practically always associated with tube involvement. Oophoritis was occupying 0.80% of the PID pathology.
| Conclusion|| |
In the rural population, a large no of women are suffering from PID causing morbidity and mortality to infected females. The diagnostic modalities, such as PCR, should be included along with other investigations for the diagnosis of PID, especially in those cases in which diagnosis is suspicious but not confirmed. Frequent screening camps and counseling program should be carried out and education must be provided on how to maintain of proper personal hygiene, promoting hospital deliveries.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Rohrbeck P. Pelvic inflammatory disease among female recruit trainees, active component, U.S. Armed Forces, 2002-2012. MSMR 2013;20:15-8.
Spencer TH, Umeh PO, Irokanulo E, Baba MM, Spencer BB, Umar AI, et al
. Bacterial isolates associated with pelvic inflammatory disease among female patients attending some hospital in Abuja, Nigeria. Afr J Infect Dis 2014;8:9-13.
Davis B, Turner K, Ward H. Risk of pelvic inflammatory disease after Chlamydia infection in a prospective cohort of sex workers. Sex Transm Dis 2013;40:230-4.
Herzog SA, Altaus CL, Heijne JC, Qakeshott P, Kerry S, Hay P, et al
. Timing of progression from Chlamydia trachomatis infection to pelvic inflammatory disease: A mathematical modeling study. BMC Infect Dis 2012;12:187.
Schindlbeck C, Dziura D, Mylonas I. Diagnosis of pelvic inflammatory disease (PID): Intra-operative finding and comparison of vaginal and intra-abdominal cultures. Arch Gynecol Obstet 2014;289:1263-9.
Paavonen J , Molander P. Pelvic inflammatory disease. Text book of Gynecology. Editor in Robert W. Shaw, W. Patrick Soutter, Stuart L. Stanton. China: Churchill Living Stone; 2003. p. 894.
Padubidri VG, Daftary SN. Pelvic inflammatory disease. Howkin′s and Bourne Shaw′s Textbook of Gynaecology. 12 th
ed. New Delhi: Churchill Living Stone; 1990. P. 229-38.
Nkwabong E, Dingom MA. Acute pelvic inflammatory disease in a sub-Saharan country: A cross sectional descriptive study. Int J Reprod Contracept Obstet Gynecol 2015;4:809-13.
Walner-Hansen P, Kiriat NB, Holmes KK. Atypical PID; sub acute, chronic or subclinical upper genital tract infection in women. In: Holmes KK, Mardh PA, Sparling PF, Wiesner PJ, editors. Sexually Transmitted Diseases. 2 nd
ed. New York: McGraw-Hill; 1990. p. 615-20.
Quan M. Pelvic inflammatory disease: Diagnosis and management. J Am Board Fam Pract 1994;7:110-23.
Jaiyeoba O, Soper DE. A practical approach to the diagnosis of pelvic inflammatory disease. Infect Dis Obstet Gynecol 2011;2011:753037.
Ananthanarayan R, Paniker J. Text Book of Microbiology, in editor Paniker J. Orient Longman Pvt. Ltd., 6 th
ed. Hyderabad, India 2002:324-36.
Wiese W, Patel SR, Patel SC, Ohl CA, Estrada CA. A meta-analysis of the papanicolaou smear and wet mount for the diagnosis of vaginal trichomoniasis. AM J Med 2000;108:301-8.
Semeniuk H, Zenter A, Read R, Church D. Evaluation of sequential testing strategies using non amplified and amplified methods for the detection of Chlamydia Trachomatis in endo cervix and urine specimens from women. Diagn Microbiol Infect Dis 2002;42:43-51.
Bose M. Female genital tract tuberculosis: How long will it elude diagnosis. Indian J Med Res 2011;134:13-4.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]