RHL Commentary by Pattinson RC

1. EVIDENCE SUMMARY
This Cochrane Review highlights an area that requires urgent research. The question of whether the use of an antibiotic as a prophylactic is beneficial in women with incomplete abortions cannot be answered because of a lack of adequate research. Only one trial (1), is included in this review as it was the only one that fulfilled the criteria of the reviewers; a second trial (2), was excluded owing to high losses to follow-up in the study. The trial included in the review found no difference in the rates of postabortion infection between those who received routine antibiotic prophylaxis and those who did not. The methodology was perfectly adequate.

2. RELEVANCE TO UNDER-RESOURCED SETTINGS 2.1. Magnitude of the problem

If one considers that normally about 15% of clinically established pregnancies will end in abortion and in developing countries, where the fertility rate is high, it is clear that managing abortion cases is a common problem, which takes up a significant amount of time and resources of the health services. In developing countries, unwanted pregnancies and induced abortion are much more common than in developed countries owing to lack of access to methods of family planning and availability of reproductive health services. In the Pretoria region of South Africa (a mainly urban and peri-urban setting in a developing African country), incomplete abortion is the most common reason for the admission of a woman to a gynaecological ward. Complications of abortion are also the most common reason for maternal death and severe maternal morbidity in the region. While uncomplicated incomplete abortions are in themselves a major problem in developing countries, when complications related to abortion occur, such as severe haemorrhage or sepsis, the amount of time and resources required the manage them escalate rapidly.

2.2. Feasibility of the intervention

There is no intervention proposed in this review. However, the question remains a very valid one, should prophylactic antibiotics be used in incomplete abortions or not. The argument goes around whether they are effective in preventing complications, (for which there is currently no evidence) and whether they would be cost-effective - i.e. would the cost reduction in complications in women receiving antibiotics be large enough to justify the costs of giving antibiotics to all women with incomplete abortions. The answer to these questions is unknown. The use of prophylactic antibiotics has been shown in a systematic review to reduce postabortion sepsis in surgically-induced abortion (3). For low-risk patients 35 women would need to be treated to prevent one infection, whereas only 10 would need to be treated in high-risk women to prevent one case. This was found to be cost-effective, if a 100 mg of doxycycline, given orally one hour before the procedure and followed by 200 mg after the procedure, was given. Women regarded at high risk for developing post-abortion upper genital infection were; age less than 20

years, nulligravidity, (especially if the patient reports two or more sex partners within a year), previous pelvic inflammatory disease (PID) or gonorrhoea, and untreated gonorrhoea, chlamydia, or bacterial vaginosis at the time of abortion. In a study at a large hospital serving a mainly semi-urban and rural black population in South Africa, 35% of women presenting themselves for a termination of pregnancy were diagnosed as having a sexually transmitted disease (4). 23% had chlamydia and 5% had gonorrhoea. It would be logical to assume in this population that most women presenting with an incomplete abortion would be regarded as high-risk for post abortion infection, even though there may not be clinical evidence of infection at the time of presentation. Should prophylactic antibiotics be used, a single dose of doxycycline or a two-dose regimen as described above would be feasible and inexpensive. Doxycycline would be preferred to other tetracyclines because it has a long half-life, less gastrointestinal side-effects and does not chelate to food or calcium.

2.3. Applicability of the results of the Cochrane Review

The only study included in this review was performed in Zimbabwe, which is a developing country. Thus, the findings of this review should be applicable to other developing countries where there is a high prevalence of sexually transmitted diseases. The poor compliance of the patients with the prescribed antibiotic regimen in the trial illustrates the problem of prescribing a course of antibiotics as opposed to a single-dose regime. As the review did not find any benefit from the use of prophylactic antibiotics, no intervention can be recommended.

2.4. Implementation of the intervention

There is no evidence for clinicians to alter their current practice.

2.5. Research
Urgent research is required to determine whether the use of prophylactic antibiotics in incomplete abortion is useful. A single dose of antibiotics used around the time of the evacuation of the uterus should be tested. Although it is unrealistic to expect it from individual randomized controlled trials, one would like to see data on more significant end points such as hysterectomy and mortality. It would also be useful to learn whether different in antibiotic regimes yield different results and whether the results are different in high-risk and low-risk subjects. Sources of support: MRC Maternal and Infant Health Care Strategies Research Unit, South Africa. Acknowledgement: None.

References

Seeras R. Evaluation of prophylactic use of tetracycline after evacuation in abortion in Harare Central Hospital. East African medical journal 1989;66:607-610. Prieto JA, Eriksen NL, Blanco JD. A randomised trial of prophylactic doxycycline for curettage in incomplete abortion. Obstetrics and gynecology 1995;85:692-696. Sawaya G, Grady D, Kerlikowske K, Grimes D.. E Antibiotics at the time of induced abortion: the case for universal prophylaxis based on a meta-analysisl. East African medical journal 1996;87:884-890. Fernandes L, Mahomed MF, Mazibuko DM, Hoosen AA. Sexually transmitted pathogens in women attending for termination of pregnancy. Geneeskunde 1998;40 (2):16-19.

This document should be cited as: Pattinson RC. Antibiotics for incomplete abortion: RHL commentary (last revised: 24 June 2002). The WHO Reproductive Health Library; Geneva: World Health Organization.