Original Article Received: February 4, 2014 Accepted: March 18, 2015 Published online: April 23, 2015
Gynecol Obstet Invest DOI: 10.1159/000381772
Predictive Markers of Tubo-Ovarian Abscess in Pelvic Inflammatory Disease Suk Woo Lee a Chae Chun Rhim a Jang Heub Kim b Sung Jong Lee b Sie Hyeon Yoo c Shin Young Kim b Young Bin Hwang b So Young Shin b Joo Hee Yoon b a
Department of Obstetrics and Gynecology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, b Department of Obstetrics and Gynecology, College of Medicine, Catholic University of Korea, and c Department of Anesthesiology and Pain Medicine, Soonchunhyang University of Medicine of Korea, Asan, Korea
Abstract Background/Aims: The purpose of this study was to identify predictive markers for tubo-ovarian abscess (TOA) through a comparison of clinical and laboratory data in patients diagnosed with pelvic inflammatory disease (PID). Methods: We reviewed the medical charts of 499 females who were admitted to hospital with clinical, surgical, imaging-based diagnoses of PID between 2001 and 2011. The patients were divided into the following two groups: (1) PID with TOA and (2) PID without TOA. Results: The TOA and non-TOA groups were comprised of 69 and 430 females, respectively. Mean age, history of intrauterine device (IUD) insertion and inflammatory markers, including erythrocyte sedimentation rate, C-reactive protein (CRP) and CA-125 levels, were higher in the TOA group than the non-TOA group. Independent factors that predicted TOA were older age, IUD insertion, increased CRP and CA-125, and chlamydia infection. CA-125 was found to have the highest predictive value for TOA. TOA size was associated with increased surgical therapy com-
© 2015 S. Karger AG, Basel 0378–7346/15/0000–0000$39.50/0 E-Mail [email protected] www.karger.com/goi
pared to patients with smaller abscesses. Conclusions: Increased age, IUD insertion, chlamydia infection, and increased CRP and CA-125 level were the independent factors predictive of TOA in acute PID. These predictive values will be expected to help decrease gynecological morbidity by early diagnosis and appropriate treatment of TOA. © 2015 S. Karger AG, Basel
Introduction
Pelvic inflammatory disease (PID) comprises a spectrum of inflammatory disorders of the female upper genital tract. Tubo-ovarian abscess (TOA) is an inflammatory mass involving the fallopian tube, ovary and, occasionally, surrounding structures (e.g. bowel, bladder) [1]. TOA is one of the most severe complications of PID and can lead to significant morbidity and occasional mortality. TOA is reported to occur in as many as 34% of patients diagnosed with PID [2]. Risk factors for TOA are similar to those for PID, including multiple sexual partners, prior history of PID, no history of contraceptive use, history of intrauterine device (IUD) insertion, and low socioeconomic status [3]. Long-term complicaJoo Hee Yoon, MD, PhD Department of Obstetrics and Gynecology, St. Vincent’s Hospital, College of Medicine Catholic University of Korea, 93 Jungbu-daero, Paldal-gu Suwon, Gyeonggi-do 442-723 (Korea) E-Mail jhyoon @ catholic.ac.kr
Downloaded by: NYU Medical Center Library 128.122.253.212 - 6/8/2015 2:30:27 AM
Key Words CA-125 · Chlamydial infection · Pelvic inflammatory disease · Tubo-ovarian abscess
Methods We reviewed the medical records of all female patients hospitalized at Saint Vincent’s Hospital between January 2001 and December 2011 with a diagnosis at discharge of PID, salpingitis, endometritis, or TOA. This retrospective and case-control study was approved by the Institutional Review Board of the Catholic University of Korea. The definition of PID was based on a clinical history of abdominal pain and physical examination findings of abdominal, cervical motion and adnexal tenderness. Additionally, at least one of the following minor criteria was required: temperature ≥38.3 ° C, abnormal cervical or vaginal mucopurulent discharge, elevated ESR or CRP, and laboratory confirmation of a cervical infection with N. gonorrhoeae or C. trachomatis [7]. TOA was diagnosed based on physical examination findings of a tender adnexal mass or masses and ultrasonographic or abdominal CT scanning. Ultrasonographic diagnosis of TOA was based on demonstration of a complex, cystic mass with thick, irregular walls, partitions and internal echoes and no peristalsis [8]. The CT diagnosis of TOA was based on adnexal wall thickening and enhancement as well as complex fluid collection that could contain internal septa and a fluid-debris level [9]. The diagnosis of TOA was also based on satisfying the PID criteria stated above as well as finding at least one of the aforementioned complex pelvic masses on ultrasound or CT examination [7].
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Gynecol Obstet Invest DOI: 10.1159/000381772
A total of 1,039 charts were reviewed. During that time, 218 females were excluded because they did not undergo a CA-125 test, and 176 females were excluded because they lacked a vaginal swab test for chlamydia. Additionally, 130 females did not meet the inclusion criteria because they did not fit the diagnostic criteria of PID, and a further 10 females were excluded because of uterine or adnexal pathology, including epithelial and germ-cell-origin ovarian neoplasia, endometriosis, leiomyoma, or adenomyosis. Finally, 6 females were excluded because they had a history of pelvic surgery, obstetric delivery or abortion during the previous 30 days. After applying the exclusion criteria, 499 women were enrolled in the current study. Axillary body temperature was measured in all patients. The definition of fever was ≥38 ° C. The WBC count was quantified using the XE-2100TM (Sysmex Inc., Mundelein, Ill., USA). The intraand interassay coefficients of variation (CVs) were 1.7 and 1.9%, respectively. Leukocytosis was defined as a WBC count >11,000 cells/mm3. Serum ESR concentration was measured with the modified Westergren method using a Test-1 automated analyzer (Ailfax, Padova, Italy). The intra- and interassay CVs were 3.5 and 3.4%, respectively. The upper limit of normal for females younger than 50 years of age is 20 mm/h. Serum CRP concentration was measured with turbidimetric immunoassay using a Hitachi 7600110® Automatic Analyzer (Hitachi Co., Tokyo, Japan). The intraand interassay CVs were 5.4 and 2.7%, respectively. Normal serum CRP levels are 0–0.6 mg/dl. Serum CA-125 level was measured by chemiluminescent microparticle immunoassay using the CA-125 IITM (Abbott Architect, Inc., Chicago, Ill., USA). The intra- and interassay CVs were 2.4 and 3.9%, respectively. CA-125 was considered abnormal if the concentration was ≥35 IU/ml. Endocervical swabs and real-time polymerase chain reaction testing were used to identify N. gonorrhoeae and C. trachomatis. Statistical comparisons of demographic, clinical and laboratory data between the two groups were performed using the two-tailed Student t test and χ2 test or Fisher’s exact χ2 test if the expected count was
Gynecol Obstet Invest DOI: 10.1159/000381772
Predictive Markers of Tubo-Ovarian Abscess in Pelvic Inflammatory Disease Suk Woo Lee a Chae Chun Rhim a Jang Heub Kim b Sung Jong Lee b Sie Hyeon Yoo c Shin Young Kim b Young Bin Hwang b So Young Shin b Joo Hee Yoon b a
Department of Obstetrics and Gynecology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, b Department of Obstetrics and Gynecology, College of Medicine, Catholic University of Korea, and c Department of Anesthesiology and Pain Medicine, Soonchunhyang University of Medicine of Korea, Asan, Korea
Abstract Background/Aims: The purpose of this study was to identify predictive markers for tubo-ovarian abscess (TOA) through a comparison of clinical and laboratory data in patients diagnosed with pelvic inflammatory disease (PID). Methods: We reviewed the medical charts of 499 females who were admitted to hospital with clinical, surgical, imaging-based diagnoses of PID between 2001 and 2011. The patients were divided into the following two groups: (1) PID with TOA and (2) PID without TOA. Results: The TOA and non-TOA groups were comprised of 69 and 430 females, respectively. Mean age, history of intrauterine device (IUD) insertion and inflammatory markers, including erythrocyte sedimentation rate, C-reactive protein (CRP) and CA-125 levels, were higher in the TOA group than the non-TOA group. Independent factors that predicted TOA were older age, IUD insertion, increased CRP and CA-125, and chlamydia infection. CA-125 was found to have the highest predictive value for TOA. TOA size was associated with increased surgical therapy com-
© 2015 S. Karger AG, Basel 0378–7346/15/0000–0000$39.50/0 E-Mail [email protected] www.karger.com/goi
pared to patients with smaller abscesses. Conclusions: Increased age, IUD insertion, chlamydia infection, and increased CRP and CA-125 level were the independent factors predictive of TOA in acute PID. These predictive values will be expected to help decrease gynecological morbidity by early diagnosis and appropriate treatment of TOA. © 2015 S. Karger AG, Basel
Introduction
Pelvic inflammatory disease (PID) comprises a spectrum of inflammatory disorders of the female upper genital tract. Tubo-ovarian abscess (TOA) is an inflammatory mass involving the fallopian tube, ovary and, occasionally, surrounding structures (e.g. bowel, bladder) [1]. TOA is one of the most severe complications of PID and can lead to significant morbidity and occasional mortality. TOA is reported to occur in as many as 34% of patients diagnosed with PID [2]. Risk factors for TOA are similar to those for PID, including multiple sexual partners, prior history of PID, no history of contraceptive use, history of intrauterine device (IUD) insertion, and low socioeconomic status [3]. Long-term complicaJoo Hee Yoon, MD, PhD Department of Obstetrics and Gynecology, St. Vincent’s Hospital, College of Medicine Catholic University of Korea, 93 Jungbu-daero, Paldal-gu Suwon, Gyeonggi-do 442-723 (Korea) E-Mail jhyoon @ catholic.ac.kr
Downloaded by: NYU Medical Center Library 128.122.253.212 - 6/8/2015 2:30:27 AM
Key Words CA-125 · Chlamydial infection · Pelvic inflammatory disease · Tubo-ovarian abscess
Methods We reviewed the medical records of all female patients hospitalized at Saint Vincent’s Hospital between January 2001 and December 2011 with a diagnosis at discharge of PID, salpingitis, endometritis, or TOA. This retrospective and case-control study was approved by the Institutional Review Board of the Catholic University of Korea. The definition of PID was based on a clinical history of abdominal pain and physical examination findings of abdominal, cervical motion and adnexal tenderness. Additionally, at least one of the following minor criteria was required: temperature ≥38.3 ° C, abnormal cervical or vaginal mucopurulent discharge, elevated ESR or CRP, and laboratory confirmation of a cervical infection with N. gonorrhoeae or C. trachomatis [7]. TOA was diagnosed based on physical examination findings of a tender adnexal mass or masses and ultrasonographic or abdominal CT scanning. Ultrasonographic diagnosis of TOA was based on demonstration of a complex, cystic mass with thick, irregular walls, partitions and internal echoes and no peristalsis [8]. The CT diagnosis of TOA was based on adnexal wall thickening and enhancement as well as complex fluid collection that could contain internal septa and a fluid-debris level [9]. The diagnosis of TOA was also based on satisfying the PID criteria stated above as well as finding at least one of the aforementioned complex pelvic masses on ultrasound or CT examination [7].
2
Gynecol Obstet Invest DOI: 10.1159/000381772
A total of 1,039 charts were reviewed. During that time, 218 females were excluded because they did not undergo a CA-125 test, and 176 females were excluded because they lacked a vaginal swab test for chlamydia. Additionally, 130 females did not meet the inclusion criteria because they did not fit the diagnostic criteria of PID, and a further 10 females were excluded because of uterine or adnexal pathology, including epithelial and germ-cell-origin ovarian neoplasia, endometriosis, leiomyoma, or adenomyosis. Finally, 6 females were excluded because they had a history of pelvic surgery, obstetric delivery or abortion during the previous 30 days. After applying the exclusion criteria, 499 women were enrolled in the current study. Axillary body temperature was measured in all patients. The definition of fever was ≥38 ° C. The WBC count was quantified using the XE-2100TM (Sysmex Inc., Mundelein, Ill., USA). The intraand interassay coefficients of variation (CVs) were 1.7 and 1.9%, respectively. Leukocytosis was defined as a WBC count >11,000 cells/mm3. Serum ESR concentration was measured with the modified Westergren method using a Test-1 automated analyzer (Ailfax, Padova, Italy). The intra- and interassay CVs were 3.5 and 3.4%, respectively. The upper limit of normal for females younger than 50 years of age is 20 mm/h. Serum CRP concentration was measured with turbidimetric immunoassay using a Hitachi 7600110® Automatic Analyzer (Hitachi Co., Tokyo, Japan). The intraand interassay CVs were 5.4 and 2.7%, respectively. Normal serum CRP levels are 0–0.6 mg/dl. Serum CA-125 level was measured by chemiluminescent microparticle immunoassay using the CA-125 IITM (Abbott Architect, Inc., Chicago, Ill., USA). The intra- and interassay CVs were 2.4 and 3.9%, respectively. CA-125 was considered abnormal if the concentration was ≥35 IU/ml. Endocervical swabs and real-time polymerase chain reaction testing were used to identify N. gonorrhoeae and C. trachomatis. Statistical comparisons of demographic, clinical and laboratory data between the two groups were performed using the two-tailed Student t test and χ2 test or Fisher’s exact χ2 test if the expected count was
