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Pelvic Inflammatory Disease. A Condition Requiring Closer Attention. Prof. Aruna Batra Obstetrics & Gynecology VMMC & SJH, N. Delhi. PID: A Neglected Issue. • Low disease awareness

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pelvic inflammatory disease
Pelvic Inflammatory Disease

A

Condition

Requiring

Closer Attention

Prof. Aruna Batra

Obstetrics & Gynecology

VMMC & SJH, N. Delhi

pid a neglected issue
PID: A Neglected Issue

• Low disease awareness

• Sub-optimal management

• 50% named correct antibiotic regimen

• < 25% examined the sexual partners

A National Audit of PID Diagnosis & Management in GP: England and WalesInt. J STD AIDS 2000 Jul;11(7):440-4

objectives
Objectives

• What is Pelvic Inflammatory Disease?

• Why is it important to treat timely?

• Causative factors and transmission?

• How does the patient present?

• Treatment Plan?

- Drug therapies

- Surgical procedures

- Follow up

what is pid
What is PID ?

• Acute/ Chronic clinical syndrome

• Inflammation of pelvic structures

• Ascending spread of infection from the vagina and endocervix to the endometrium, fallopian tubes, ovaries, &/ or adjoining structures

• Upper genital tract infection, salpingitis endometritis, parametritis, tubo-ovarian abscess & pelvic peritonitis

slide5

Transmission

  • • Sexual transmission
  • via the vagina & cervix
  • • Gynecological
  • surgical procedures
  • • Child birth/ Abortion
  • • A foreign body inside uterus (IUCD)
slide6

Transmission

  • • Contamination from
  • other inflamed structures
  • in abdominal cavity
  • (appendix, gallbladder)
  • • Blood-borne transmission
  • (pelvic TB)
infective organisms
Infective Organisms
  • • Sexually transmitted - Chlamydia trachomatis
          • Neisseria gonorrhoeae
  • • Endogenous Aerobic - Streptococci
          • Haemophilus
  • E. coli
  • • Anaerobes - Bacteroides, Peptostrptococcus
  • - Bacterial Vaginosis
          • - Actinomyces israelii
  • • Mycoplasma hominis, Ureaplasma
  • • Mycobacterium tuberculosis & bovis
predisposing factors
Predisposing Factors
  • • Frequent sexual encounters, many partners
  • • Young age, early age at first intercourse
  • • Exposure immediately prior to menstruation.
  • • Relative ill-health & poor nutritional status.
  • • Previously infected tissues (STD/ PID)
  • • Frequent vaginal douching
why is it important to treat pid
Whyis it Important to Treat PID ?
  • • Systemic upset / Tubo-ovarian abscess
  • • Chronic Pain (15-20 %)→ Hysterectomy
      • ● Ectopic pregnancy (6-10 fold)
      • ● Infertility (Tubal): 20% ~ 2 episodes 40% ~ 3 episodes
      • ● Recurrence (25%)
      • ● Male genital disease (25%)
      • ● Cancer Cervix/ Ovarian Cancer?
presentation acute pid
Presentation: Acute PID
  • • Severe pain & tenderness lower abdomen
  • • Fever, Malaise, vomiting, tachycardia
  • • Offensive vaginal discharge
  • • Irregular vaginal bleeding
  • • B/L adnexal tenderness
  • • cervical excitation
  • • Tubo-ovarian mass
  • • Fitz-Hugh-Curtis Syndrome
          • Poor sensitivity & specificity
          • Correct diagnosis : 45 – 70%
presentation chronic pid
Presentation: Chronic PID
  • • Chronic lower abdominal pain, Backache
  • • General malaise & fatigue
  • • Deep dyspareunia, Dysmennorhea
  • • Intermittent offensive vaginal discharge
  • • Irregular menstrual periods
  • • Lower abdominal/ pelvic tenderness
  • • Bulky, tender uterus
  • Infertility ( “Silent epidemic” )
pid differential diagnosis
PID: Differential Diagnosis
  • Ectopic Pregnancy
  • Torsion/ Rupture adnexal mass
  • Appendicitis
  • Endometriosis
  • Cystitis/ pyelonephritis
laboratory studies
Laboratory Studies

•Pregnancy test

• Complete blood count, ESR, CRP

• Urinalysis

•Gonorrhea, Chlamydia detection (Gram stain/ Cultures / ELISA/ FA/ DNA )

• Tests for TB, syphilis, HIV

• Pelvic Ultrasound

• Culdocentesis

• Laparoscopy

syndromic diagnosis of pid minimum criteria for diagnosis cdc 2002
Syndromic Diagnosis of PID Minimum Criteria for Diagnosis (CDC 2002)
  • • Lower abdominal tenderness on palpation
  • • Bilateral adnexal tenderness
  • • Cervical motion tenderness
  • No other established cause
  • Negative pregnancy test
additional criteria cdc 2002
Additional Criteria (CDC 2002)
  • • Oral temperature > 38.3°C (101°F)
  • • Abnormal cervical / vaginal discharge
  • • Elevated ESR
  • • Elevated C-reactive protein
  • • WBCs on saline micro. of vaginal sec.
  • • Lab. documentation of cervical infection with N. gonorrhoeae/ C. trachomatis
slide23

Definitive Criteria (CDC 2002)

• Endometrial biopsy with histopathology evidence of endometritis

• TVS/ MRI: Thickened fluid filled tubes/

free pelvic fluid / tubo-ovarian complex

• Laparoscopic abnormalities consistent with PID

management issues
Management Issues
  • • Inpatient vs. outpatient management ?
  • • Broad-spectrum antibiotic therapy
  • without microbiological findings
  • vs.
  • Antibiotic treatment adapted to the microbiological agent identified ?
  • • Oral vs. Parenteral therapy?
  • • Duration of the treatment ?
  • • Associated treatment ?
  • • Prevention of re-infection ?
criteria for hospitalization cdc 2002
Criteria for Hospitalization (CDC 2002)

• Surgical emergencies not excluded

• Severe illness/ nausea/ vomit/ high fever

• Tubo-ovarian abscess

• Clinical failure of oral anti-microbials

• Inability to follow/ tolerate oral regimen

• Pregnancy

• Immunodeficient (HIV ē low CD4 counts,

immunosuppressive therapy)

antibiotic therapy
Antibiotic Therapy

Gonorrhea : Cephalosporins, Quinolones

Chlamydia: Doxycycline, Erythro-mycin & Quinolones (Not to cephalosporins)

Anaerobic organisms: Flagyl, Clindamycin and in some cases to Doxycycline.

Beta hemolytic streptococcus and E. Coli Penicillin derivatives, Tetracyclines, and Cephalosporins., E. Coli is most often treated with the penicillins or gentamicin.

antibiotic regimens cdc 2002
Antibiotic Regimens (CDC 2002)

Parenteral regimen A

Cefoxitin 2 g IV q 6h / cefotetan 2 g IV q 12h +

Doxycycline 100 mg PO/IV q12h +

Metronidazole or Clindamycin (TO abscess)

Parenteral regimen B

Clindamycin 900 mg IV q 8h

+

Gentamicin Loading dose 2 mg/kg IV/IM, maintenance 1.5 mg/kg IV/ IM q 8h

other 2 nd 3 rd generation cephalosporins
Other 2nd/ 3rd Generation Cephalosporins

Ceftizoxime - Cefizox,

Cefotaxime - Omnatex,

Ceftriaxone - Monocef,

Cefoperazone - Magnamycin,

Ceftizidime - Fortum

alternative parenteral regimens cdc 2002
Alternative Parenteral Regimens (CDC 2002)

Ofloxacin 400 mg IV q 12 hours

or

Levofloxacin 500 mg IV once daily

WITH OR WITHOUT

Metronidazole 500 mg IV q 8 hours

or

Ampicillin/Sulbactam 3 g IV q 6 hrs

PLUS

Doxycycline 100 mg orally/ IV q 12 hrs

outpatient antibiotic therapy regimen a cdc 2002
Outpatient Antibiotic Therapy Regimen A (CDC 2002)

Ofloxacin 400 mg twice daily for 14 days

or

Levofloxacin 500 mg once daily for 14 days

WITH OR WITHOUT

Metronidazole 500 mg twice daily for 14 days

outpatient antibiotic therapy regimen b cdc 2002
Outpatient Antibiotic Therapy Regimen B (CDC 2002)

Ceftriaxone 250 mg IM once

OR

Cefoxitin 2 g IM ē probenecid 1 g PO once

+

Doxycycline 100 mg PO bid for 14

WITH OR WITHOUT

Metronidazole 500 mg BD x 14 d

cdc recommendations
CDC Recommendations

• No efficacy data compare parenteral with oral regimens

•Clinical experience should guide decisions reg. transition to oral therapy

•Until regimens that do not adequately cover anaerobes have been demonstrated to prevent sequelae as successfully as regimens active against these microbes, anaerobic coverage should be provided

slide33

When should treatment be stopped ?

• Parenteral changed to oral therapy after 72 hrs, if substantial clinical improvement

• Continue Oral therapy until clinical & biological signs (leukocytosis, ESR, CRP) disappear or for at least 14 days

• If no improvement, additional diagnostic tests/ surgical intervention for pelvic mass/ abscess rupture

slide34

Associated treatment

Rest at the hospital or at home

Sexual abstinence until cure is achieved

Anti-inflammatory treatment

Dexamethasone 3 tablets of 0.5 mg a day

or Non steroidal anti-inflammatory drugs

Oestro-progestatives: contraceptive effect

+ protection of the ovaries against a peritoneal inflammatory reaction +

cervical mucus induced by OP has preventive effect against re-infection.

slide35

Special Situations

Pregnancy

- Augmentin or Erythromycin

- Hospitalization

Concomitant HIV infection

- Hospitalization and i.v. antimicrobials

- More likely to have pelvic abscesses

- Respond more slowly to antimicrobials

- Require changes of antibiotics more often

- Concomitant Candida and HPV infections

slide36

Surgery in PID

Indications

Acute PID

-Ruptured abscess

- Failed response to medical treatment

- Uncertain diagnosis

Chronic PID

- Severe, progressive pelvic pain

- Repeated exacerbations of PID

- Bilateral abscesses / > 8 cm. diameter

- Bilateral uretral obstruction

surgery in pid
Surgery in PID

• Timing of Surgery

- No improvement within 24-72 hours

- Quiescent (2-3 months after acute stage)

• Type of Surgery

- Colpotomy

- Percutaneus drainage/ aspiration

- Exploratory Laparotomy

• Extent of Surgery

- Conservation if fertility desired

- U/L or B/L S.Ophrectomy ē/ š subtotal/ TAH

- Drainage of abscess at laporortomy

- Identification of ureters

ruptured pelvic abscess
Ruptured Pelvic Abscess

▪ Generalized Septic Peritonitis

  • ↑ absorption of bacterial endotoxins
  • ↑ fluid from inflamed peritoneal surfaces
  • Fluid shift intravascular to interstitial spaces
  • Hypovolemia, ↓ CO, VC, ↑ PR
  • ↓ tissue perfusion, ARDS, hyoxemia
  • Multi-organ system failure

Prompt Diagnosis & Treatment

ruptured abscess management
Ruptured Abscess- Management
  • Pre-Operative
    • Rapid/ adequate metabolic/hemodynamic preparation
    • Blood chemistry, CVP monitoring, ABG
    • X-match blood, IV fluids, aggressive antibiotics
  • Operative Management
    • Technical difficulties
    • Aggressive lavage of peritoneal cavity
    • Exploration for sub-diaphragmatic collection
    • Closed suction drain
  • Post- Operative
    • Shock, infection, ileus, fluid balance
follow up
Follow Up

●Re-screening for Chlamydia & Gonorrhea

● Patient counseling:

- Risk of re- infection and sequel.

- Sexual counseling

- Avoid douching

slide41

Management of sex partners

• Examination and treatment

if they had sexual contact

with patients during the 60 days preceding the onset of symptoms

in the patients.

• Empirical treatment with regimens

effective against C. trachomatis

and N. gonorrhoeae

opportunities for control
Opportunities for Control

STD

PID

Infertility

STD

Influenced by Interaction of following Environments

Genital MicrobialEnvironment

Individual BehavioralEnvironment

Socio-geographicEnvironment

slide43

Prevention

  • Primary Prevention:
  • - Sexual counseling: practice safe sex, limit the number of partners, avoid contact with high-risk partners, delay the onset of sexual activity until ≥ 16 years.
  • - Barrier and Oral contraceptives reduce the risk for developing PID.
  • Secondary Prevention:
  • • - Screening for infections in high- risk.
  • - Rapid diagnosis and effective treatment of STD and lower urinary tract infections.
  • Tertiary Prevention:
  • -Early intervention & complete treatment.
conclusion
Conclusion
  • ● PID in women - “Silent epidemic”
  • ● Can have serious consequences.
  • ● Be aware of limitations of clinical diagnosis.
  • ● Adequate analgesia and antibiotics.
  • ● Proper follow up is essential.
  • ● Treatment of male partner
  • ● Educational campaigns for young women and health professionals.
  • ● Prevention by appropriate screening for STD and promotion of condom usage.