pelvic inflammatory disease
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Pelvic Pelvic Inflammatory Inflammatory
DiseaseDisease
Does LEEP increase the Does LEEP increase the risk of PTB before 37 risk of PTB before 37
weeks?weeks? Compared women with history of LEEP toCompared women with history of LEEP to
1.1. Women with no history of CIN or LEEPWomen with no history of CIN or LEEP
2.2. Women with history of CIN but no LEEPWomen with history of CIN but no LEEP History of LEEP verses Group 1History of LEEP verses Group 1
RR 1.61RR 1.61 History of LEEP verses Group 2History of LEEP verses Group 2
RR 1.08RR 1.08 Risks factors leading to CIN probably more Risks factors leading to CIN probably more
important than the LEEPimportant than the LEEP
PathophysiologyPathophysiology
Starts as cervicitis caused by GC, Starts as cervicitis caused by GC, chlamydia, or mycoplasmchlamydia, or mycoplasm
In the presence of bacterial In the presence of bacterial vaginosis, there is a breakdown of vaginosis, there is a breakdown of mucous and other natural barriers mucous and other natural barriers allowing an ascending infectionallowing an ascending infection
Normal vaginal flora is the source of Normal vaginal flora is the source of a polymicrobial infection.a polymicrobial infection.
TOATOA
Causative AgentsCausative Agents
N. gonorrheaN. gonorrhea
▪ ▪ 20% of women with this 20% of women with this cervicitis will cervicitis will develop acute develop acute PIDPID
▪ ▪ Intense inflammatory Intense inflammatory reactions in the reactions in the tubal mucosatubal mucosa
Causative AgentsCausative Agents
ChlamydiaChlamydia
▪ ▪ More prevalent than More prevalent than NeisseriaNeisseria
▪ ▪ Clinically produces a mild for Clinically produces a mild for of of salpingitis with an insidious salpingitis with an insidious onsetonset
▪ ▪ 30% of women with this 30% of women with this cervicitis cervicitis develop PIDdevelop PID
Microorganisms Isolated Microorganisms Isolated from the Fallopian Tubes from the Fallopian Tubes
with Acute PIDwith Acute PID Type of AgentType of Agent
STDSTD
Endogenous agent Endogenous agent aerobic or facultativeaerobic or facultative
AnaerobicAnaerobic
OrganismOrganism Chlamydia trachomatisChlamydia trachomatis Neisseria gonorrheaNeisseria gonorrhea Mycoplasma hominisMycoplasma hominis
Streptococcus sp.Streptococcus sp. Staphylococcus sp.Staphylococcus sp. Haemophilus sp.Haemophilus sp. Escherichia coliEscherichia coli
Bacteroides, Bacteroides, Peptococcus, Peptococcus, Clostridium, ActinomycesClostridium, Actinomyces
Weström L: Sex Transm Dis 11:439, 1984
SymptomsSymptoms
Abdominal painAbdominal pain Abnormal dischargeAbnormal discharge Postcoital spottingPostcoital spotting FeverFever Low back painLow back pain Nausea/vomitingNausea/vomiting
How to approach the How to approach the diagnosis?diagnosis?
Does she have cervicitis?Does she have cervicitis? Is the cervix inflamed, tender, and/or Is the cervix inflamed, tender, and/or
friable?friable? Is the there leukocytes in the wet Is the there leukocytes in the wet
mount?mount?
Mucopurulent cervicitisMucopurulent cervicitis
Mucopurulent cervicitis caused by C. trachomatis (Holmes, 1999; reprinted with permission from McGraw Hill.)
Physical FindingsPhysical Findings
Pelvic tendernessPelvic tenderness Cervical, uterine, or adenexalCervical, uterine, or adenexal
Less than 1/3 have feverLess than 1/3 have fever WBC commonly normalWBC commonly normal Sed rate is generally elevatedSed rate is generally elevated
CDC recommends CDC recommends treating sexually active treating sexually active women 25 or less years women 25 or less years
old at risk for STD if they old at risk for STD if they are having pelvic or low are having pelvic or low abdominal pain AND 1) abdominal pain AND 1)
cervical, uterine, or cervical, uterine, or adenexal tenderness; 2) adenexal tenderness; 2) no other causes of painno other causes of pain
Presumptive Diagnosis of Presumptive Diagnosis of CervicitisCervicitis
Gonococcal CervicitisGonococcal Cervicitis
RecommendedRecommended Ceftriaxone 250 mg IM plus Azithromycin 1 Ceftriaxone 250 mg IM plus Azithromycin 1
gm po or doxycycline 100 mg po BID x gm po or doxycycline 100 mg po BID x 7days7days
Alternative regimenAlternative regimen Cefixime 400 mg po plus Azithromycin 1 Cefixime 400 mg po plus Azithromycin 1
gm po or doxycycline 100 mg po BID x gm po or doxycycline 100 mg po BID x 7days7days
If penicillin allergyIf penicillin allergy Azithromycin 2 gm poAzithromycin 2 gm po
Cervicitis TreatmentCervicitis Treatment
Azithromycin 1 gm po x 1 ORDoxycline 100 mg bid x 7d PLUSCeftriaxone 125 mg IM
ORCefixime 400 mg po
PLUSTreat for BV if present
Outpatient PIDOutpatient PID
Indications to Indications to hospitalize…hospitalize…
PregnancyPregnancy Adolescents with unpredictable Adolescents with unpredictable
compliancecompliance Immunodeficient ( HIV with low CD4 Immunodeficient ( HIV with low CD4
counts) counts) Uncertain diagnosisUncertain diagnosis Nausea and vomiting, high feverNausea and vomiting, high fever Inadequate response to outpatient therapyInadequate response to outpatient therapy TOATOA
CDC .Guidelines for Treatment of Sexually Transmitted Diseases 2002, MMWR 2002: 51: 1041
Inpatient PIDInpatient PID
Inpatient PIDInpatient PID
Post HospitalizationPost Hospitalization
Doxycycline 100 mg orally twice a Doxycycline 100 mg orally twice a day for 14 daysday for 14 days
Clindamycin 450 mg orally four time Clindamycin 450 mg orally four time s a day for 14 dayss a day for 14 days
Not sure what she has …Not sure what she has …
TOATOA
Tubo-ovarian abscess (TOA)Tubo-ovarian abscess (TOA)• collection of pus delimited by the collection of pus delimited by the
adherence of the fallopian tubes, ovaries, adherence of the fallopian tubes, ovaries, and adjacent organsand adjacent organs
• serious manifestation of PID and generates serious manifestation of PID and generates 350,000 hospitalization/150,000 350,000 hospitalization/150,000 surgeries/yrsurgeries/yr
• 34% of PID cases hospitalized have TOA34% of PID cases hospitalized have TOA• TOA ruptured -mortality rate is as high as TOA ruptured -mortality rate is as high as
9%9%• 1-4% rupture at initial presentation or during 1-4% rupture at initial presentation or during
conservative managementconservative managementSoper DE. Pelvic inflammatory disease. Infect Dis Clin North Am. 1994;8:821-840
Tuboovarian abscessTuboovarian abscess Presenting symptoms and Presenting symptoms and
findings with TOAfindings with TOA Pelvic pain Pelvic pain Pelvic massPelvic mass Fever/chillsFever/chills Vaginal dischargeVaginal discharge Abnormal uterine bleedingAbnormal uterine bleeding Nausea/vomitingNausea/vomiting Temp.>100°FTemp.>100°F WBC>10,000WBC>10,000
Landers DV and Sweet RL: Rev Infect Dis 5:879, 1983
Pelvic inflammatory disease, proven chlamydial pyosalpinx. Right tube is swollen and tortuous (arrow) (Holmes, 1999; reprinted with permission from McGraw Hill.)
Diagnostic testsDiagnostic tests
UltrasoundUltrasound
Complex cystic mass Complex cystic mass containing multiple containing multiple septations and septations and internal echoesinternal echoes
correctly identified correctly identified TOA in 94% of pt. TOA in 94% of pt. confirmed by surgeryconfirmed by surgery
Bulas DI. Radiology. 1992;183:435Bulas DI. Radiology. 1992;183:435
Criteria for treatment Criteria for treatment success:success:
Clinical improvement may take Clinical improvement may take 72 hours72 hours Resolution of abdominal pain, Resolution of abdominal pain,
defervescence, decreased WBC, defervescence, decreased WBC, stabilization or decrease in mass stabilization or decrease in mass size.size.
clinically deterioration or clinically deterioration or development of an acute abdomen development of an acute abdomen should prompt surgical interventionshould prompt surgical intervention
Post Hospitalization for Post Hospitalization for TOTO
Clindamycin 450 mg orally four Clindamycin 450 mg orally four times a day for 14 daystimes a day for 14 days
SurgerySurgery
TAH/BSOTAH/BSO Laparoscopy with Laparoscopy with
endoscopic endoscopic drainage, drainage, irrigation, lysis irrigation, lysis of adhesionsof adhesions
Ultrasound Ultrasound guided guided percutaneous percutaneous drainagedrainage
SequelaeSequelae
Chronic pelvic painChronic pelvic pain Ectopic pregnancyEctopic pregnancy InfertilityInfertility
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