CONTINOUS MEDICAL EDUCATION BY DR NAZ

1. PELVIC INFLAMMATORY DISEASE
• DR:SHABNAM NAZ SHAIKH
• ASSISTANT PROFESSOR
• OBGYN
• CMC,SMBBMU LARKANA

2. PID: A NEGLECTED ISSUE
• Low disease awareness
• Sub-optimal management
• 50% named correct antibiotic regimen
• < 25% examined the sexual partners

3. 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

4. PELVIC INFLAMMATORY DISEASE
• Clinical syndrome associated with ascending
spread of microorganisms from the vagina or
cervix to the endometrium, fallopian tubes,
ovaries, and contiguous structures.
• Comprises a spectrum of inflammatory disorders
including any combination of endometritis,
salpingitis, tubo-ovarian abscess, and pelvic
peritonitis.

6. NORMAL CERVIX WITH ECTOPY

9. INCIDENCE
• The exact prevalence is hard to ascertain
as many cases may go undetected, but is
thought to be in the region of 1-3% of
sexually active young women.

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

11. Transmission
•
• Contamination from
other inflamed structures
in abdominal cavity
(appendix, gallbladder)
• Blood-borne transmission
(pelvic TB)

12. IUCD

13. PATHOGENESIS

14. INFECTIVE ORGANISMS
• Sexually transmitted - Chlamydia trachomatis
Neisseria gonorrhoeae
• Endogenous Aerobic - Streptococci
Haemophilus
E. coli
• Anaerobes - Bacteroides, Pepto-streptococcus
- Bacterial Vaginosis
- Actinomyces Israeli
• Mycoplasma hominies, Urea plasma
• Mycobacterium tuberculosis & bovis

15. 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

16. PATHWAY OF ASCENDANT INFECTION
Cervicitis
Endometritis
Salpingitis/
oophoritis/ tubo-
ovarian abscess
Peritonitis

17. NORMAL HUMAN FALLOPIAN TUBE
TISSUE

18. C. TRACHOMATIS INFECTION (PID)

19. PID CLASSIFICATION
Mild to
Subclinical/ moderate
silent symptoms
60% 36%
Overt
40%
Severe
symptoms
4%

20. PROTECTIVE FACTORS
• These include the use of barrier
contraception, the levonorgestral releasing
system (Mirena IUS) and the COCP.

21. WHY IS IT IMPORTANT TO TREAT PID ?
CONSEQUES
• 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%)

23. 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%

24. FITZ HURTS CURTIZ SYNDROME

25. PRESENTATION: CHRONIC PID
• Chronic lower abdominal pain, Backache
• General malaise & fatigue
• Deep dyspareunia, Dysmenorrhea
• Intermittent offensive vaginal discharge
• Irregular menstrual periods
• Lower abdominal/ pelvic tenderness
• Bulky, tender uterus
Infertility ( “Silent epidemic” )

26. PID: DIFFERENTIAL DIAGNOSIS
• Ectopic Pregnancy
• Torsion/ Rupture adnexal mass
• Appendicitis
• Endometriosis
• Cystitis/ pyelonephritis

27. 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

28. MUCOPURULENT CERVICAL DISCHARGE
(POSITIVE SWAB TEST)

29. Endometritis (thickened heterogeneous endometrium)

30. Hydrosalpinx (anechoic tubular structure)

31. Hydrosalpinx.

32. Pyosalpinx (tubular structure with debris in adnexa

33. Tuboovarian abscess resulting from tuberculosis

34. Right hydrosalpinx with an occluded left fallopian tube

35. 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

36. 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. gonorrhea/ C. trachomatis

37. 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

38. 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 ?

39. GENERAL PID CONSIDERATIONS
Regimens must provide coverage of N. gonorrhea, C.
trachomatis, anaerobes, Gram-negative bacteria, and
streptococci
Treatment should be instituted as early as possible to
prevent long term squeal

40. CRITERIA FOR HOSPITALIZATION
• Inability to exclude surgical emergencies
• Pregnancy
• Non-response to oral therapy
• Inability to tolerate an outpatient oral
regimen
• Severe illness, nausea and vomiting, high
fever or tubo-ovarian abscess
• HIV infection with low CD4 count

41. ANTIBIOTIC THERAPY
Gonorrhea : Cephalosporin's, Quinolones
Chlamydia: Doxycycline, Erythromycin &
Quinolones (Not to cephalosporin's)
Anaerobic organisms: Flagyl, Clindamycin
and in some cases to Doxycycline.
Beta hemolytic streptococcus and E. Coli
Penicillin derivatives, Tetracycline's, and
Cephalosporin's., E. Coli is most often treated
with the penicillin's or gentamicin.

42. ORAL REGIMENS
• CDC-recommended oral regimen A
• Ceftriaxone 250 mg IM in a single dose, PLUS
• Doxycycline 100 mg orally 2 times a day for 14 days
With or Without
• Metronidazole 500 mg orally 2 times a day for 14 days
• CDC-recommended oral regimen B
• Cefoxitin 2 g IM in a single dose and Probenecid 1 g orally in a
single dose, PLUS
• Doxycycline 100 mg orally 2 times a day for 14 days
With or Without
• Metronidazole 500 mg orally 2 times a day for 14 days
• CDC-recommended oral regimen C
• Other parenteral third-generation cephalosporin (e.g.,
Ceftizoxime, Cefotaxime), PLUS
• Doxycycline 100 mg orally 2 times a day for 14 days
With or Without
• Metronidazole 500 mg orally 2 times a day for 14 days

43. FOLLOW-UP
• Patients should demonstrate substantial improvement
within 72 hours.
• Patients who do not improve usually require
hospitalization, additional diagnostic tests, and
surgical intervention.
• Some experts recommend re-screening for C.
trachomatis and N. gonorrhea 4-6 weeks after
completion of therapy in women with documented
infection due to these pathogens.
• All women diagnosed clinical acute PID should be
offered HIV testing.

44. PARENTERAL REGIMENS
• CDC-recommended parenteral regimen A
• Cefotetan 2 g IV every 12 hours, OR
• Cefoxitin 2 g IV every 6 hours, PLUS
• Doxycycline 100 mg orally or IV every 12 hours
• CDC-recommended parenteral regimen B
• Clindamycin 900 mg IV every 8 hours, PLUS
• Gentamicin loading dose IV or IM (2 mg/kg),
followed by maintenance dose (1.5 mg/kg) every 8
hours. Single daily gentamicin dosing may be
substituted.

45. ALTERNATIVE PARENTERAL REGIMEN
• Ampicillin/Sulbactam 3 g IV every 6 hours, PLUS
• Doxycycline 100 mg orally or IV every 12 hours.
• It is important to continue either regimen A or B
• or alternative regimens for at least 24 hours after
substantial clinical improvement occurs and also
to complete a total of 14 days therapy with:
• Doxycycline 100mg orally twice a day OR
• Clindamycin 450mg orally four times a day.

46. 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 squeal as successfully as
regimens active
against these microbes, anaerobic
coverage should be provided

47. 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

48. 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.

49. 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

50. 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 ureteral obstruction

51. SURGERY IN PID
• Timing of Surgery
- No improvement within 24-72 hours
- Quiescent (2-3 months after acute stage)
• Type of Surgery
- Colpotomy
- Percutaneous 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 laparotomy
- Identification of ureters

52. 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, hypoxemia
• Multi-organ system failure
Prompt Diagnosis & Treatment

53. 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

54. FOLLOW UP
● Re-screening for Chlamydia & Gonorrhea
● Patient counseling:
- Risk of re- infection and sequel.
- Sexual counseling
- Avoid douching

55. 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. gonorrhea

56. OPPORTUNITIES FOR CONTROL
STD PID Infertility
STD
Influenced by Interaction of
following Environments
Genital Microbial Environment
Individual Behavioral Environment
Socio-geographic Environment

57. PREVENTION
• PRIMARY PRVENTION
• To reduce the incidence of PID, screen
and treat for chlamydia.
• Annual chlamydia screening is
recommended for:
• Sexually active women 25 and under
• Sexually active women >25 at high risk
• Screen pregnant women in the 1st
trimester.

58. PARTNER MANAGEMENT
• Male sex partners of women with PID
should be examined and treated if they
had sexual contact with the patient
during the 60 days preceding the
patient’s onset of symptoms.

59. PARTNER MANAGEMENT (CONTINUED)
• Male partners of women who have PID
caused by C. trachomatis or N. gonorrhea
are often asymptomatic.
• Sex partners should be treated empirically
with regimens effective against both C.
trachomatis and N. gonorrhea, regardless of
the apparent etiology of PID or pathogens
isolated from the infected woman.

60. REPORTING
• Report cases of PID to the local STD
program in states where reporting is
mandated.
• Gonorrhea and chlamydia are
reportable in all states.

61. PATIENT COUNSELING AND EDUCATION
• Nature of the infection
• Transmission
• Risk reduction
• Assess patient's behavior-change
potential
• Discuss prevention strategies
• Develop individualized risk-reduction
plans

62. .
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.

63. 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.

64. SUMMARY
● 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.

65. THANKS