test powerpoint

1. PID and TOA Morgan Taylor

2. Clinical Features Lower abdominal pain Bilateral Recent onset Worsens with coitus Worsens with jarring movements Onset during or shortly after menses AUB in 1/3 of patients New vaginal discharge Fever and chills

3. Risk Factors <25yo Early coitarche New, multiple, or symptomatic sexual partners Nonbarrier contraception Also, factors facilitating PID include hx PID, sex during menses, vaginal douching, BV, and IUDs.

4. Physical Examination ½ have fever Diffuse tenderness, greater in LQs May or may not be symmetrical RUQ pain may be perihepatitis Purulent endocervical discharge Acute cervical motion tenderness Adnexal tenderness (sign that correlates best with the finding of endometritis)

5. Perihepatitis Fitz-Hugh Curtis Syndrome Infection of liver capsule and peritoneal surfaces Patchy purulent and fibrinousexudate in the acute phase that primarily affects anterior surfaces of the liver Sudden onset of RUQ pain with pleuritic component sometime referred to right shoulder Can be mistaken for cholecystitis AST/ALT abnormal in ½ of patients

6. Diagnostic Criteria Empiric therapy for women with abdominal pain and one of the following: Cervical motion or uterine/adnexal tenderness Temp > 38.3 Peripheral leukocytosis Cervical or vaginal mucopurulent discharge WBCs on saline microscopy of vaginal secretions Elevated ESR Elevated CRP

7. Diagnostic Criteria II Patients with pelvic pain and tenderness and one or more of following are confirmed cases: Endometritis or acute salpingitis on biopsy GC or Chl in genital tract Gross salpingitis seen at laparoscopy or laparotomy Isolation of pathogenic bacteria from clean specimen from the upper genital tract Inflammatory/purulent pelvic peritoneal fluid w/o another source

8. Definitive Diagnosis Histologic evidence of endometritis Imaging revealing thickened fluid filled oviducts Laparoscopic abnormalities consistent with PID (tubal erythema, edema, adhesions, purulent exudate or cul-de-sac fluid, abnormal fimbriae)

9. Testing Labs: Pregnancy test UA CBC (fewer than ½ of PID pts have leukocytosis) Gram stain and microscopic eval of vaginal D/C GC/Chl Occult blood test CRP (optional)

10. Imaging Transvaginal USG In one series of 55 women with definitive PID who underwent TVUSG, the findings of abnormal oviducts, multicystic ovaries, and increased cul-de-sac fluid were 32%, 42%, and 37% sensitive and 97%, 86%, 58% specific.

11. Indications for hospitalization Pregnancy Lack of response or tolerance to oral meds Nonadherence Inability to take meds 2ndary to N/V Severe illness (high fever, N/V, severe pain) Pelvic abscess Possible surgical intervention or diagnostic exploration

12. Pathogens Two most important pathogens are Chlamydia Trachomatis and Neisseriagonorrhoeae Should also have coverage for: A and B streptococci E. Coli, Klebs, Proteus BV flora

13. Rec’d Regimens GC becoming more and more resistant to fluoroquinolones. Parenteral 1) Cefoxitin or Cefotetan plus Doxycycline 2) Clindamycin plus Gentamicin 3) Ampicillin-sulbactam plus Doxycycline Doxycycline causes pain when infused intravenously so PO administration is recommended.

14. Rec’d Regimens Oral therapy 1) Ceftriaxone IM plus Doxycyclinew/ or w/o Metronidazole 2) Cefoxitin IM with Probenecid plus Doxycyclinew/ or w/o Metronidazole 3) 3G Cephalosporin IM like Cefotaxime or Ceftizoxime plus Doxycyclinew/ or w/o Metronidazole Metro added for pelvic abscess, suspected Trichomonas or BV, hx of gynecologic instrumentation

15. Duration of treatment Optimal duration unknown but most studies used 14 days and CDC guidelines use this. If outpatient therapy selected, must F/U within first 48-72hrs to ascertain clinical improvement.

16. TOA Epidemiology TOA occurs in up to 1/3 of patients. Estimated 100,000 cases per year Most commonly in women 20-40yo Previous PID not more common in TOA pts Does not appear to be increased risk with newer IUD devices …no clear risk factors for TOA in PID

17. Diagnosis TOA should be suspected in any PID patient. Absence of fever and/or leukocytosis is not an argument against TOA (60-80% have). Abdominal findings of ileus may be more common in PID patients with TOA. Unclear whether pelvic examination helps One study showed 90% were clinically appreciated Unsuspected TOA seen with high frequency when laparotomy performed for failure of medical therapy.

18. USG Test of choice to R/O TOA. One study, TVUSG identified 32 of 33 surgically confirmed TOAs, and ruled out 33 of 34 patients. Appears as one or more homogeneous, somewhat symmetrical, cystic, thin-walled, well-demarcated mass(es) which are usually contiguous. Septations and AFLs may be seen. USG indicated in patients with PID and 1) palpable mass, 2) severely ill, 3) those failing medical therapy 4) adequate exam unable to be performed.

19. Medical Therapy for TOA? Retrospective review of 119 cases of TOA showed a 75% success rate with a trial of medical therapy. When medical therapy not successful, or large abscess is identified, drainage procedures should be employed.

20. Transvaginal Drainage Largest study had 302 women, 282 of which were successfully treated with ultrasound-guided aspiration and medical therapy. The sizes of the abscesses in the study ranged from 3 to 15cm. Although 1/3 of patients needed more than one aspiration, only 7% eventually underwent surgery. Size of abscess or multilocularity not important Patient tolerance was excellent Laparoscopic drainage with concurrent medical therapy is aother option.

21. Surgery Almost all patients failing to respond within four days require surgery. Closure of the skin and subcutaneous layer is primarily appropriate for those with no free pus in abdomen.