Management of Pelvic Inflammatory Disease (PID)
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Lecture delivered at BOGSCON 41 (The Annual Conference of Bengal Obstetric and Gynaecological Society)
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Management of Pelvic Inflammatory Disease (PID)
- 1. Management of PID Dr Sujoy Dasgupta MBBS (Gold Medalist, Hons) MS (OBGY- Gold Medalist) DNB (OBGY)
- 2. Albert Ludwig Sigesmund Neisser
- 3. Pelvic Inflammatory Disease (PID) Acute/ Chronic inflammation of upper genital tract • Endometrium → Endometritis • Fallopian tubes → Salpingitis • Ovaries → Oophoritis → TO abscess • Adjoining structures → Parametritis → Pelvic peritonitis → Pelvic abscess
- 4. EPIDEMIOLOGY 1-2% in young sexually active women 85% Spontaneous Infection (STD) 15% Iatrogenic
- 5. DIAGNOSIS
- 6. Dilemma • Vague signs/ symptoms • Variety of s/s • Often asymptomatic or mild • No single finding is both sensitive and specific • Higher PPV among the population at risk of STI
- 7. If delayed - Chronic pelvic pain and ill health - Infertility - Adhesions - Tubo-ovarian abscess - Ectopic pregnancy
- 9. Clinical Diagnostic Criteria A sexually active woman Other woman at risk factor for PID C/O lower abdominal/ pelvic pain No other cause identified Plus Any One of the Minimum Criteria Cervical Motion Tenderness Uterine Tenderness Adnexal Tenderness
- 10. Additional Criteria At least one Oral temperature- >101°F (>38.3°C) Cervical/ vaginal mucopurulent discharge Abundant WBC-s on saline M/E of vaginal fluid Elevated ESR Elevated CRP Lab documentation of cervical infection with N. gonorrhoeae or C. Trachomatis
- 11. Most Specific Criteria Any one of Endometrial biopsy H/P evidence of Endometritis TVS/ MRI Thickened, fluid-filled tubes Free pelvic fluid Tubo-ovarian complex, Doppler- tubal hyperemia Laparoscopy Hyperaemia/ oedema of tubes Exudates from fimbrial ends Violent-string adhesions in pelvis Perihepatic adhesions Pyosalpinx Pelvic collection
- 12. Differential Diagnosis • Appendicitis • Disturbed ectopic pregnancy • Twisted/ruptured ovarian cyst • Endometriosis • Diverticulitis • Urinary tract infection • Functional pain
- 13. Further Testing (CDC 2015, European Guideline 2012) • Serology for HIV • Testing for N. gonrrhoeae • Testing for Chlamydia • Testing for bacterial vaginosis (BV)- ? • Urine pregnancy test
- 14. TREATMENT
- 15. Principles Prompt (as soon as presumptive diagnosis) Empiric broad spectrum- N.gonorrhoeae and C. trachomatis Regimens with anti-anaerobic activity should be considered Therapeutic goal: 1. Elimination of acute infection. 2. Prevention of complications. (PEACH Study, 2002)
- 16. Which regime? • Optimum treatment regime and duration- ? • Oral or parenteral- • OPD or In patient- • Consider 1. Cost 2. Availability 3. Local epidemiology 4. Disease severity 5. Patient acceptance
- 17. Recommended Treatment Regimens REGIMEN A REGIMEN B OUTPATIENT REGIMEN A REGIMEN B INPATIENT CDC
- 18. Outpatient Therapy of Acute PID Regimen A: * Better coverage against N gonorrhoeae **500 mg (UK Guideline, 2011) Ceftriaxone* 250 mg** IM Single dose Plus Doxycycline 100 mg Orally BD 14 days With/ without Metronidazole 500 mg Orally BD 14 days
- 19. REGIMEN B: *Better anaerobic coverage Cefoxitin* 2 g IM Single dose }ConcurrentlyProbenacid 1 g Oral Single dose Plus Doxycycline 100 mg Oral BD 14 days With/ Without Metronidazole 500 mg Oral BD 14 days Outpatient Therapy of Acute PID (Contd..)
- 20. Outpatient Therapy of Acute PID (Contd...) 1. Other Cephalosporins Ceftizoxime/ Cefotaxime Single dose Plus Doxycycline 100 mg BD x 14 days With/ without Metronidazole 500 mg BD x 14 days 2. Macrolide Azithromycin 1g orally once a week x 2 weeks Plus Ceftriaxone 250 mg IM single dose Specially active against N gonorrhoeae 3. Amoxiclav Plus Doxycycline More GI side effects 4. Quinolones •Emergence of quinolone-resistant N gonorrhoeae (QRNG) •Used only if cephalosporin not available/ allergic to it and prevalence and risk of gonrrhoea is low •Diag test for N gonorrhoeae must be performed Levofloxacin 500 mg OD x 14 days Or Ofloxacin 400 mg BD x 14 days Or Moxifloxacin 400 mg OD x 14 days Plus Metronodazole 500 mg BD x 14 days Alternative Regimes:
- 21. Review • After 72 hours • Clinical improvement is evident by 1. Defervescence 2. Reduction in: Direct and rebound abdominal tenderness Uterine, adnexal and cervical motion tenderness.
- 22. Consider: • Subsequent hospitalisation (for out patient therapy) • Antimicrobial sensitivity assessment • Review diagnosis • Diag Lap • Surgical modalities If no improvement in 72 hours
- 23. Indications for Admission Surgical emergency cannot be excluded Clinically severe disease (severe illness, peritonitis, nausea and vomiting, or high fever) Tubo-ovarian abscess (at least 24 hr observation) PID in pregnancy Lack of response to oral therapy (within 72 hr) Intolerance to oral therapy
- 24. Parenteral Regimen A: *Oral is preferred for same bioavailability Inpatient Therapy of Acute PID Cefotetan 2 g IV q 12 hrly Or Cefoxitin 2 g IV q 6 hrly Plus Doxycycline 100 mg IV/ Oral* q 12 hrly Followed by (at least 24 hr after clinical improvement) Doxycycline 100 mg Oral BD 14 days
- 25. Parenteral Regimen B: *a single daily dose of 3-5 mg/kg may be substituted Inpatient Therapy of Acute PID (Contd..) Clindamycin 900 mg IV q 8 hrly Plus Gentamicin* Loading 2 mg/kg f/b 1.5 mg/kg IV IV q 6 hrly Followed by either (at least 24 hr after clinical improvement) 1. Clindamycin 450 mg Oral QDS 14 days Or (especially in case of TO abscess) 2. Doxycycline 100 mg Oral BD 14 days Plus Metronidazole 400 mg Oral BD 14 days
- 26. Inpatient Therapy of Acute PID (Contd..) Quinolones Levofloxacin 500 mg IV OD Ofloxacin 400 mg IV q 12 hrly With/ Without Metronidazole 500 mg IV q 8 hrly Penicillin Ampicillin/ Sulbactam 3 g IV q 6 hrly Plus Doxycycline 100 mg IV/ Oral q 12 hrly Covers C. trachomatis, N. gonorrhoeae and anaerobes in TO abscess 3rd Generation Cephalosporins Ceftizoxime, Cefotaxime, Ceftriaxone Limited data No anaerobic coverage Macrolide Azithromycin 500 mg IV/d 1-2 days f/b 250 mg/d Oral x 5-6 days With/ Without 12 days course of Metronidazole Alternative Parenteral Regimens:
- 27. Surgical Management Indications: • Uncertain diagnosis • Failed medical management. • Severe diseases • TO Abscess, Pelvic Abscess
- 28. Laparoscopy • Confirm diagnosis • Prognosis predicted • Management can be planned 1. Explore all the organs 2. Aspiration 3. Drainage of abscess 4. Peritoneal fluid send for culture and sensitivity 5. Adhesiolysis- pelvic and perihepatic adhesions 6. Irrigation
- 29. Pelvic abscess • Resuscitation • Management of septic shock • Drainage 1. Percutaneous guided USG guided- Less invasive If fails→ CT guided Drain may is placed 2. Laparoscopy 3. Colpotomy 4. Laparotomy Peritoneal wash Vault left open for drainage Penrose drain is kept Consider abdominal suction drains
- 30. Other Advices • Avoidance of unprotected intercourse until declared cured • Review at 4 weeks • If documented chlamydial or gonococcal PID → retest 3 months after treatment (or at least once before next 12 months)
- 31. Chronic PID Surgical decision depends on • Age • Parity • Symptoms • Pelvic pathology • Laparopscopic adhesiolysis adnexectomy salpingectomy tuboplasty salpingoscopy hysterectomy • Hysteroscopic falloposcopy balloonplasty
- 32. Management of sexual partners 1. Contact and offer health services 2. Screening for gonorrhoea and chlamydia (especially those who contacted the woman within 60 days of onset of PID symptoms) 3. Empirical therapy for both gonorrhoea and chlamydia 4. Abstinence until both have completed the treatment course.
- 33. Management of sexual partners (Contd..) 5. Test for HIV 6. Condom promotion 7. Expedited Partner Therapy (EPT) or Patient-Delivered Partner Therapy (PDPT)
- 34. SPECIAL CASES
- 35. Adolescents • No difference between OPD and in patient management • Ofloxacin should be avoided in young women • Doxycycline can be safely used >12 years
- 36. HIV/ AIDS • Same antibiotic regimens as women HIV negative • Increased incidence of Mycoplasma hominis and Streptococcus • More incidence of TO abscess
- 37. Pregnancy • High risk for maternal morbidity and preterm delivery • Hospitalized and treated with IV antibiotics. • Avoid teratogens- e.g., tetracycline group • Chlamydia- can affect neonate • If infected with C trachomatis, → Confirm cure by lab test after 3-4 weeks, after 3 months, 3rd trimester (for high risk group)
- 38. IUCD • Mild disease- left in situ • If no improvement after 72 hours of antibiotic- Remove • Severe disease- Remove after the antibiotic attains therapeutic plasma concentration
- 40. Client-oriented treatment approach for low resource settings 1. History 2. Clinical exam 3. Lab exam- wherever feasible 4. Treatment with drugs 5. Follow up 6. Partner management
- 41. Syndromic Management for PID C/O lower abdominal pain ± Vaginal discharge Elicit H/O P/A, P/V and P/S examination- Adnexal/ Uterine/ Cx motion tenderness Urine Pregnancy Test •Missed/ overdue period •Vaginal bleeding •Recent delivery/ abortion •Rebound tenderness, guarding •Pelvic mass •Bowel sign/ symptoms •Sudden severe pain •Dyspareunia •+ve UPT Yes •Refer to higher level urgently •Set up UV access •Resuscitation No Start Treatment
- 42. •Treat For PID (Kit-6- Yellow Colour) 1. Cefixime 400mg Oral Stat 2. Metronidazole 400mg BD Oral For 14 Days 3. Doxycycline 100mg BD For 14 Days •Educate, Counsel •Provide Condom & Promote Use •Treat Partner •Refer To ICTC •Review After 3 Days •Follow Up After 7, 14 Day Symptoms persist No Yes Cured •Educate, Counsel •Provide Condom & Promote Use Refer to higher level Treatment Steps Syndromic Management for PID (Contd..)
- 43. Conclusion • Overdiagnosis of PID is better than inviting complications • Broad spectrum antibiotics • Surgery when indicated • Partner treatment • Prevention- education and counseling