Transcript Document

Pelvic Inflammatory Disease
A
Condition
Requiring
Closer Attention
Prof. Aruna Batra
Obstetrics & Gynecology
VMMC & SJH, N. Delhi
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 Wales
Int. J STD AIDS 2000 Jul;11(7):440-4
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 ?
• 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
Transmission
•
• Sexual transmission
via the vagina & cervix
• Gynecological
surgical procedures
• Child birth/ Abortion
• A foreign body inside uterus (IUCD)
Transmission
•
• Contamination from
other inflamed structures
in abdominal cavity
(appendix, gallbladder)
• Blood-borne transmission
(pelvic TB)
Pathogenesis
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
•
• 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 ?
• 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
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• 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
• 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
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Ectopic Pregnancy
Torsion/ Rupture adnexal mass
Appendicitis
Endometriosis
Cystitis/ pyelonephritis
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
Endometritis (thickened heterogenous endometrium)
Hydrosalpinx (anechoic tubular structure)
Hydrosalpinx.
Pyosalpinx (tubular structure with debris in adnexa
Tuboovarian abscess resulting from tuberculosis
Right hydrosalpinx with an occluded left fallopian tube
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)
• 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
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
•
• 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)
• 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
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)
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 2nd/ 3rd Generation Cephalosporins
Ceftizoxime - Cefizox,
Cefotaxime - Omnatex,
Ceftriaxone - Monocef,
Cefoperazone - Magnamycin,
Ceftizidime - Fortum
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)
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)
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
• 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
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
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.
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
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
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
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Ruptured Pelvic Abscess
▪ Generalized Septic Peritonitis
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↑ 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
• 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
Re-screening for Chlamydia & Gonorrhea
● Patient counseling:
- Risk of re- infection and sequel.
- Sexual counseling
- Avoid douching
●
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
STD
PID
Infertility
STD
Influenced by Interaction of
following Environments
Genital Microbial Environment
Individual Behavioral Environment
Socio-geographic Environment
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
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.
●