Transcript Pelvic Inflammatory Disease

Pelvic Inflammatory
Disease
Does LEEP increase the risk of
PTB before 37 weeks?
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Compared women with history of LEEP to
1.
2.
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History of LEEP verses Group 1
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RR 1.61
History of LEEP verses Group 2
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Women with no history of CIN or LEEP
Women with history of CIN but no LEEP
RR 1.08
Risks factors leading to CIN probably more
important than the LEEP
Pathophysiology
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Starts as cervicitis caused by GC, chlamydia, or
mycoplasm
In the presence of bacterial vaginosis, there is a
breakdown of mucous and other natural barriers
allowing an ascending infection
Normal vaginal flora is the source of a
polymicrobial infection.
TOA
Causative Agents
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N. gonorrhea
▪ 20% of women with this cervicitis will
develop acute PID
▪ Intense inflammatory reactions in the
tubal mucosa
Causative Agents
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Chlamydia
▪ More prevalent than Neisseria
▪ Clinically produces a mild for of
salpingitis with an insidious onset
▪ 30% of women with this cervicitis
develop PID
Microorganisms Isolated from the
Fallopian Tubes with Acute PID
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Type of Agent
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STD
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Organism
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Endogenous agent
aerobic or facultative
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Anaerobic
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Chlamydia trachomatis
Neisseria gonorrhea
Mycoplasma hominis
Streptococcus sp.
Staphylococcus sp.
Haemophilus sp.
Escherichia coli
Bacteroides, Peptococcus,
Clostridium, Actinomyces
Weström L: Sex Transm Dis 11:439, 1984
Symptoms
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Abdominal pain
Abnormal discharge
Postcoital spotting
Fever
Low back pain
Nausea/vomiting
How to approach the diagnosis?
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Does she have cervicitis?
Is the cervix inflamed, tender, and/or friable?
 Is the there leukocytes in the wet mount?
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Mucopurulent cervicitis
Mucopurulent cervicitis caused by C. trachomatis (Holmes, 1999; reprinted with
permission from McGraw Hill.)
Physical Findings
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Pelvic tenderness
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Cervical, uterine, or adenexal
Less than 1/3 have fever
WBC commonly normal
Sed rate is generally elevated
CDC recommends treating
sexually active women 25 or less
years old at risk for STD if they are
having pelvic or low abdominal
pain AND 1) cervical, uterine, or
adenexal tenderness; 2) no other
causes of pain
Presumptive Diagnosis of
Cervicitis
Gonococcal Cervicitis
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Recommended
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Alternative regimen
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Ceftriaxone 250 mg IM plus Azithromycin 1 gm po
or doxycycline 100 mg po BID x 7days
Cefixime 400 mg po plus Azithromycin 1 gm po or
doxycycline 100 mg po BID x 7days
If penicillin allergy
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Azithromycin 2 gm po
Cervicitis Treatment
Azithromycin 1 gm po x 1
OR
Doxycline 100 mg bid x 7d
PLUS
Ceftriaxone 125 mg IM
OR
Cefixime 400 mg po
PLUS
Treat for BV if present
Outpatient PID
Indications to hospitalize…
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Pregnancy
Adolescents with unpredictable compliance
Immunodeficient ( HIV with low CD4 counts)
Uncertain diagnosis
Nausea and vomiting, high fever
Inadequate response to outpatient therapy
TOA
CDC .Guidelines for Treatment of Sexually Transmitted Diseases
2002, MMWR 2002: 51: 1041
Inpatient PID
Inpatient PID
Post Hospitalization
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Doxycycline 100 mg orally twice a day for 14
days
Clindamycin 450 mg orally four time s a day for
14 days
Not sure what she has …
TOA
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Tubo-ovarian abscess (TOA)
collection of pus delimited by the adherence of the
fallopian tubes, ovaries, and adjacent organs
serious manifestation of PID and generates 350,000
hospitalization/150,000 surgeries/yr
34% of PID cases hospitalized have TOA
TOA ruptured -mortality rate is as high as 9%
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1-4% rupture at initial presentation or during
conservative management
Soper DE. Pelvic inflammatory disease. Infect Dis
Clin North Am. 1994;8:821-840
Tuboovarian abscess
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Presenting symptoms and
findings with TOA
 Pelvic pain
 Pelvic mass
 Fever/chills
 Vaginal discharge
 Abnormal uterine bleeding
 Nausea/vomiting
 Temp.>100°F
 WBC>10,000
Pelvic inflammatory disease, proven chlamydial pyosalpinx. Right tube is swollen and
tortuous (arrow) (Holmes, 1999; reprinted with permission from McGraw Hill.)
Landers DV and Sweet RL: Rev
Infect Dis 5:879, 1983
Diagnostic tests
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Ultrasound
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Complex cystic mass
containing multiple septations
and internal echoes
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correctly identified TOA in
94% of pt. confirmed by
surgery
Bulas
DI. Radiology. 1992;183:435
Criteria for treatment success:
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Clinical improvement may take 72 hours
Resolution of abdominal pain, defervescence,
decreased WBC, stabilization or decrease in
mass size.
 clinically deterioration or development of an
acute abdomen should prompt surgical
intervention
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Post Hospitalization for TO
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Clindamycin 450 mg orally four times a day for
14 days
Surgery
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TAH/BSO
Laparoscopy with
endoscopic drainage,
irrigation, lysis of
adhesions
Ultrasound guided
percutaneous drainage
Sequelae
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Chronic pelvic pain
Ectopic pregnancy
Infertility