L46 Pelvic Inflammatory Disease (PID)

L46 Pelvic Inflammatory Disease (PID)

• 1.
  Pelvic Inflammatory Disease (PID)
• 2.
  Introduction endometritis, salpingitis, parametritis,oophoritis, tubo-ovarian abscess and/or pelvic peritonitis Most commonly ascending infection Can lead to chronic pelvic pain , ectopic pregnancy & infertility  Chlamydia trachomatis and Neisseria gonorrhoeae are the most important organisms .  Gardenella vaginalis , anaerobes and other organisms such as mycoplasma commonly found in the vagina may also be implicated
• 3.
  Risk factors 1. Youngage < 25 yrs . 2. Multiple sexuale partners . 3. Past Hx of sexually transmitted infections . 4. Termination of pregnancy . 5. Insertion of IUCD in the previous 6 weeks . 6. Hysterosalpingography . 7. IVF procedure . 8. Post partum endometritis . 9. Bacterial vaginosis . 10. Recent new sexual partner
• 4.
  Diagnosis Clinical : The followingfeatures are suggestive of a diagnosis of PID1, 2, 4, 5: • lower abdominal pain which is typically bilateral • deep dyspareunia • abnormal vaginal bleeding, including post coital, inter-menstrual and menorrhagia • abnormal vaginal or cervical discharge which is often purulent Signs • lower abdominal tenderness which is usually bilateral • adnexal tenderness on bimanual vaginal examination • cervical motion tenderness on bimanual vaginal examination • fever (>38°C)
• 5.
  Diagnosis Exclude pregnancy inall child bearing age women (BHCG ) screening for sexually transmitted infections including HIV20 Vaginal and endocervical swab culture The absence of endocervical or vaginal pus cells has a good negative predictive value (95%) for a diagnosis of PID but their presence is non-specific (poor positive predictive value – 17%) Gonorrhea tested by endocervical swab Chlamydia tested by NAAT (nucleic acid amplification test )
• 6.
  Diagnosis Leukocytosis & ElevatedCRP & ESR can support the diagnosis . Laparoscopy (support the diagnosis but not routine ) Transvaginal ultrasound : inflamed and dilated tubes and tubo-ovarian masses
• 7.
  Treatment Medical Surgical : intubo-ovarian abscess In all suspected cases antibiotic should be started early even before confirming the diagnosis Inpatient or outpatient
• 8.
  Treat as inpatientif : a surgical emergency cannot be excluded • lack of response to oral therapy • clinically severe disease • presence of a tuboovarian abcess • intolerance to oral therapy • pregnancy
• 9.
  Outpatient regimens IM ceftriaxone*500mg single dose followed by oral doxycycline 100mg twice daily plus metronidazole 400mg twice daily for 14 days oral ofloxacin 400mg twice daily plus oral metronidazole 400mg twice daily for 14 days intramuscular ceftriaxone 500 mg immediately, followed by azithromycin 1 g/week for 2 weeks oral moxifloxacin 400mg once daily for 14 days
• 10.
  Inpatient regimens i.v. ceftriaxone2g daily plus i.v. doxycycline 100mg twice daily (oral doxycycline may be used if tolerated) followed by oral doxycycline 100mg twice daily plus oral metronidazole 400mg twice daily for a total of 14 days i.v. clindamycin 900mg 3 times daily plus i.v. gentamicin (2mg/kg loading dose) followed by 1.5mg/kg 3 times daily [a single daily dose of 7mg/kg may be substituted]) followed by either oral clindamycin 450mg 4 times daily or oral doxycycline 100mg twice daily plus oral metronidazole 400mg twice daily to complete 14 days
• 11.
  Screening and treatmentof the sexual partner is needed (gonorrhea and chlamydia ) Ceftriaxone 500 mg IM stat + azithromycin 1g stat Contact tracing of all partners in the previous 6 months is recommended .
• 12.
  Management in pregnancy A pregnancy test should be performed in all women suspected of having PID to help exclude an ectopic pregnancy.  PID is rare in women with an intrauterine pregnancy except in the case of septic abortion.  Pregnant women should ideally receive IV therapy , because PID associated with higher maternal and fetal morbidity
• 13.
  PID with IUD Considerationshould be given to removing an IUD in women presenting with PID, especially if symptoms have not resolved within 72 hours. Removal of the IUD should be considered and may be associated with better short-term clinical outcomes
• 14.
  Complications tubal factor infertility ectopicpregnancy chronic pelvic pain Fitz –Hugh-Curtis syndrome It is presented as right upper quadrant pain associated with perihepatitis, most frequently in women with chlamydial PID