PRESENTED BY OHUNAKIN A.

AFOLABI(Dr)

Introduction Definition and incidence Risk factors Morbidity and mortality Aetiology and mode of spread Presentation and Diagnosis Investigations Treatment Prevention References

Dx of the female upper genital tract Pelvic inflammatory disease (PID) is a common cause of morbidity and accounts for 1 in 60 GP consultations by women under the age of 45 Delays of only a few days in receiving appropriate treatment markedly increase the risk of sequelae, which include infertility, ectopic pregnancy and chronic pelvic pain PID is usually the result of infection ascending from the endocervix causing endometritis, salpingitis, parametritis, oophoritis, tuboovarian abscess and/or pelvic peritonitis

An acute pelvic infection, with ascending spread of micro-organisms from the vagina and cervix to the endometrium,fallopian tubes and/or contiguous structures. It is usually a polymicrobial infection.

True incidence is unknown because of the inaccuracy of diagnosis. Among teenagers, the incidence is estimated to be 1.5% annually. Increase in the incidence in women less than 25 yrs.(18-20/1000women) 10-13/1000 women above 16yrs of age in Sweden 1 in 7 women of reproducvtive age group receive treatment for PID in USA. 5-20% of all admission to gynae wards. 75% are nulliparous

Young age (<25 years) Multiple sexual partners Past history of STI (in the patient or her partners) Termination of pregnancy Insertion of IUCD in the past 6 weeks Hysterosalpingography(HSG) In-vitro fertilization procedure(IVF) Postpartum endometritis Bacterial vaginosis A recent new sexual partner (within the previous 3 months) Previous PID Menstruation Low socioeconomic status Tobacco smoking

A delay in diagnosis or tx can result in long term sequelae e.g tubal infertility Each repeated episode of PID doubles the risk for tubal factor infertility Women with hx of PID have a 7-10 fold increase risk for ectopic pregnancy(tubal pregnancy) Chronic pelvic pain can also follow PID Occur more frequently in adolescents 15-19yrs

1.Exogenous agents: Neisseria gonorrhoea Chlamydia trachomatis Mycoplasma hominis Mycobacteria Tuberculosis. 2.Endogenous organisms. (usually coliforms): E.coli Streptococcus faecalis Enterococcus Bacteroides Actinomyces especially associated with IUCD.

1.Ascending through the cervix,uterine cavity, and the fallopian tubes.Theories of spread includes: a.Uterine muscular activity. b.Role of vectors; Spermatozoa & Trichomonas vaginalis. c.Association with intrauterine manipulation: .IUCD .HSG .D&C D.Association with cervical dilation: .Menstruation .Miscarriage & Childbirth. 2.Heamatogenous spread - pelvic tuberculosis. 3. Spread from affected contiguous structures: Acute appendicitis Acute diverticulitis

Infection is by direct spread of microbes ascending from the vagina and cervix Cervical mucus protects against upward spread but bacteria can penetrate the cervical mucus and cause widespread extension of infection

Vulva close apposition of the labia Apocrine gland secretions fungicidal b. Vagina Lactobacilli produce acid which keeps other organisms in check. Closure of the vagina by apposition of anterior and posterior walls c. Cervix Plug of the cervix by bacteriolytic mucous d. Endometrium Regular shedding prevents infection.
a.

Hx of pain-present in >90% of cases

Most common presenting symptom Dull,aching and constant Begin a few days after onset of LMP and tends to accentuated by motion,exercise or coitus Last <7 days(usually)

Abnormal vaginal discharge 75% of cases Unanticipated vaginal bleeding 40 % of cases Temperature > 38C (30%), nausea, and vomiting manifest late in the clinical course of the disease Pelvic examination is sensitive only in 60% Dysuria or urinary frequency occurs in 15% of patients.

There is lack of definitive clinical diagnostic criteria Low threshold for empirical treatment is recommended The following clinical features are suggestive of a diagnosis of PID: Lower abdominal pain and tenderness Deep dyspareunia Abnormal vaginal or cervical discharge

Unscheduled vaginal bleeding

Cervical excitation and adnexal tenderness motion Fever (> 38C).

Clinical symptoms and signs, however, lack sensitivity and specificity (the positive predictive value of a clinical diagnosis is 6590% compared with laparoscopic diagnosis) The presence of excess leucocytes on a wet mount vaginal smear is associated with PID

Uterine /adnexal tenderness Cervical excitatory tenderness

Temp >38 Abnormal cervical/vaginal mucopurulent discharge Presence of WBC on saline microscopy of vaginal secretions Increase ESR >15mmhr Increase C-reactive protein level Culture of N.gonorrhea or C.trachomatis

Vaginal wet mount(HVS,ECS) increase WBC ESR-non specific C-reactive protein-non-specific FBC-increase WBC Gonorrhea culture Chlamydia culture

Ultrasound-transvaginal

Not very useful in diagnosis of mild or atypical PID Poor sensitivity <81% Poor specificity <78% Useful in documenting adnexal mass or hydrosalphinx

MRI-highly sensitive >90%

Highly specific >95%
Costly Rarely indicated in acute PID Can demonstrate hydrosalphinx with(out) free pelvic

fluid or tuboovarian complex

Culdocentesis-invasive and no longer in use because of Ultrasound Laparoscopy-gold standard of diagnosis

Mild PID .Erythema of the fallopian tubes without pus formation.

Moderately severe PID .Sero-purulent exudates from fimbriated end or serosal surface of fallopian tubes.
Severe PID. .Inflammatory mass .Pyosalpinx .Abscess.

.Oedema & swelling of fallopian tubes that are otherwise freely mobile.

Adnexal tumors Appendicitis Ectopic pregnancy Endometriosis Rupture of an adnexal mass Adnexal torsion Perihepatic inflammation- Fitz Hugh Curtis syndrome Septic abortion diverticulitis

In mild or moderate PID (in the absence of a tubo-ovarian abscess), there is no difference in outcome when patients are treated as outpatients or admitted to hospital Delay in treatment will result in long term sequelea; ectopic pregnancy, subfertility and pelvic pain oral ofloxacin 400 mg twice a day plus oral metronidazole 400 mg twice a day for 14 days intramuscular ceftriaxone 250 mg immediately or intramuscular cefoxitin 2 g immediately with oral probenecid 1 g, followed by oral doxycycline 100 mg twice a day plus metronidazole 400 mg twice a day for 14 days.

Admission to hospital would be appropriate in the following circumstances: surgical emergency cannot be excluded clinically severe disease tubo-ovarian abscess PID in pregnancy lack of response to oral therapy intolerance to oral therapy.

Intravenous cefoxitin 2 g three times a day plus intravenous doxycycline 100 mg twice a day (oral doxycycline may be used if tolerated), followed by oral doxycycline 100 mg twice a day plus oral metronidazole 400 mg twice a day for a total of 14 days

OR

Intravenous clindamycin 900 mg three times a day plus intravenous gentamicin: 2 mg/kg loading dose followed by 1.5 mg/kg three times a day (a single daily dose of 7 mg/kg may be substituted), followed by

EITHER:

Oral clindamycin 450 mg four times a day to complete 14 days

OR

Oral doxycycline 100 mg twice a day plus oral metronidazole 400 mg twice a day to complete 14 days7,25,29,30

OR Intravenous ofloxacin 400 mg twice a day plus intravenous metronidazole 500 mg three times a day for 14 days.

A pregnancy test should be performed in all women suspected of having PID to help exclude an ectopic pregnancy. The risk of giving any of the recommended antibiotic regimens in very early pregnancy (prior to a positive pregnancy test) is low, with any significant drug toxicity resulting In an intrauterine pregnancy, PID is extremely rare, except in the case of septic abortion. Cervicitis may occur, however, and is associated with increased maternal and fetal morbidity. Treatment regimens will be dependent upon the organisms isolated. Drugs known to be toxic in pregnancy should be avoided e.g. tetracyclines. Erythromycin and amoxycillin are not known to be harmful in pregnancy

An intrauterine contraceptive device (IUCD) may be left in situ in women with clinically mild PID but should be removed in cases of severe disease. An IUCD only increases the risk of developing PID in the first few weeks after insertion. A single small randomised controlled trial suggests that removing an IUCD does not affect the response to treatment but the study has suboptimal outcome measures An observational study also showed no benefit in removing an IUCD in this situation.

Laparotomy/laparoscopy may help early resolution of the disease by division of adhesions and drainage of pelvic abscesses Ultrasound-guided aspiration of pelvic fluid collections is less invasive and may be equally effective It is also possible to perform adhesiolysis in cases of perihepatitis although there is no evidence as to whether this is superior to antibiotic therapy alone. Contact tracing of sexual partners and treatment are compulsory for every patient with PID

The use of the combined oral contraceptive pill has usually been regarded as protective against symptomatic PID Retrospective casecontrol and prospective studies(RCOG) have, however, shown an association with an increased incidence of asymptomatic cervical infection with C. trachomatis This has led to the suggestion that the oral contraception may mask endometritis Women using the oral contraceptive pill should be warned that its effectiveness may be reduced when taking antibiotic therapy. Auditable outcomes: Little is known about the long-term outcomes, in relation to future fertility, ectopic pregnancy and chronic pelvic pain, following the treatment of PID.

Infertility-from tubal and peritubal damage Chronic pelvic pain Ectopic pregnancy

Effective prevention of the majority of PID cases is theoretically achievable through the reduction and prevention of chlamydial and gonococcal infections in the community and treating cervical infection prior to uterine instrumentation. Prevention encompasses measures to prevent exposure to infection (primary prevention) The detection and treatment of lower genital tract infection to prevent ascent to the upper genital tract (secondary prevention) Early effective treatment to limit tubal damage (tertiary prevention).

Pelvic infections :HaithamHamoda and Chris Bignellcurrent obstetrics and gyneacology MANAGEMENT OF ACUTE PELVIC INFLAMMATORY DISEASE-setting standards to improve women`s healthRoyal college of Obstetricians and Gyneacologists Pelvic Inflammatory Disease-Author: James B Hill, MD, Staff Physician, Department of Obstetrics and Gynecology, Walter Reed Army Medical Center ACUTE PELVIC INFLAMMATORY DISEASE- By DR.M.A.OKUNLOLA Consultant Obstetrician &Gynaecologist PELVIC INFLAMMATORY DISEASE (PID)- DR. CHRISTOPHER A ENAKPENE

Nursing Care

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