PID.pdf

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OBSTETRICS & GYNECOLOGY PELVIC INFLAMMATORY DISEASE      

INTRODUCTION PID Infection in the upper genital tract not associated with pregnancy or intraperitoneal pelvic infections Salpingitis – infection of the oviducts; most characteristic & common component of PID Primary prevention: prevent exposure & acquisition of STIs – safe sex practices Secondary prevention: Universal screening for those at high risk for chlamydia & gonorrhea Screening for active cervicitis Sensitive tests for diagnosing lower genital infection Treatment of sexual partners Education

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Acute PID Ascending infection from bacterial flora of vagina & cervix Mucosal surface – endometrium & fallopian tubes Rare in women without menstrual period Polymicrobial Most common serious infection of women ages 16-25 years old May develop from the following procedures: endometrial biopsy, curettage, IUD insertion, hysterosalpingography, hysteroscopy

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Postmenopausal women – genital malignancies, diabetes, or concurrent intestinal diseases Rate of ectopic pregnancy increases 6-to 10-fold Chronic pelvic pain increases 4-fold Infertility – depending on severity of infection, number of episodes, & age Nonspecific signs & symptoms Silent/Asymptomatic PID – may have tubal infertility without prior history of signs or symptoms of acute infection

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ETIOLOGY 2 classic sexually transmitted organisms associated with PID: N. gonorrhoeae C. trachomatis N. gonorrhoeae Transparent colonies on culture medium attach more readily to epithelial cells -> produce tubal infection more frequently Ascends to fallopian tube -> selectively adheres to nonciliated mucussecreting cells -> inflammatory response -> cell death & tissue damage > removal of dead cells & fibroblast -> scarring & tubal adhesions

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C. trachomatis intracellular, sexually-transmitted More prevalent Remain in the fallopian tubes for months after initial colonization Primary infections – self-limited, with mild symptoms & little permanent damage Atypical/silent PID – relatively asymptomatic inflammation of the upper genital tract Sequelae of repeated infection: tubal infertility & ectopic pregnancy

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Mycoplasma hominis Spread is via the parametria rather than the mucosa Does not appear to produce damage to the tubal mucosa Not highly pathogenic

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Most common aerobic organisms: Nonhemolytic Streptococcus E. coli Group B Streptococcus Coagulase-negative Staphylococcus

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Most common anaerobic organisms (predominant over aerobic): Bacteroides spp. Peptostreptococcus Peptococcus

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Transcervical penetration of the cervical mucus barrier with instrumentation of the uterus Genetic variation SIGNS & SYMPTOMS Classic triad: (17%) Fever Elevated ESR Adnexal tenderness or mass Most frequent symptom: new-onset lower abdominal & pelvic pain – diffuse, bilateral, constant, & dull Exacerbated by motion or sexual activity May become cramping Duration: 10,000 cells/mL - 15mm/hr – 75% Sensitive test for hCG – help in the differential diagnosis of ectopic pregnancy Inflammatory test for endocervical mucus Increased vaginal WBC – most sensitive laboratory indicator Endometrial biopsy – for evidence of endometritis Vaginal ultrasonography – adnexal mass Dilated & fluid-filled tubes Free peritoneal fluid MRI – sensitive, but expensive & limited availability

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TREATMENT   

Key issues: Need for hospitalization Patient education – use of contraceptives Treatment of sexual partners Careful follow-up 2 most important goals: Resolution of symptoms Preservation of tubal function Not treated in the 1st 72 hours following symptom onset – 3x likely to develop tubal infertility or ectopic pregnancy

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IV antibiotics continued for at least 24 hours after substantial improvement (+) mass – add ampicillin to clindamycin & gentamicin (-) mass – oral antibiotics if symptoms have diminished & afebrile for 24 hours Operative Treatment life-threatening infections Ruptured tubo-ovarian abscess Laparoscopic drainage of pelvic abscess Persistent masses in those whom future childbearing is not a consideration Persistent symptomatic mass Unilateral removal of tubo-ovarian complex or abscess – frequent conservative procedure Drainage of abscess – if no response to parenteral broad-spectrum antibiotics Transvaginal or transabdominal percutaneous aspiration or drainage of pelvic abscesses under ultrasonic or CT guidance – contraindicated if there is suspicion of infected carcinoma Laparoscopic aspiration of tubo-ovarian complexes – carries more operative risks than ultrasound-guided aspiration SEQUELAE Ectopic pregnancy Chronic pain Infertility Damaged yet patent oviduct Peritubular and periovarian adhesions -> complete tubular obstruction

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Reexamine within 48 to 72 hours of initiating outpatient therapy Hospitalize if therapeutic response is not optimal If responding well, reexamine after 4 to 6 weeks of therapy

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Acute PID associated with IUD More advanced at time of diagnosis due to misinterpretation of early signs & symptoms Often caused by anaerobic bacteria Outpatient therapy leaving the IUD in situ may be attempted if close follow-up is possible

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