PELVIC INFLAMMATORY DISEASE    • DR:SHABNAM NAZ SHAIKH          • ASSISTANT PROFESSOR                  • OBGYN        • CM...
PID: A NEGLECTED ISSUE• Low disease awareness• Sub-optimal management• 50% named correct antibiotic regimen• < 25% examine...
OBJECTIVES• What is Pelvic Inflammatory Disease?• Why is it important to treat timely?• Causative factors and transmission...
PELVIC INFLAMMATORY DISEASE• Clinical syndrome associated with ascending  spread of microorganisms from the vagina or  cer...
NORMAL CERVIX WITH ECTOPY
INCIDENCE• The exact prevalence is hard to ascertain  as many cases may go undetected, but is  thought to be in the region...
Transmission•    • Sexual transmission     via the vagina & cervix    • Gynecological     surgical procedures    • Child b...
Transmission•    • Contamination from     other inflamed structures     in abdominal cavity    (appendix, gallbladder)    ...
IUCD
PATHOGENESIS
INFECTIVE ORGANISMS• Sexually transmitted - Chlamydia trachomatis                        Neisseria gonorrhoeae• Endogenous...
PREDISPOSING FACTORS•    • Frequent sexual encounters, many partners    • Young age, early age at first intercourse    • E...
PATHWAY OF ASCENDANT INFECTION Cervicitis              Endometritis                         Salpingitis/                  ...
NORMAL HUMAN FALLOPIAN TUBE          TISSUE
C. TRACHOMATIS INFECTION (PID)
PID CLASSIFICATION                               Mild toSubclinical/                 moderate  silent                     ...
PROTECTIVE FACTORS• These include the use of barrier  contraception, the levonorgestral releasing  system (Mirena IUS) and...
WHY IS IT IMPORTANT TO TREAT PID ?            CONSEQUES   • Systemic upset / Tubo-ovarian abscess  • Chronic Pain (15-20 %...
PRESENTATION: ACUTE PID•   • Severe pain & tenderness lower abdomen    • Fever, Malaise, vomiting, tachycardia    • Offens...
FITZ HURTS CURTIZ SYNDROME
PRESENTATION: CHRONIC PID• Chronic lower abdominal pain, Backache• General malaise & fatigue• Deep dyspareunia, Dysmenorrh...
PID: DIFFERENTIAL DIAGNOSIS• Ectopic Pregnancy• Torsion/ Rupture adnexal mass• Appendicitis• Endometriosis• Cystitis/ pyel...
LABORATORY STUDIES• Pregnancy test• Complete blood count, ESR, CRP• Urinalysis• Gonorrhea, Chlamydia detection (Gram stain...
MUCOPURULENT CERVICAL DISCHARGE       (POSITIVE SWAB TEST)
Endometritis (thickened heterogeneous 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 PIDMINIMUM CRITERIA FOR DIAGNOSIS                 (CDC 2002)• Lower abdominal tenderness on palpati...
ADDITIONAL CRITERIA (CDC 2002)• Oral temperature > 38.3°C (101°F)• Abnormal cervical / vaginal discharge• Elevated ESR• El...
Definitive Criteria (CDC 2002)• Endometrial biopsy with histopathology evidence of endometritis• TVS/ MRI: Thickened fluid...
MANAGEMENT ISSUES•    • Inpatient vs. outpatient management ?    • Broad-spectrum antibiotic therapy     without microbiol...
GENERAL PID CONSIDERATIONSRegimens must provide coverage of N. gonorrhea, C.trachomatis, anaerobes, Gram-negative bacteria...
CRITERIA FOR HOSPITALIZATION• Inability to exclude surgical emergencies• Pregnancy• Non-response to oral therapy• Inabilit...
ANTIBIOTIC THERAPY  Gonorrhea : Cephalosporins, Quinolones  Chlamydia: Doxycycline, Erythromycin &Quinolones (Not to cepha...
ORAL REGIMENS•   CDC-recommended oral regimen A     • Ceftriaxone 250 mg IM in a single dose, PLUS    • Doxycycline 100 mg...
FOLLOW-UP• Patients should demonstrate substantial improvement  within 72 hours.• Patients who do not improve usually requ...
PARENTERAL REGIMENS•   CDC-recommended parenteral regimen A    •   Cefotetan 2 g IV every 12 hours, OR    •   Cefoxitin 2 ...
ALTERNATIVE PARENTERAL REGIMEN      •   Ampicillin/Sulbactam 3 g IV every 6 hours, PLUS      •   Doxycycline 100 mg orally...
CDC RECOMMENDATIONS•   No efficacy data compare parenteral    with oral regimens•   Clinical experience should guide    de...
When should treatment be stopped ?   • Parenteral changed to oral therapy after     72 hrs., if substantial clinical impro...
Associated treatment     Rest at the hospital or at home     Sexual abstinence until cure is achieved     Anti-inflammator...
Special SituationsPregnancy  - Augmentin or Erythromycin  - HospitalizationConcomitant HIV infection  - Hospitalization an...
Surgery in PIDIndicationsAcute PID- Ruptured abscess- Failed response to medical treatment- Uncertain diagnosisChronic PID...
SURGERY IN PID• Timing of Surgery - No improvement within 24-72 hours - Quiescent (2-3 months after acute stage)• Type of ...
RUPTURED PELVIC ABSCESS▪ Generalized Septic Peritonitis•   ↑ absorption of bacterial endotoxins•   ↑ fluid from inflamed p...
RUPTURED ABSCESS- MANAGEMENT• Pre-Operative  • Rapid/ adequate metabolic/hemodynamic preparation  • Blood chemistry, CVP m...
FOLLOW UP● Re-screening for Chlamydia & Gonorrhea● Patient counseling:   - Risk of re- infection and sequel.   - Sexual co...
Management of sex partners• Examination and treatment if they had sexual contact   with patients during the 60 days       ...
OPPORTUNITIES FOR CONTROL  STD             PID           Infertility STD          Influenced by Interaction of          fo...
PREVENTION• PRIMARY PRVENTION• To reduce the incidence of PID, screen  and treat for chlamydia.• Annual chlamydia screenin...
PARTNER MANAGEMENT• Male sex partners of women with PID  should be examined and treated if they  had sexual contact with t...
PARTNER MANAGEMENT (CONTINUED)• Male partners of women who have PID  caused by C. trachomatis or N. gonorrhea  are often a...
REPORTING• Report cases of PID to the local STD  program in states where reporting is  mandated.• Gonorrhea and chlamydia ...
PATIENT COUNSELING AND EDUCATION  • Nature of the infection  • Transmission  • Risk reduction   • Assess patients behavior...
.    Secondary Prevention:•   - Screening for infections in high- risk.    - Rapid diagnosis and effective treatment      ...
CONCLUSION● PID in women - “Silent epidemic”● Can have serious consequences.● Be aware of limitations of clinical diagnosi...
SUMMARY● PID in women - “Silent epidemic”● Can have serious consequences.● Be aware of limitations of clinical diagnosis.●...
THANKS
Pid by dr shabnam naz
Pid by dr shabnam naz
Pid by dr shabnam naz
Pid by dr shabnam naz
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  1. 1. PELVIC INFLAMMATORY DISEASE • DR:SHABNAM NAZ SHAIKH • ASSISTANT PROFESSOR • OBGYN • CMC,SMBBMU LARKANA
  2. 2. PID: A NEGLECTED ISSUE• Low disease awareness• Sub-optimal management• 50% named correct antibiotic regimen• < 25% examined the sexual partners
  3. 3. 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
  4. 4. PELVIC INFLAMMATORY DISEASE• Clinical syndrome associated with ascending spread of microorganisms from the vagina or cervix to the endometrium, fallopian tubes, ovaries, and contiguous structures.• Comprises a spectrum of inflammatory disorders including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.
  5. 5. NORMAL CERVIX WITH ECTOPY
  6. 6. INCIDENCE• The exact prevalence is hard to ascertain as many cases may go undetected, but is thought to be in the region of 1-3% of sexually active young women.
  7. 7. Transmission• • Sexual transmission via the vagina & cervix • Gynecological surgical procedures • Child birth/ Abortion • A foreign body inside uterus (IUCD)
  8. 8. Transmission• • Contamination from other inflamed structures in abdominal cavity (appendix, gallbladder) • Blood-borne transmission (pelvic TB)
  9. 9. IUCD
  10. 10. PATHOGENESIS
  11. 11. INFECTIVE ORGANISMS• Sexually transmitted - Chlamydia trachomatis Neisseria gonorrhoeae• Endogenous Aerobic - Streptococci Haemophilus E. coli• Anaerobes - Bacteroides, Pepto-streptococcus - Bacterial Vaginosis - Actinomyces Israeli• Mycoplasma hominies, Urea plasma• Mycobacterium tuberculosis & bovis
  12. 12. 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
  13. 13. PATHWAY OF ASCENDANT INFECTION Cervicitis Endometritis Salpingitis/ oophoritis/ tubo- ovarian abscess Peritonitis
  14. 14. NORMAL HUMAN FALLOPIAN TUBE TISSUE
  15. 15. C. TRACHOMATIS INFECTION (PID)
  16. 16. PID CLASSIFICATION Mild toSubclinical/ moderate silent symptoms 60% 36% Overt 40% Severe symptoms 4%
  17. 17. PROTECTIVE FACTORS• These include the use of barrier contraception, the levonorgestral releasing system (Mirena IUS) and the COCP.
  18. 18. WHY IS IT IMPORTANT TO TREAT PID ? CONSEQUES • 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%)
  19. 19. PRESENTATION: ACUTE PID• • 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%
  20. 20. FITZ HURTS CURTIZ SYNDROME
  21. 21. PRESENTATION: CHRONIC PID• Chronic lower abdominal pain, Backache• General malaise & fatigue• Deep dyspareunia, Dysmenorrhea• Intermittent offensive vaginal discharge• Irregular menstrual periods• Lower abdominal/ pelvic tenderness• Bulky, tender uterus Infertility ( “Silent epidemic” )
  22. 22. PID: DIFFERENTIAL DIAGNOSIS• Ectopic Pregnancy• Torsion/ Rupture adnexal mass• Appendicitis• Endometriosis• Cystitis/ pyelonephritis
  23. 23. 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
  24. 24. MUCOPURULENT CERVICAL DISCHARGE (POSITIVE SWAB TEST)
  25. 25. Endometritis (thickened heterogeneous endometrium)
  26. 26. Hydrosalpinx (anechoic tubular structure)
  27. 27. Hydrosalpinx.
  28. 28. Pyosalpinx (tubular structure with debris in adnexa
  29. 29. Tuboovarian abscess resulting from tuberculosis
  30. 30. Right hydrosalpinx with an occluded left fallopian tube
  31. 31. SYNDROMIC DIAGNOSIS OF PIDMINIMUM CRITERIA FOR DIAGNOSIS (CDC 2002)• Lower abdominal tenderness on palpation• Bilateral adnexal tenderness• Cervical motion tenderness No other established cause Negative pregnancy test
  32. 32. 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. gonorrhea/ C. trachomatis
  33. 33. 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
  34. 34. 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 ?
  35. 35. GENERAL PID CONSIDERATIONSRegimens must provide coverage of N. gonorrhea, C.trachomatis, anaerobes, Gram-negative bacteria, andstreptococciTreatment should be instituted as early as possible toprevent long term squeal
  36. 36. CRITERIA FOR HOSPITALIZATION• Inability to exclude surgical emergencies• Pregnancy• Non-response to oral therapy• Inability to tolerate an outpatient oral regimen• Severe illness, nausea and vomiting, high fever or tubo-ovarian abscess• HIV infection with low CD4 count
  37. 37. ANTIBIOTIC THERAPY Gonorrhea : Cephalosporins, Quinolones Chlamydia: Doxycycline, Erythromycin &Quinolones (Not to cephalosporins) Anaerobic organisms: Flagyl, Clindamycin and in some cases to Doxycycline. Beta hemolytic streptococcus and E. ColiPenicillin derivatives, Tetracyclines, andCephalosporins., E. Coli is most often treatedwith the penicillins or gentamicin.
  38. 38. ORAL REGIMENS• CDC-recommended oral regimen A  • Ceftriaxone 250 mg IM in a single dose, PLUS • Doxycycline 100 mg orally 2 times a day for 14 days With or Without • Metronidazole 500 mg orally 2 times a day for 14 days• CDC-recommended oral regimen B • Cefoxitin 2 g IM in a single dose and Probenecid 1 g orally in a single dose, PLUS • Doxycycline 100 mg orally 2 times a day for 14 days With or Without • Metronidazole 500 mg orally 2 times a day for 14 days• CDC-recommended oral regimen C • Other parenteral third-generation cephalosporin (e.g., Ceftizoxime, Cefotaxime), PLUS • Doxycycline 100 mg orally 2 times a day for 14 days With or Without • Metronidazole 500 mg orally 2 times a day for 14 days
  39. 39. FOLLOW-UP• Patients should demonstrate substantial improvement within 72 hours.• Patients who do not improve usually require hospitalization, additional diagnostic tests, and surgical intervention.• Some experts recommend re-screening for C. trachomatis and N. gonorrhea 4-6 weeks after completion of therapy in women with documented infection due to these pathogens.• All women diagnosed clinical acute PID should be offered HIV testing.
  40. 40. PARENTERAL REGIMENS• CDC-recommended parenteral regimen A • Cefotetan 2 g IV every 12 hours, OR • Cefoxitin 2 g IV every 6 hours, PLUS • Doxycycline 100 mg orally or IV every 12 hours• CDC-recommended parenteral regimen B • Clindamycin 900 mg IV every 8 hours, PLUS • Gentamicin loading dose IV or IM (2 mg/kg), followed by maintenance dose (1.5 mg/kg) every 8 hours. Single daily gentamicin dosing may be substituted.
  41. 41. ALTERNATIVE PARENTERAL REGIMEN • Ampicillin/Sulbactam 3 g IV every 6 hours, PLUS • Doxycycline 100 mg orally or IV every 12 hours. • It is important to continue either regimen A or B • or alternative regimens for at least 24 hours after substantial clinical improvement occurs and also to complete a total of 14 days therapy with: • Doxycycline 100mg orally twice a day OR • Clindamycin 450mg orally four times a day.
  42. 42. 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 squeal as successfully as regimens active against these microbes, anaerobic coverage should be provided
  43. 43. 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
  44. 44. 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 aperitoneal inflammatory reaction + cervical mucus induced by OP haspreventive effect against re-infection.
  45. 45. Special SituationsPregnancy - Augmentin or Erythromycin - HospitalizationConcomitant 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
  46. 46. Surgery in PIDIndicationsAcute PID- Ruptured abscess- Failed response to medical treatment- Uncertain diagnosisChronic PID- Severe, progressive pelvic pain- Repeated exacerbations of PID- Bilateral abscesses / > 8 cm. diameter- Bilateral ureteral obstruction
  47. 47. SURGERY IN PID• Timing of Surgery - No improvement within 24-72 hours - Quiescent (2-3 months after acute stage)• Type of Surgery - Colpotomy - Percutaneous 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 laparotomy - Identification of ureters
  48. 48. RUPTURED PELVIC ABSCESS▪ Generalized Septic Peritonitis• ↑ absorption of bacterial endotoxins• ↑ fluid from inflamed peritoneal surfaces• Fluid shift intravascular to interstitial spaces• Hypovolemia, ↓ CO, VC, ↑ PR• ↓ tissue perfusion, ARDS, hypoxemia• Multi-organ system failure Prompt Diagnosis & Treatment
  49. 49. 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
  50. 50. FOLLOW UP● Re-screening for Chlamydia & Gonorrhea● Patient counseling: - Risk of re- infection and sequel. - Sexual counseling - Avoid douching
  51. 51. 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. gonorrhea
  52. 52. OPPORTUNITIES FOR CONTROL STD PID Infertility STD Influenced by Interaction of following Environments Genital Microbial Environment Individual Behavioral Environment Socio-geographic Environment
  53. 53. PREVENTION• PRIMARY PRVENTION• To reduce the incidence of PID, screen and treat for chlamydia.• Annual chlamydia screening is recommended for: • Sexually active women 25 and under • Sexually active women >25 at high risk• Screen pregnant women in the 1st trimester.
  54. 54. PARTNER MANAGEMENT• Male sex partners of women with PID should be examined and treated if they had sexual contact with the patient during the 60 days preceding the patient’s onset of symptoms.
  55. 55. PARTNER MANAGEMENT (CONTINUED)• Male partners of women who have PID caused by C. trachomatis or N. gonorrhea are often asymptomatic.• Sex partners should be treated empirically with regimens effective against both C. trachomatis and N. gonorrhea, regardless of the apparent etiology of PID or pathogens isolated from the infected woman.
  56. 56. REPORTING• Report cases of PID to the local STD program in states where reporting is mandated.• Gonorrhea and chlamydia are reportable in all states.
  57. 57. PATIENT COUNSELING AND EDUCATION • Nature of the infection • Transmission • Risk reduction • Assess patients behavior-change potential • Discuss prevention strategies • Develop individualized risk-reduction plans
  58. 58. . 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.
  59. 59. 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.
  60. 60. SUMMARY● 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.
  61. 61. THANKS

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