pelvic inflammatory disease

1. PELVIC INFLAMMATORY DIAEASE
(PID)
PRESENTED BY
ABHILASHA VERMA
LECTURER (OBG. GYNAE)
JHALAWAR NURSING COLLEGE

2. DEFINITION
• Pelvic Inflammatory Disease (PID) is a spectrum of
inflammatory disorders of the upper female genital
tract, including any combination of endometritis,
salpingitis, tubo-ovarian abscess, and pelvic
peritonitis.

3. ETIOLOGICAL AGENTS
• Sexually transmitted organisms, especially N. gonorrhoea
and C. trachomatis, are More common.
• Microorganisms of the vaginal flora (e.g., anaerobes, G.
vaginalis, Haemophilus influenzae, enteric Gram-negative
rods, and Streptococcus agalactiae) also have been
associated with PID
• M. [Mycoplasma] hominis and U. [Ureaplasma]
urealyticum might be etiological agents of PID.

4. EPIDEMIOLOGY
• PID is commonly associated with Sexually Transmitted
Diseases (STDs)
• About 85% are spontaneous infection in sexually active
females of reproductive age.
• Iatrogenic procedures: favor organism to ascend
1. Endometrial biopsy
2. Uterine curettage
3. Insertion of IUD
4. Hysterosalpingography

5. 34%
66%
DISTRIBUTION A/C AGE
>25 YEARS
<25 YEARS85%
15%
EPIDEMIOLOGY
STD
IATROGENI
C
95%
4%1%
CLINICAL PRESENTATION
ASYMPOTOMATIC
MILD TO
MODERATE
SEVERE

6. RISK FACTORS
1. Menstruating teenagers.
2. Multiple sexual partners.
3. Previous history of acute PID.
4. IUD users.
5. Sexual partner with urethritis or STI.
6. Prior infection with chalmydia or gonorrhoea.
7. Younger age of onset of sexual activity.
8. Sexually transmitted infection.
9. Low socio-economic condition.
10. High frequency of sexual intercourse.
11. No use of contraceptive barrier methods.
12. Intercourse during PID.

7. PROTECTIVE FACTORS
• CONTRACEPTIVE
PRACTICES
• Barrier method specially
condom, diaphragm with
spermcide.
• Oral steroidal
contraceptives , produce
thick mucus plug which
prevent going up of sperm
and bacterial penetration.
• Monogamy or partner with
vasectomy.
• OTHERS
• Pregnancy
• Menopause
• Azoospermic male

8. MICROBIOLOGY
ACUTE PID:
• Usually poly microbial
 Primary organisms
• Sexually transmitted
 Secondary organisms - Normally found in vagina
• Aerobic: Non-hemolytic streptococcus, E. coli, Group-B
streptococcus & staphylococcus
• Anaerobic: Bacteroides species- fragilis & bivius,
Peptostrepococcus & peptococcus
16%
16%
5%63%
MICROBIOLOGY
N. gonorrhoeae
Chlamydia
trachomatis
Mycoplasma
hominis
Others

9. MODE OF TRANSMISSION
 ASCENDING INFECTION (CANALICULAR SPREAD)-
 Ascend of gonococcal & chlamydial organisms by surface
extension from the lower genital tract through the cervical
canal by way of the endometrium to the fallopian tubes .
 Facilitated by the sexually transmitted vectors such as sperms
& trichomonads
 Reflux of menstrual blood along with gonococci into the
fallopian tubes may be the other possibility.

12.  THROUGH UTERINE LYMPHATIC & BLOOD VESSELS ACROSS
PARAMETRIUM-
 Mycoplasma hominis
 Secondary organisms

14.  GYNECOLOGICAL PROCEDURES FAVORING ASCEND OF
INFECTION-
E.g. D&C, D&E
 BLOOD-BORNE TRANSMISSION -
Pelvic tuberculosis
 DIRECT SPREAD FROM CONTAMINATED STRUCTURES IN
ABDOMINAL CAVITY-
E.g. Appendicitis, cholecystitis

15. ACUTE PID PATHOLOGY
• Involvement of the fallopian tubes is almost bilateral
• Pathological process is initiated primarily in the endosalpinx .
• It usually follows menses due to loss of genital defence.
• Gross destruction of epithelial cells, cilia & microvilli.
• Acute inflammatory reaction: all layers are involved.
• Tubes become edematous & hyperemic; exfoliated cells &
exudate pour into lumen & agglutinate the mucosal folds.
• Abdominal ostium: closed by edema & inflammation Uterine
end: closed by congestion.

16. • Depending on the virulence: watery or purulent exudate
• Hydrosalpinx or Pyosalpinx.
• Deeper penetration & more destruction.
• Possibilities Oophoritis Tubo-ovarian abscess Peritonitis Pelvic abscess or
Resolution in 2-3 weeks with/without chronic sequela
• Depending on the virulence: watery or purulent exudate
• Hydrosalpinx or Pyosalpinx
• Deeper penetration & more destruction
• Possibilities Oophoritis Tubo-ovarian abscess, Peritonitis, Pelvic abscess
or Resolution in 2-3 weeks with/without chronic sequel.

18. CLINICAL FEATURES
SYMPTOMS-
Patients with acute PID present wide range of non specific
symptoms, usually appears at the time and immediately after
menstruation.
 Bilateral lower abdominal & pelvic dull aching pain is characteristic of
acute PID. The onset of pain is more rapid in gonococcal infection (3 day)
then of chalmydia infection ( 5-7 Days)
 Nausea, vomiting, lassitude, headache.
 Fever (Oral temperature > 38.3˚C/101F)
 Abnormal vaginal discharge becomes purulent and copious.
 Symptoms suggestive of dysuria.
 Dyspareunia.
 Pain and discomfort in right hypochondrium region ( upper), pain resulting
from ascending pelvic infection and inflammation of the liver capsule or
diaphragm. Liver involved due to transperitoneal or vascular
dissemination of either gonococcal or chlamydial infection.
( Fitz-Hugh-Curtis syndrome)

19. SIGN
• Temperature >38.3° C
• Abdominal palpation reveal tenderness on both quadrants of
lower abdomen. Liver may be enlarged and tender.
• Vaginal examination reveals –
1) Abnormal vaginal discharge , may be purulent.
2) Congested external urethral meatus or opening of
bartholine’s ducts through which pus may be seen scraping
out on pressure.
3) Speculum examination reveals congested cervix with
purulent discharge.
4) Bimaual examination reveals bilateral tenderness on fornix
palpation, which increases more with movement of cervix
( Cervical motion tenderness) also known as (Chandelier
sign)
Thickening or a definite mass felt through fornices.

20. Definitive criteria
•Histopathologic evidence
of endometritis on bipsy.
•Imaging study TVS/MRI
evidence of thick fluid
filled tubes , tubo ovarian
abscess.
•Laparoscopic evidence of
PID

21. INVESTIGATIONS
• Complete blood count
• Erythrocyte sedimentation rate
• Vaginal wet mount
1. WBCs suggest PID
2. Genetic probe or culture of vaginal secretions for gonorrhea and
chlamydia
3. Nucleic acid amplification tests (NAATs) for organisms
• C – reactive protein
• Urine Pregnancy Test (UPT), urinalysis
• Urine culture and sensitivity
• Urine NAATs
• Faecal occult blood test
• Tests for tuberculosis
• Tests for syphilis
• Tests for HIV

22. DIFFERENTIAL DIAGNOSIS
1. Appendicitis
2. 2. Ectopic pregnancy
3. 3. Endometritis
4. 4. Ovarian cyst
5. 5. Ovarian torsion

23. COMPLICATION OF PID
IMMEDIATE
• Pelvic perotinitis
• Generalised perotinitis.
• Septicemia producing arthritis,
myocarditis.
LATE
• Dyspareunia
• Infertility 12%, after two
episode 25%, after three
episode 50%. Due to tubo-
ovarian mass.
• Chronic pelvic inflammation
• Formations of adhesions
• Hydrosalpinx
• Tubo-ovarian abscess.
• Increase risk of ectopic
pregnancy.

24. TREATMENT
 ESSENTIAL STEPS-
• Public health awareness.
• Prevention of STDs
• Health education regarding
safer sex practices.
• Use of contraceptives.
• Routine risk of high risk
population.
 PRINCIPLES OF THERAPY-
• To control infection
• To prevent complications.
• To prevent re-infection.

25. OUT PATIENT THERAPY-
• Adequate rest & analgesics.
• Antibiotics even before
microbial report.
• Combination antibiotics
given.
• Ceftrixone 250mg IM single
dose
• Doxycycline 100 mg bid for
14 days with or without
• Metronidazole 500mg bid
14 days.
• Evaluated after 48 hrs and
if no response, are to
behospitalised.
IN PATIENT THERAPY-
• Hospitalization. IV fluids only
– Suspected tubo-ovarian abscess
– Surgical emergencies.
– Unresponsive out-patient treatment.
– Intolerance to oral abs.
– Co-existing pregnancy.
– Patient is known to have HIV infection.
 Regimen A
Cefoxitine 2 gm IV 6 hrly for 2-4 days
+ doxycycline 100 mg bid for 14 days.
 Regimen B
Clindamycin 900 mg IV 8 hrly +
gentamycin 2 mg/kg IV ( Loading)
follwed by 1.5 mg/kg IV
( maintenance) every 8 hrly.
 Alternative Regimen –
Ampicillin- salbactum 3gm IV 6hrly 3-5
days + Doxycycline 100 mg oral bid for
14 days.

26. MANAGEMENT PROTOCOL
YES
NO
YES
NO
YES
NO
History physical examination
& pregnancy test
PREGNANCY
Cervical motion, uterine and
adnexal tenderness.
Consider surgical consultation,
laparotomy for appendicitis
consider USG and abdominal &
pelvic CT
Evaluate for ectopic pregnancy
with β-HCG test and TVS
Consider PID, TVS to evaluate tubo-
ovarian abscess

27. YES
NO
YES
NO
Pelvic mass on examination
Dysuria and white blood cells
on urinanalysis
Evaluating UTI or pyelonephritis;
obtain urine culture
Consider ovarian cyst, ovarian
torsion, degenerating uterine
fibroid, endometriosis, obtain TVS
TVS to evaluate for other
diagnosis

28. SURGERY INDICATION
• Generalized perotinitis.
• Pelvic abscess
• Tubo-ovarian abscess not responding.
• Adhesions .

29. RE-INFECTION PREVENTION
• Educate about re-infection avoidance need and potential
hazards of re-infection.
• Warned against multiple sexual partners.
• Contraceptive practices.
• Seek medical attention at early time period.
• Follow up visits as schaduled.

30. FOLLOW UP
• Repeat smear and culture on 7th day from discharge.
• Repeat microbial test following each menstrual period until
become negative for three consecutive reports when patient
declared cured.
• Avoid sexual intercourse until both partners declared cured.
• Proof of successful treatment after salpingitis ia an intra
uterine pregnancy.

31. NURSING RESPONCIBILITY