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  • Appreciate the slide material. Here are a few suggestions:
    1. The immediate management is to drain the contents of the uterus by cervical dilatation as mentioned. The endometrial/endocervical biopsy can be deferred until the pus stops draining completely.
    2. At the time of biopsy it is prudent to send endometrium for PCR/Tuberculosis
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  1. 1. Pyometra: Diagnosis and Management
  2. 2. <ul><li>Definition: Accumulation of pus in uterine cavity, caused by interference with natural drainage of uterus is pyometra. </li></ul><ul><li>First case was described by John & Clarke of London in 1812. Attention was drawn by Whiteley and Hemlat l (1971) of more frequent association of pyometra with benign as compared to malignant disease of genital tract. </li></ul><ul><li>Diversity in methods of management of these cases indicate that a logical approach is needed for their management. </li></ul><ul><li>Attention is focused to review on etiology, improving clinical diagnosis, applying newer technology and early diagnosis . </li></ul> Pyometra: History:
  3. 3. Etiology of pyometra <ul><li>Senile Endometritis </li></ul><ul><li>Malignant-endometrial carcinoma </li></ul><ul><ul><ul><ul><ul><li>Ednocervical carcinoma </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Ectocervical carcinoma </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Previous gynae surgery </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Obstetrical puerperal sepsis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Foreign body (IUCD) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Others: </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Radiation effect for uterine carcinoma </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Tubercular endometritis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Uterovaginal prolapse </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Submucous fibroid polyp </li></ul></ul></ul></ul></ul>
  4. 4. Newer mechanisms <ul><li>Detection of pyometra after ovum retrieval for IVF with the routine use of ultrasound-guided embryo transfer. </li></ul><ul><li>( Fertil Steril: 2004 Apr;81(4) 1156(4); author reply 1156-7.) </li></ul>
  5. 5. contd….. Etiology of pyometra <ul><li>It can also occur secondary to intrauterine infection. Actinomycotic pyometra has been reported as a complication of a forgotten intra-uterine device. Recently there has been an increase in genital tuberculosis, and this occasionally presents with pyometra. </li></ul>
  6. 6. Pathogenesis <ul><li>Association with squamous metaplasia of endometrium - reported with varying frequency. It may precede squamous carcinoma of endometrium. </li></ul><ul><li>Pyometra chiefly appears to be result of malignancy as cervical canal is blocked by big tumor growth or presence of big necrotic growth in endometrium itself predisposes to formation of pyometra. </li></ul>
  7. 7. Pyometra <ul><li>After menopause, when endometrium loses its resistance - not shed repeatedly, infection which gains entrance to uterus persists as senile endometritis. </li></ul><ul><li>The pus which tends to collect in uterus forms pyometra, as cervix is narrowed by senile change & atrophied myometrium unable to expel it. </li></ul><ul><li>Hysterectomy is recommended in pyometra due to senile endometritis. </li></ul>
  8. 8. Pyometra <ul><li>In cases where surgery is not done for various reasons, cyclic oestrogen therapy has definitely shown to reduce the risk of recurrence of pyometra. </li></ul><ul><li>Oestrogen therapy helps in healing of senile endometritis lesion thus preventing recurrence of pyometra. </li></ul>
  9. 9. <ul><li>Uterine: </li></ul><ul><li>Leiomyomata </li></ul><ul><li>Adenomyosis </li></ul><ul><li>Adenomyoma </li></ul><ul><li>Stromatosis </li></ul><ul><li>Hemangiopericytoma </li></ul><ul><li>Endometrial: </li></ul><ul><li>Polyps </li></ul><ul><li>Endometrial cancer </li></ul><ul><li>Adenomatoid tumor </li></ul><ul><li>Plexiform tumorlet </li></ul><ul><li>Lipoma </li></ul><ul><li>Vascular tumors </li></ul><ul><li>Hematometra </li></ul><ul><li>Pyometra </li></ul><ul><li>Hydrometra </li></ul><ul><li>Gestational trophoblastic neoplasia </li></ul><ul><li>Congenital abnormalities </li></ul> Differential Diagnosis
  10. 10. Investigations <ul><li>Vaginal swabs may be negative in up to 50% of cases, since the principle organisms are anaerobes and these are difficult to culture. </li></ul><ul><li>If tuberculosis is suspected, tuberculin testing, culture, histology, hysterosalpingogram and nucleic acid amplification testing may be indicated. </li></ul>
  11. 11. Contd….Investigations <ul><li>The mainstay of investigation is imaging. Ultrasound scanning has been employed for over 20 years, and remains the chosen modality in most cases. </li></ul><ul><li>It can also complicate endometrial carcinoma and Doppler scanning may be used to detect blood flow changes in this event. </li></ul>
  12. 12. Pyometra <ul><li>Diagnostic USG to gynaecological field makes correct diagnosis. </li></ul><ul><li>Frequent association of pyometra with uterine malignancy reported. </li></ul><ul><li>CT scanning seems as sensitive to ultrasound, but the latter is often easier to access. </li></ul>
  13. 13. <ul><li>Most women are treated with dilation of the cervix and drainage, with regular monitoring to detect recurrent or persistent disease. Antibiotics are only necessary if there is evidence of invasive infection, in the form of generalized malaise, pyrexia, or altered laboratory parameters. </li></ul><ul><li>If antibiotics have to be used, preparations covering aerobic and also anaerobic bacteria should be used, </li></ul><ul><li>Current research is focused on a group of drugs called carbapanems, which have an exceptionally wide spectrum of activity. Tubercular pyometra should be treated with appropriate anti-tubercular chemotherapy. </li></ul> Management
  14. 14. <ul><li>Drainage of pus by repeat dilatations, usually done biweekly or putting a Foley’s catheter/drainage tube followed by curettage under antibiotic was the primary treatment. </li></ul><ul><li>Time required for drainage of pus was found to be significantly shortened in cases of foley’s catheter tube were inserted into the uterine cavity. Pus around 15-500 ml average of 65 ml collects. </li></ul> Primary Treatment
  15. 15. <ul><li>When cause of pyometra was malignant or other specific disease management is as per case. </li></ul><ul><li>Management of pyometra because of senile endometritis – Panhysterectomy within one month under routine antibiotic coverage. Those not fit for surgery medical management by prolonged cyclic oestrogen therapy (premarine0.625 mgm daily) for 4-6 months. </li></ul><ul><li>Recurrences occur 2-11 months. </li></ul> Secondary Treatment
  16. 16. Prognosis <ul><li>The prognosis in pyometra will depend both on the underlying cause (e.g. malignancy) and of the possibility of spontaneous perforation. Prompt recognition and treatment of the condition improves the prognosis considerably. </li></ul>