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PELVIC INFLAMMATORY DISEASE

DR. K.C. SAMUELSON

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OUTLINE

  • Introduction
  • Risk factors
  • Aetiologic organisms
  • Pathogenesis
  • Clinical Features
  • Diagnosis
  • Treatment
  • Indications for admission
  • Complications
  • Prevention
  • Conclusion

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INTRODUCTION

  • Female genital tract infections can be generally classified into
    • Lower Genital tract Infections
    • Upper Genital tract infections

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  • Pelvic inflammatory disease is an ascending infection involving the upper female genital tract.
  • It affects;
    • Endometrium – Endometritis
    • Fallopian tube – Salpingitis
    • Ovaries – Oophoritis
    • Fallopian tubes+ovaries – Tubo-ovarian abscess
    • Pelvic peritoneum – Pelvic peritonitis
    • etc

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RISK FACTORS

  • Being sexually active, especially with multiple partners
  • History of sexually transmitted infections (STIs)
  • Previous history of PID
  • Use of intrauterine devices (IUDs) for contraception
  • Douching
  • Unsafe abortion
  • Young age (less than 25 years old)

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Aetiologic Organisms

  • The major organisms are
    • Neisseria gonnorrhea
    • Chlamydia trachomatis (most common cause of PID)
  • Other less common organisms include
    • Gardnerella vaginalis
    • Peptostreptococcus
    • Prevotella
    • Mycobacterium tubercolosis (in virgins)
    • Escherichia coli (post menopausal women)

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PATHOGENESIS

  • Infection of cervix with chlamydia or gonorrhea
  • Infection ascends to affect the endometrium, fallopian tubes, ovaries, pelvic peritoneum
  • Usually facilitated by Gadnerella vaginalis

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CLINICAL FEATURES

  • Abdominal and/or pelvic pain
  • Deep Dyspareunia
  • Mucopurulent vaginal discharge
  • Pyrexia (>38° C)
  • Dysuria
  • Heavy/intermenstrual bleeding
  • Cervical motion tenderness
  • Adnexal tenderness
  • Palpable adnexal mass
  • Generalized sepsis in severe and systemic infection

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DIAGNOSIS

  • MINIMUM CRITERIA
    • Lower abdominal/uterine tenderness
    • Cervical motion tenderness
    • Adnexal tenderness

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  • Additional criteria
  • Oral temperature ≥ 38oc
  • Leucocytosis ≥ 10,000/ml
  • Abnormal cervical or vaginal discharge
  • Raised C-reactive protein/ESR
  • Laboratory evidence of positive cervical infection with Gonorrhoea or C. trachomatis (rapid diagnostic test on cervical exudates)
  • Histopathologic evidence of endometritis on endometrial biopsy.
  • Sonographic evidence of tubo-ovarian complex
  • Laparoscopic evidence of PID

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INVESTIGATIONS

  • Endocervical swab MCS
  • Ultrasound
  • NAAT eg PCR
  • FBC
  • Laparoscopy (gold standard)

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Laparoscopic findings in PID

  • Hyperaemia and oedema (hydrosalpingx) of the tubes
  • Purulent exudates from the fimbrial ends (pyosalpingx)
  • Tubes not freely movable
  • Tubo-ovarian complex/abscess
  • Pelvic collection of puss
  • Violin string like adhesions around the liver (Fitz-Hugh-cutis syndrome) suggests gonococcal or chlamydial infection

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Fitz hugh curtiz syndrome

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TREATMENT

  • Standard OPD treatment
    • IM Ceftriaxone 250mg stat/Tabs Cefixime 400mg stat
    • Caps Doxycycline 100mg bd x 14 days
    • Tabs Metronidazole 500mg bd x 14 days

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  • INPATIENT TREATMENT REGIMEN
    • IV Cefoxitin 2g 6 hourly
    • Caps Doxycycline 100mg bd
    • IV Metronidazole 500mg bd
  • Give for 24 to 48 hours till patient feels better, then convert to oral and complete 14 days treatment

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  • Alternative treatment regimen
    • Iv clindamycin 90mg tds +
    • Gentamicin 1.5mg/kg 8 hourly for 2 – 4 days,
    • then Doxycycline 100mg bd for 10 – 14 days

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  • During treatment of PID, take note of the following;
    • Treat partner
    • Avoid intercourse during treatment or use condom
    • Avoid alcohol during treatment

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  • Treatment could also include SURGERY to drain pelvic abscess

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INDICATIONS FOR ADMISSION

  • Suspected pelvic abscess
  • Pregnant woman with PID
  • Severe infection
  • Generalized sepsis
  • Poor/Inadequate response to oral treatment
  • Teenagers who still have a long reproductive career ahead
  • Uncertain of diagnosis
  • Patient has HIV infection

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COMPLICATIONS

  • Septic shock
  • Chronic PID (chronic pelvic pain, dysmenorrhea, pelvic adhesions, dyspareunia)
  • Hydrosalpingx, Pyosalpingx
  • Pelvic abscess
  • Subfertility
  • Ectopic pregnancy

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PREVENTION

  • A, B, C

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CONCLUSION