PID.pptx
- 2. CONTENTS DEFINITION CAUSATIVE ORGANISMS INCIDENCE ETIOLOGY RISK FACTORS PROTECTIVE METHODS PATHOLOGY MODE OF TRANSMISSION CLINICAL FEATURES CDC DIAGNOSTIC CRITERIA 2015 INVESTIGATIONS DIFFERENTIAL DIAGNOSIS STAGES OF PID MANAGEMENT (MEDICAL & SURGICAL) COMPLICATIONS SEQUELAE OF PID REFERENCE
- 3. Definition •Pelvic Inflammatory Disease (PID) : Comprises a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis , salpingitis ,oophoritis , tubo-ovarian abscess, and pelvic peritonitis. Center for Disease Control & Prevention (CDC) Treatment Guidelines 2015
- 4. Causative organisms • Sexually transmitted organisms : N. gonorrhoeae & C. Trachomatis. • vaginal flora : G. vaginalis, Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus agalactiae. • cytomegalovirus (CMV) , M. Hominis , M.genitalium • anerobic bacteria : prevotella , peptostreptococci , G. vaginalis.
- 5. PID : Microbiology • Acute PID: Usually polymicrobial 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 30% 30% 10% 30% Primary organisms N. gonorrhoeae Chlamydia trachomatis Mycoplasma hominis Others
- 6. • Acute PID : Among sexually active women Incidence is 1-2 % per year. • PID is common bacterial infection in women age 16 - 25yrs. 70% 30% Distribution among age groups <25 years >25 years Incidence
- 7. Etiology 85% 15% Causes of PID STDs Iatrogenic Iatrogenic procedures: 1. Endometrial biopsy 2. Uterine curettage 3. Insertion of IUD 4. Hysterosalpingography 5. hysteroscopy Te-linde’s- 10th edition
- 8. Risk Factors •Multiple sex partners •High frequency of coitus •Early age of sexual activity •Past history of PID •Low socioeconomic status •Vaginal douching •Intrauterine contraceptive device •Smoking •Substance abuse (medroxyprogesterone ) •Virulence of the pathogen
- 9. Protective method 1. Barrier methods: condom with spermicidal chemicals (Nonoxynol-9 which is bactericidal & virucidal) 2. Oral contraceptive pills : • -Thick mucus plug (preventing ascend of sperm and bacterial penetration) • -Decrease in duration of menstruation (Short interval of bacterial colonization of the upper tract) • Women with monogamous partner • Vaccines : hepatitis B,HPV
- 10. Acute PID : Pathology Cervicitis Endometritis Salpingitis Oophoritis Tubo-ovarian abscess Peritonitis • Micro-organisms colonizing the endocervix ascend into the endometrium, fallopian tubes, and peritoneum
- 11. pathology • Involvement of the fallopian tubes is almost bilateral • initiated primarily in the endosalpinx • 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
- 12. Pathology 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 sequelae
- 13. PID : Mode of transmission Ascending infection (Canalicular spread) Ascent of gonococcal & chlamydial organisms by surface extension(continuity &contiguity) from the lower genital tract 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
- 14. PID : Mode of transmission Through uterine lymphatic & blood vessels across parametrium • Mycoplasma hominis • Secondary organisms
- 15. PID : Mode of transmission Gynecological procedures favoring ascend of infection • E.g. D&C,IUCD insertion,biopsy Blood-borne transmission • Pelvic tuberculosis Direct spread from contaminated structures in abdominal cavity • E.g. Appendicitis, cholecystitis
- 16. SYMPTOMS - PID Constitutional: • Fever >101’F • Nausea and vomiting • Diarrhoea and tenesmus Specific: • Abnormal vaginal or cervical discharge • Abnormal vaginal bleeding (intermenstrual , postcoital) • Deep dyspareunia • Right upper abdominal pain • Bilateral lower abdominal pain
- 17. SIGNS • uterine tenderness • Adnexal mass/tenderness • Cervical motion tenderness • Vaginal discharge • Mucopurulent/purulent discharge from the cervix • Right hypochondrial tenderness • Fullness in the pouch of douglas Gonorrhea Chlamydia
- 19. Acute PID : Diagnosis Investigations • Complete blood count • C – reactive protein • Erythrocyte sedimentation rate • Urine Pregnancy Test (UPT), urinalysis • Urine culture • Vaginal wet mount 1. WBCs suggest PID 2. Cervical chlamydia and gonorrhea testing 3. Nucleic acid amplification tests (NAATs) for organisms • Tests for tuberculosis • Tests for syphilis • Tests for HIV
- 20. Microbiological test NEISSERIA GONORRHEA CHLAMYDIA TRACHOMATIS 1.Endocervical swab - CULTURE -should be placed in transport medium -must reached lab within 6H but less than 24H otherwise viability will be lost 2.NAAT 1.Endocervical swab for chlamydia NAAT (nucleic acid amplification test) -PCR ,strand displacement amplification -More sensitive than culture -Can be used as diagnostic / screening test on non invasively collected specimens (urine and vulvo-vaginal swabs) Women with suspected PID should be tested for gonorrhoea and chlamydia -RCOG Green-top Guideline No. 32
- 21. Imaging • TVS ( with doppler) • TAS • Abdominal CT or MRI Diagnostic procedures • Culdocentesis • Endometrial biopsy • Laparoscopy (gold standard) Diagnosis of severity of PID and future fertility prognosis. Mild- tubes edema , erythema , no purulent exudates & mobile. Mod – purulent exudates from fimbrial ends & tubes not freely movable Severe- pyosalpinx , inflammatory complex/ Tubo-ovarian mass Pus for microbiology
- 22. Perihepatic Violin string like adhesions (chlamydia) Fitz Hugh & Curtis Syndrome Consists of Rt. hypochondrium pain resulting from ascending pelvic infection and inflammation of the liver capsule (perihepatitis) or diaphragm Although it is typically associated with acute salpingitis, it can exist without signs of acute pelvic inflammatory disease (PID)
- 23. DIFFERENTIAL DIAGNOSIS 1.Ectopic pregnancy 2.Complication of ovarian cyst(rupture/torsion) 3.Acute appendicitis / diverticulitis 4.Irritable bowel syndrome 5.Endometriosis 6.Inflammatory bowel disease 7.Urinary tract infection 8.Psychosomatic pain
- 24. Stages of PID • Stage I – Acute salpingitis without peritonitis • Stage II – Acute salpingitis with peritonitis • Stage III – Acute salpingitis with superimposed tubal occlusion or tubo-ovarian complex • Stage IV – Ruptured tubo-ovarian abscess • Stage V – Tubercular salpingitis *Gainesville staging. Shaw's Textbook of Gynaecology
- 25. Acute PID : Management Therapeutic considerations • PID treatment regimens must provide empiric, broad spectrum coverage of likely pathogens • All regimens should also be effective against N. gonorrhoeae & C. Trachomatis because negative endocervical screening for these organisms does not rule out URTI. • Anaerobic bacteria are also involved in PID – treatment
- 26. Acute PID : Hospital admission (CDC-2015 Criteria) 1. Patient meeting following criteria a. severe illness, nausea and vomiting, or high fever b. Surgical emergencies (e.g., appendicitis) cannot be excluded c. tubo-ovarian abscess d. does not respond clinically to oral antimicrobial therapy e. unable to follow or tolerate an outpatient oral regimen f. pregnancy
- 27. Management : Parenteral pain associated with intravenous infusion, doxycycline should be administered orally when possible Oral and IV administration of doxycycline provide similar bioavailability Parenteral therapy can be discontinued 24 hours after clinical improvement, but oral therapy with doxycycline (100 mg twice a day) should continue to complete 14 days of therapy When tubo-ovarian abscess is present, clindamycin or metronidazole with doxycycline can be used for continued therapy rather than doxycycline alone because this regimen provides more effective anaerobic coverage CDC-2015 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
- 28. Management : Parenteral Parenteral therapy can be discontinued 24 hours after clinical improvement On-going oral therapy should consist of doxycycline 100 mg orally twice a day, or clindamycin 450 mg orally four times a day to complete a total of 14 days of therapy When tubo-ovarian abscess is present, clindamycin should be continued rather than doxycycline, because clindamycin provides more effective anaerobic coverage CDC-2015 Regimen B Clindamycin 900 mg IV every 8 hours PLUS Gentamicin loading dose IV or IM (2 mg/kg of body weight), followed by a maintenance dose (1.5 mg/kg) every 8 hours Single daily dosing (3–5 mg/kg) can be substituted
- 29. Management : Parenteral Ampicillin/sulbactam plus doxycycline is effective against C. trachomatis, N. gonorrhoeae, and anaerobes in women with tubo-ovarian abscess One trial demonstrated high short-term clinical cure rates with azithromycin, either as monotherapy for 1 week (500 mg IV for 1 or 2 doses followed by 250 mg orally for 5–6 days) or combined with a 12-day course of metronidazole CDC-2015 Alternate parenteral Regimens Ampicillin/Sulbactam 3 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV every 12 hours
- 30. Management : intramuscular/Oral CDC-2015 Oral Regimen A Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days With Metronidazole 500 mg orally twice a day for 14 days CDC-2015 Oral Regimen B Cefoxitin 2 g IM in a single dose and Probenecid 1 g orally administered concurrently in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days With or without Metronidazole 500 mg orally twice a day for 14 days
- 31. Management : intramuscular/Oral The optimal choice of a cephalosporin is unclear; although cefoxitin has better anaerobic coverage, ceftriaxone has better coverage against N. gonorrhoea The theoretical limitations in coverage of anaerobes by recommended cephalosporin antimicrobials might require the addition of metronidazole to the treatment regimen Adding metronidazole also will effectively treat BV, which is frequently associated with PID CDC-2015 Oral Regimen C Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) PLUS Doxycycline 100 mg orally twice a day for 14 days With or without Metronidazole 500 mg orally twice a day for 14 days
- 32. Alternate IM / oral regimen CDC -2015 ALTERNATE REGIMEN Azithromycin 1g orally once a week X 2wks Plus ceftriaxone 250 mg IM single dose Plus metronidazole 500mg BD X 14 days PARENTRAL CEPHALOSPORIN NOT FEASIBLE levofloxacin 500 mg orally once daily x 14 days OR ofloxacin 400 mg twice daily x 14 days Or moxifloxacin 400 mg once daily x 14 days PLUS metronidazole 500 mg orally BD X 14 days
- 33. • Because of emergence of quinolone-resistant Neisseria gonorrhoea, regimens that include a quinolone agent are no longer recommended. • If parenteral cephalosporin therapy is not feasible, use of fluoroquinolones can be considered if community prevalence & individual risk for gonorrhoea are low. • Diagnostic tests for gonorrhoea must be performed before therapy & the patient managed as follows if test is positive If the culture for gonorrhoea is positive, treatment should be based on results of antimicrobial susceptibility If isolate is quinolone-resistant N. gonorrhoeae (QRNG) or if antimicrobial susceptibility cannot be assessed (e.g if only NAAT test available) consultation with infectious disease specialist is recommended.
- 34. Management & Follow-up Out-patient Oral regimen In-patient Parenteral regimen 3 Days (72 hours) Substantial clinical improvement ???? Defervescence Reduction in direct or rebound abdominal tenderness Reduction in uterine, adnexal & cervical motion tenderness NO Reassessment of patient & treatment Additional diagnostic testing After 3 - months Regardless of whether sex partners were treated , Repeat testing of all women who have been diagnosed with chlamydia or gonorrhoea Yes Switch to oral from parenteral after 24 hours of clinical improvement If on oral – continue the same Admit
- 35. PID : Management of Partner • Male sex partners of women with PID should be treated if they had sexual contact with the patient during the 60 days preceding the patient’s onset of symptoms • treatment are imperative because of the risk for reinfection of the patient and the strong likelihood of urethral gonococcal or chlamydial infection in the sex partner • Male partners of women who have PID caused by C. trachomatis and/or N. gonorrhoea frequently asymptomatic CDC-2015
- 36. PID : Management of Partner Management of partner Ceftriaxone 125mg I.M +doxy 100mg BD X 7days Oral azithromycin 1g Ofloxacin 300mg BD X 7 days • sex partners are treated empirically with regimens effective against both of these infections, regardless of the etiology of PID or pathogens isolated from the infected woman
- 37. PID : Special situation Pregnancy Considerations Maternal morbidity Pre-term delivery Management Hospitalization & In-patient management Parenteral cefotaxime+azithromycin+metronidazole x 14 days HIV infected patient Considerations No difference in presentation but more likely to have tubo-ovarian abscess The microbiologic findings were similar, except HIV-infected women had higher rates of concomitant M. hominis, streptococcal infections. management Women with HIV responded equally to parenteral & IM/oral antibiotics as women without HIV infection
- 38. PID : Special situation IUD users Considerations The risk for PID associated with IUD use is primarily confined to the first 3 weeks after insertion and is uncommon thereafter Practitioners might encounter PID in IUD users because it’s a popular method of contraception Management Evidence is insufficient to recommend the removal of IUDs However If improvement is not seen within 72 hrs of starting treatment then removal of IUCD is considered Women on hormonal contraception presenting with breakthrough bleeding should be screened for genital tract infection, especially C. trachomatis. If a woman is likely to be at risk of future PID and requests an IUD for contraception, the LNG-IUS would be the most appropriate choice -RCOG Green-top Guideline No. 32
- 39. Management : Surgery in PID Type of surgeries 1.Posterior Colpotomy 2. Percutaneous drainage ↓USG / CT guidance 3.Transabdominal needle aspiration ↓CT guidance 4.Laproscopic drainage of pelvic abscess 5.Laparotomy & drainage Extend of surgeries 1. Conservation - if fertility desired 2. U/L or B/L Salpingo-oophorectomy with/without hysterectomy
- 40. Posterior colpotomy 1. The abscess must be midline . 2. The abscess should be adherent to the cul-de-sac peritoneum - should dissect the rectovaginal septum to assure the surgeon that the drainage will be extraperitoneal - pus will not be disseminated transperitoneally. 3. The abscess should be cystic or fluctuant to ensure adequate drainage. Te-linde’s- 10th edition
- 41. Posterior colpotomy Te-linde’s- 10th edition
- 42. Percutaneous drainage & trans-abdominal aspiration ↓USG / CT guidance
- 43. Laparoscopic drainage of pelvic abscess
- 44. Chronic Pelvic Infection Occurs due to • Following acute pelvic infection ( delayed Rx or inadequate) • Low grade recurrent infection • Tubercular infection Pyogenic : Pathogenesis Both openings of tube are blocked with damage to structures This can result in hydro or pyosalpinx Recurrent peritoneal surface infection can result in either flimsy (gonococcal) or dense (non-gonococcal) adhesions with surrounding structures Resulting fibrosis affects surrounding structures & may result in frozen pelvis
- 45. Chronic Pelvic Infection Symptoms • Chronic pelvic pain • Dyspareunia • Congestive dysmenorrhea • Menorrhagia • Vaginal discharge • Infertility Signs Tenderness on one or both iliac fossa An irregular tender pelvic mass PV findings similar to CDC criteria for Acute PID PR - Involvement of parametrium & uterosacral ligament
- 46. Chronic Pelvic Infection Surgery Nature of surgery • TAH with BSO in patients who have completed their family • Pt. who desires to have family - Salpingectomy for chronic salpingitis - Salpingo-oophorectomy for chronic tubo-ovarian mass TAH with BSO
- 47. -Total abdominal hysterectomy & unilateral salpingo-oophorectomy from extensive chronic salpingo-oophoritis. -A small hydrosalpinx on the opposite side can be left in to preserve blood supply to the ovary. -When significant chronic pelvic inflammatory disease involves only one adnexa and preservation of uterine function is indicated -a unilateral salpingo-oophorectomy can be performed.
- 48. salpingectomy C B A A.Mesosalpinx is clamped with multiple Kelly clamps and cut B.Cornual wound is closed with 2’0 delayed-absorbable suture C.Mattress suture is placed to cover operative area,Round ligament and broad ligament cover operative area.
- 49. Salpingo-oophorectomy A. The infundibulopelvic ligament is doubly clamped B. A suture has been placed to ligate the ascending uterine vessels just below the cornual incision. C. The infundibulopelvic ligament and the rest of the broad ligament vessels have been ligated.
- 50. Complications PID • Pelvic peritonitis • General peritonitis • Rupture of tubo-ovarian abscess • Septicaemia • Subdiaphragmatic/perinephric abscess • Septic thrombophlebitis
- 51. 1.Infertility: • peritubular & periovarian adhesions interfere with ovum pickup, complete tubal obstruction. • infertility rate ↑ with ↑in episodes of PID 2.Ectopic pregnancy : • 50% ectopic pregnancy occur in fallopian tubes damaged by previous salpingitis. • Chance of ectopic pregnancy is increased by 6- 10 fold in pts with previous salpingitis. SEQUELAE
- 52. SEQUELAE 3.Chronic pelvic pain : • Hydrosalpinx • Pyosalpinx • Tubo-ovarian complex • Adhesions surrounding the ovary Mortality: • Before antibiotic Rx it was 1% • Deaths were due to ruptured tuboovarian abscess • Today death is rare; but it can be high as 5%-10% ruptured tubo-ovarian abscess Te-linde’s- 10th edition
- 53. (Main complications in Stage IV PID : Ruptured abscess) During operation 1. Septic shock 2. Injury to small bowel 3. Injury to rectum Post-operative 1. Pus collected again 2. Chest empyema 3. Septicemia 4. Septic shock 5.. Recto-vaginal fistula 6. Wound abscess or infection 7. Pneumonia 8. Renal failure 9. Liver failure
- 54. References 1.Telinde’s operative gynaecology(10th edition) 2.CDC guidelines -2015 3. RCOG green top guidelines NO.32 (2008) 4.Shaw’s textbook of gynaecology 5.Berek and Novak’s (15th edition)