Pelvic Pelvic Inflammatory Inflammatory

DiseaseDisease

Does LEEP increase the Does LEEP increase the risk of PTB before 37 risk of PTB before 37

weeks?weeks? Compared women with history of LEEP toCompared women with history of LEEP to

1.1. Women with no history of CIN or LEEPWomen with no history of CIN or LEEP

2.2. Women with history of CIN but no LEEPWomen with history of CIN but no LEEP History of LEEP verses Group 1History of LEEP verses Group 1

RR 1.61RR 1.61 History of LEEP verses Group 2History of LEEP verses Group 2

RR 1.08RR 1.08 Risks factors leading to CIN probably more Risks factors leading to CIN probably more

important than the LEEPimportant than the LEEP

PathophysiologyPathophysiology

Starts as cervicitis caused by GC, Starts as cervicitis caused by GC, chlamydia, or mycoplasmchlamydia, or mycoplasm

In the presence of bacterial In the presence of bacterial vaginosis, there is a breakdown of vaginosis, there is a breakdown of mucous and other natural barriers mucous and other natural barriers allowing an ascending infectionallowing an ascending infection

Normal vaginal flora is the source of Normal vaginal flora is the source of a polymicrobial infection.a polymicrobial infection.

TOATOA

Causative AgentsCausative Agents

N. gonorrheaN. gonorrhea

▪ ▪ 20% of women with this 20% of women with this cervicitis will cervicitis will develop acute develop acute PIDPID

▪ ▪ Intense inflammatory Intense inflammatory reactions in the reactions in the tubal mucosatubal mucosa

Causative AgentsCausative Agents

ChlamydiaChlamydia

▪ ▪ More prevalent than More prevalent than NeisseriaNeisseria

▪ ▪ Clinically produces a mild for Clinically produces a mild for of of salpingitis with an insidious salpingitis with an insidious onsetonset

▪ ▪ 30% of women with this 30% of women with this cervicitis cervicitis develop PIDdevelop PID

Microorganisms Isolated Microorganisms Isolated from the Fallopian Tubes from the Fallopian Tubes

with Acute PIDwith Acute PID Type of AgentType of Agent

STDSTD

Endogenous agent Endogenous agent aerobic or facultativeaerobic or facultative

AnaerobicAnaerobic

OrganismOrganism Chlamydia trachomatisChlamydia trachomatis Neisseria gonorrheaNeisseria gonorrhea Mycoplasma hominisMycoplasma hominis

Streptococcus sp.Streptococcus sp. Staphylococcus sp.Staphylococcus sp. Haemophilus sp.Haemophilus sp. Escherichia coliEscherichia coli

Bacteroides, Bacteroides, Peptococcus, Peptococcus, Clostridium, ActinomycesClostridium, Actinomyces

Weström L: Sex Transm Dis 11:439, 1984

SymptomsSymptoms

Abdominal painAbdominal pain Abnormal dischargeAbnormal discharge Postcoital spottingPostcoital spotting FeverFever Low back painLow back pain Nausea/vomitingNausea/vomiting

How to approach the How to approach the diagnosis?diagnosis?

Does she have cervicitis?Does she have cervicitis? Is the cervix inflamed, tender, and/or Is the cervix inflamed, tender, and/or

friable?friable? Is the there leukocytes in the wet Is the there leukocytes in the wet

mount?mount?

Mucopurulent cervicitisMucopurulent cervicitis

Mucopurulent cervicitis caused by C. trachomatis (Holmes, 1999; reprinted with permission from McGraw Hill.)

Physical FindingsPhysical Findings

Pelvic tendernessPelvic tenderness Cervical, uterine, or adenexalCervical, uterine, or adenexal

Less than 1/3 have feverLess than 1/3 have fever WBC commonly normalWBC commonly normal Sed rate is generally elevatedSed rate is generally elevated

CDC recommends CDC recommends treating sexually active treating sexually active women 25 or less years women 25 or less years

old at risk for STD if they old at risk for STD if they are having pelvic or low are having pelvic or low abdominal pain AND 1) abdominal pain AND 1)

cervical, uterine, or cervical, uterine, or adenexal tenderness; 2) adenexal tenderness; 2) no other causes of painno other causes of pain

Presumptive Diagnosis of Presumptive Diagnosis of CervicitisCervicitis

Gonococcal CervicitisGonococcal Cervicitis

RecommendedRecommended Ceftriaxone 250 mg IM plus Azithromycin 1 Ceftriaxone 250 mg IM plus Azithromycin 1

gm po or doxycycline 100 mg po BID x gm po or doxycycline 100 mg po BID x 7days7days

Alternative regimenAlternative regimen Cefixime 400 mg po plus Azithromycin 1 Cefixime 400 mg po plus Azithromycin 1

gm po or doxycycline 100 mg po BID x gm po or doxycycline 100 mg po BID x 7days7days

If penicillin allergyIf penicillin allergy Azithromycin 2 gm poAzithromycin 2 gm po

Cervicitis TreatmentCervicitis Treatment

Azithromycin 1 gm po x 1 ORDoxycline 100 mg bid x 7d PLUSCeftriaxone 125 mg IM

ORCefixime 400 mg po

PLUSTreat for BV if present

Outpatient PIDOutpatient PID

Indications to Indications to hospitalize…hospitalize…

PregnancyPregnancy Adolescents with unpredictable Adolescents with unpredictable

compliancecompliance Immunodeficient ( HIV with low CD4 Immunodeficient ( HIV with low CD4

counts) counts) Uncertain diagnosisUncertain diagnosis Nausea and vomiting, high feverNausea and vomiting, high fever Inadequate response to outpatient therapyInadequate response to outpatient therapy TOATOA

CDC .Guidelines for Treatment of Sexually Transmitted Diseases 2002, MMWR 2002: 51: 1041

Inpatient PIDInpatient PID

Inpatient PIDInpatient PID

Post HospitalizationPost Hospitalization

Doxycycline 100 mg orally twice a Doxycycline 100 mg orally twice a day for 14 daysday for 14 days

Clindamycin 450 mg orally four time Clindamycin 450 mg orally four time s a day for 14 dayss a day for 14 days

Not sure what she has …Not sure what she has …

TOATOA

Tubo-ovarian abscess (TOA)Tubo-ovarian abscess (TOA)• collection of pus delimited by the collection of pus delimited by the

adherence of the fallopian tubes, ovaries, adherence of the fallopian tubes, ovaries, and adjacent organsand adjacent organs

• serious manifestation of PID and generates serious manifestation of PID and generates 350,000 hospitalization/150,000 350,000 hospitalization/150,000 surgeries/yrsurgeries/yr

• 34% of PID cases hospitalized have TOA34% of PID cases hospitalized have TOA• TOA ruptured -mortality rate is as high as TOA ruptured -mortality rate is as high as

9%9%• 1-4% rupture at initial presentation or during 1-4% rupture at initial presentation or during

conservative managementconservative managementSoper DE. Pelvic inflammatory disease. Infect Dis Clin North Am. 1994;8:821-840

Tuboovarian abscessTuboovarian abscess Presenting symptoms and Presenting symptoms and

findings with TOAfindings with TOA Pelvic pain Pelvic pain Pelvic massPelvic mass Fever/chillsFever/chills Vaginal dischargeVaginal discharge Abnormal uterine bleedingAbnormal uterine bleeding Nausea/vomitingNausea/vomiting Temp.>100°FTemp.>100°F WBC>10,000WBC>10,000

Landers DV and Sweet RL: Rev Infect Dis 5:879, 1983

Pelvic inflammatory disease, proven chlamydial pyosalpinx. Right tube is swollen and tortuous (arrow) (Holmes, 1999; reprinted with permission from McGraw Hill.)

Diagnostic testsDiagnostic tests

UltrasoundUltrasound

Complex cystic mass Complex cystic mass containing multiple containing multiple septations and septations and internal echoesinternal echoes

correctly identified correctly identified TOA in 94% of pt. TOA in 94% of pt. confirmed by surgeryconfirmed by surgery

Bulas DI. Radiology. 1992;183:435Bulas DI. Radiology. 1992;183:435

Criteria for treatment Criteria for treatment success:success:

Clinical improvement may take Clinical improvement may take 72 hours72 hours Resolution of abdominal pain, Resolution of abdominal pain,

defervescence, decreased WBC, defervescence, decreased WBC, stabilization or decrease in mass stabilization or decrease in mass size.size.

clinically deterioration or clinically deterioration or development of an acute abdomen development of an acute abdomen should prompt surgical interventionshould prompt surgical intervention

Post Hospitalization for Post Hospitalization for TOTO

Clindamycin 450 mg orally four Clindamycin 450 mg orally four times a day for 14 daystimes a day for 14 days

SurgerySurgery

TAH/BSOTAH/BSO Laparoscopy with Laparoscopy with

endoscopic endoscopic drainage, drainage, irrigation, lysis irrigation, lysis of adhesionsof adhesions

Ultrasound Ultrasound guided guided percutaneous percutaneous drainagedrainage

SequelaeSequelae

Chronic pelvic painChronic pelvic pain Ectopic pregnancyEctopic pregnancy InfertilityInfertility