PID.pptx pelvic inflammatory diseases obg

Obg

1. Pelvic Infection

2. OUTLINE DEFINITION AETIOLOGIC AGENTS RISK FACTORS PATHOPHYSIOLOGY CLASSIFICATION CLINICAL FEATURES CLINICAL DIAGNOSIS COMPLICATIONS TREATMENT CONCLUSION REFERENCES 2

3. Female reproductive organ

4. Defence Of the genital tract Vulval defence Anatomic : (i) Apposition of the cleft by labia; ( ii) Compound racemose type of Bartholin’s glands. Physiologic : (i) Fungicidal action of the secretion ( undecylenic acid) of the apocrine glands; (ii) Natural high resistance to infection of the vulval and perineal skin . Vaginal defence Anatomic : (i) Apposition of the anterior and posterior walls with its transverse rugae ; (ii) Strati- fied epithelium devoid of glands. Physiologic : This is maintained by the hormone oestrogen

5. Cervical defence : Anatomic — (i) Racemose type of glands , (ii) mucus plug. Physiologic —Bactericidal effect of the mucus. Uterine defence : (i) Cyclic shedding of the endometrium (ii ) Closure of the uterine ostium of the fallopian tube with slightest inflammatory reaction in the endometrium . Tubal defence : Anatomic —Integrated mucus plicae and epithelial cilia. Physiologic —Peristalsis of the tube and also the movement of the cilia are towards the uterus.

6. Phases of Life when Defence is lost i ) Following 10 days of birth till puberty is reached. ii ) During reproductive period—in the following situation: During menstruation : The vaginal pH becomes Increased, The protective cervical mucus disappears and the endometrium sheds. Following abortion and childbirth : The contaminated lochia increases the pH. The raw placental site, inevitable tear of the cervix, bruising of the vagina and presence of blood clots or remnants of decidua favour nidation of the bacterial growth. (iii) During menopause .

7. Organisms Pyogenic (50%) : Aerobes The gram-positive organisms: staphylococcus . The gram-negatives: E . coli , pseudomonas , klebsiella , N. gonorrhoeae Anaerobes The gram-positives are anaerobic streptococcus , Clostridium welchii , Cl. tetani , etc. The gram-negatives: Bacteroides fragilis is the commonest

8. 2. Sexually transmitted disease (STD) : N . gonorrhoeae , Chlamydia trachomatis , Treponema pallidum, Herpes simplex virus type II, Human papilloma virus, Haemophilus vaginalis , Donovan bodies, HIV I or II, etc. 3. Parasitic: Trichomonas vaginalis 4. Fungal : Candida albicans 5. Viral: Herpes simplex virus type II, Human papilloma virus, HIV, Condylomata accuminata , 6. Tubercular: Mycobacterium tuberculosis .

9. Modes of spread of infections The route of infection is most commonly ascending in nature. classic modes of infection of some specific organisms Through continuity and contiguity — gonococcal infection Through lymphatics and pelvic veins — postabortal and puerperal infection—by pyogenic organisms other than gonococcus Through blood stream —tubercular From adjacent infected extra-genital organs like intestine.

10. ACUTE PELVIC INFECTI ON Pelvic inflammatory disease (PID). Following delivery and abortion. Following gynecological procedures. Following IUD. Secondary to other infections—appendicitis

11. PELVIC INFLAMMATORY DISEASE

12. What is PID ? PID is a disease of the upper genital tract . An infection of vagina (Colpitis) Cevix (Endocervicitis) Uterus ( Endometritis) Fallopian tubes ( Salpingitis) Ovaries (oophoritis), Pelvic peritonitis Tubo-ovarian abscess

13. DEFINITION It is a spectrum of infection and inflammation of the upper genital tract organs typically involving the uterus (endometrium), fallopian tubes, ovaries, pelvic peritoneum and surrounding structures .(D C DUTTA) Gender-specific (female) ascending infection of the upper genital tract (uterus, fallopian tubes, and adjacent pelvic structures) that is neither linked with surgery nor pregnancy. 3

14. Incidence Varies from 1–2 per cent per year About 85 per cent among sexually active women in reproductive age. The remaining 15 per cent follow procedures ,

15. Risk Factors Menstruating teenagers. Absence of contraceptive pill use. Previous history of acute PID. IUD users. Area with high prevalence of sexually transmitted diseases . Teenagers with low hormonal defence in response to genital tract infection.

16. RISK FACTORS young age multiple sexual partners certain methods of contraception previous history of STI delayed and decreased access to care Vaginal douching Recent trans-vaginal instrumentation Previous history of PID

17. Protective factors Contraceptive practice: Barrier methods, specially condom, diaphragm with spermicides Oral steroidal contraceptives: have got two preventive aspects. −− Produce thick mucus plug preventing ascent of sperm and bacterial penetration −− Decrease in duration of menstruation, creates a shorter interval of bacterial colonization of the upper tract. Monogamy or having a partner who had vasectomy . „ Others Pregnancy Menopause Vaccines : hepatitis B, HPV

18. Mode of affection The gonococcus ascends up to affect the tubes through mucosal continuity and contiguity . This ascent is facilitated by the sexually transmitted vectors such as sperm and trichomonads . Reflux of menstrual blood along with gonococci into the fallopian tubes is the other possibility. Mycoplasma hominis probably spreads across the parametrium to affect the tube. The secondary organisms probably affect the tube through lymphatics . Rarely , organisms from the gut may affect the tube directly .

19. 19 PATHOPHYSIOLOGY Contract of infective agent Ascension to the upper genital tract Inflammation of the genital mucosal lining Destruction of the cilia and subsequent scarring of the tubal lumen. Luminal pocketing and partial obstruction predisposes to ectopic pregnancy

20. 20 PATHOPHYSIOLOGY CONT’D Mucopurulent exudates via the fimbrial terminus causes peritonitis. Resulting scarring and adhesion formations could result in tubo-ovarian abscess. Infected peritoneal fluid leaks from the pelvis to the perihepatic area leading to perihepatitis. This leads to the concomitant formation of adhesion bands between the liver capsule and the visceral peritoneum, right upper quadrant pain and tenderness resulting in the so called: Fitz-Hugh-Curtis Syndrome. (Okpere, 2007)

21. PATHOPHYSIOLOGY Cervicitis Endometritis Salpingitis/ oophoritis/ tubo- ovarian abscess Peritonitis 21

22. Normal Human Fallopian Tube Tissue Source : Patton, D.L. University of Washington, Seattle, Washington 22

23. Abnormal Human Fallopian Tube Tissue Cilia eroded in C. trachomatis Infection (PID) Source : Patton, D.L. University of Washington, Seattle, Washington 23

24. CLINICA L FEATURES Symptoms A wide range of non-specific clinical symptoms. Appear at the time and immediately after the menstruation . Dull Bilateral lower abdominal and pelvic pain with radiation to the legs Rapid and acute onset of pain in gonococcal infection (3 days) Fever , lassitude and headache.  Irregular and excessive vaginal bleeding in endometritis .

25. Symptoms … Contd Purulent and or copious vaginal discharge   Nausea and vomiting.   Dyspareunia .   Pain and discomfort in the right hypochondrium due to concomitant perihepatitis ( Fitz-Hugh- Curtis syndrome ) .

26. 26 Signs bilateral lower abdominal tenderness with radiation to the legs Adnexal tenderness Cervical motion tenderness Temperature >38.3 ° C (101 ° F) Abnormal cervical or vaginal mucopurulent discharge Presence of abundant numbers of WBCs on saline microscopy of vaginal secretions Elevated erythrocyte sedimentation rate (ESR) Elevated C-reactive protein (CRP) Gonorrhea or chlamydia test positive

27. Abnormal discharge

28. CLINICAL DIAGNOSIS Physical Examination: Lower abdominal tenderness, adnexal tenderness, pain on manipulation of the cervix Laboratory Investigations: CBC ESR , PCR , gonorrhea DNA probes and culture, clamydial DNA probes and culture. imaging studies: Transvaginal ultrasonography , Abdomino - pelvic USS Endometrial B iopsy Culdocentesis Identification of organisms in 1. Discharge from the urethra or Bartholin’s gland. 2. Cervical canal. 3. Collected pus from the fallopian tubes during laparoscopy or laparotomy 16

29. Investigations Laparoscopy : the " gold standard Laparoscopic findings and severity of PID: Mild : Tubes: edema, erythema, no purulent exudates and mobile. Mod : Purulent exudates from the fimbrial ends, tubes not freely movable. Severe : Pyosalpinx , inflammatory complex, abscess . ‘ Violin string ’ like adhesions in the pelvis and around the liver suggests chlamydial infection.

30. Diagnosis Symptoms alone are not a good predictor , and clinical diagnosis alone is difficult Major criteria Minor criteria cervical motion tenderness and uterine motion tenderness and adnexal tenderness Temperature >38 ° 3 C Abnormal cervical discharge Pelvic abscess or inflammatory complex on bimanual examination Gram stain of the endocervix showing gram negative intracellular diplococci Positive chlamydia test Leucocytosis >10x 10 9 WBC/L Elevated ESR Elevated C-reactive protein

31. The definitive criteria histopathologic evidence of endometritis on endometrial biopsy transvaginal sonography or other imaging techniques showing thickened fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex laparoscopic abnormalities consistent with PID

32. Complications Immediate : 1 ) Pelvic peritonitis or even generalized peritonitis . 2 ) Septicemia—producing arthritis or myocarditis. Late: Dyspareunia. Infertility Chronic pelvic inflammation Formation of adhesions or hydrosalpinx or pyosalpinx and tubo -ovarian abscess . Fitz- hugh - curtis Syndrome: Perihepatic adhesion 6) Chronic pelvic pain and ill health. 7) Increased risk of ectopic pregnancy )

33. FITZ-HUGH-CURTIS SYNDROME 12 ECTOPIC INFERTI L - PR E GNA N CY ITY

34. Prevention

35. Screening Community based approach to increase public health awareness. Prevention of sexually transmitted diseases with the knowledge of healthy and safer sex. Liberal use of contraceptives. Routine screening of high-risk population .

36. Management of Sex Partners Male sex partners of women with PID should be examined and treated Male partners of women who have PID caused by C. trachomatis and/or N. gonorrhoeae frequently are asymptomatic.

37. Partner Management (continued) Sex partners should be treated empirically with regimens effective against both C. trachomatis and N. gonorrhoeae , regardless of the apparent etiology of PID or pathogens isolated from the infected woman.

38. Treatment: Outpatient therapy Adequate rest Analgesic Antibiotics: Patient should have oral therapy for 14 days Broad spectrum antibiotic coverage ( cefotaxime / cefoxitin ) Evaluate after 48 hours and if no response , hospitalise .

39. Inpatient therapy Bed rest is imposed. Oral feeding is restricted. Correct Dehydration and acidosis by IV fluid . Intravenous antibiotic therapy is recommended for at least 48 hours but may be extended to 4 days Improvement of the patient is evidenced by Remission of temperature , improvement of pelvic tenderness, normal white blood cell count and negative report on bacteriological study .

40. 41 TREATMENT... Parenteral Regimens: CDC-recommended parenteral 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 CDC-recommended parenteral regimen B Clindamycin 900 mg IV every 8 hours, PLUS – Gentamicin loading dose IV or IM (2 mg/kg), followed by maintenance dose (1.5 mg/kg) every 8 hours. Single daily gentamicin dosing may be substituted.

41. Indications of surgery Generalized peritonitis. Pelvic abscess. Tubo -ovarian abscess which does not respond (48–72 hours) to antimicrobial therapy.

42. Patient Counseling and Education Educating the patient to avoid reinfection and the potential hazards of it. The patient should be warned against multiple sexual partners. To use condom. The sexual partner or partners are to be traced and properly investigated to find out the organism(s) and treated effectively

43. FOLLOW UP Repeat smears and cultures from the discharge are to be done after 7 days following the full course of treatment . The tests are to be repeated following each menstrual period until it becomes negative for three consecutive reports when the patient is declared cured . Until she is cured and her sexual partner(s) have been treated and cured . The patient must be prohibited from intercourse.

44. Nursing Diagnosis Hyperthermia Acute pain Fatigue Activity intolerance Deficient fluid volume Anxiety

45. 46 C ONC L USI O N Clinical syndrome associated with ascending spread of microorganisms from the vagina or cervix to the endometrium, fallopian tubes, ovaries, and contiguous structures; comprising a spectrum of inflammatory disorders including any combination of endometritis, salpingitis, tubo- ovarian abscess, and pelvic peritonitis. It has debilitating sequellae on the reproductive health of women. Regular screening and safe sexual practices with monogamous partners are key to its prevention.