Diagnosis and Management of PID

Aswathi Raveendran U.V

Acute PIDGoals of treatment:

Treat infectionMinimize tubal damagePrevent adhesions Reduce the risk of complications , sequelae and

chronic PID

CDC GuidelinesMinimum Criteria

Lower abdominal painAdnexal tendernessCervical motion tenderness

Additional Criteria Oral temperature > 38o CVaginal/ cervical discharge – mucopurulentVaginal discharge – WBCs on microscopyElevated ESRElevated CRPLaboratory documentation of cervical infection

with N.gonorrhoeae or C.trachomatis

Definitive CriteriaEndometrial biopsy :

Histopathological evidence of endometritisTrans Vaginal Ultra sonogram / MRI

Thickened tubesFluid filled tubes Tubo ovarian mass

LaparoscopyChanges consistent with PID:

Dilated hyperemic tubes Pyosalpinx Tubo-ovarian mass

Clinical criteria for initiating therapyIn young women

Women at risk of STI

Minimum criteria present

No other cause for illness identified

Start Empiric treatment

Management Of Acute PIDAssessment of need for hospitalizationAntimicrobial therapyTreatment of partnersCounselingAssessment of response to therapySurgical interventionFollow up for sequelae

Outpatient

One or more of minimum criteria present

No severe infection

Drugs and DosagesDRUG DOSE DURATIONCEFTRIAXONE 250mg IM single dose

(or)CEFOXITIN 2g IM single dose

(+ PROBENECID)(or)

Other THIRD – GENERATION

CEPHALOSPORIN

IM single dose

With DOXYCYCLINE

100 mg oral BD 14 days

With or withoutMETRONIDAZOLE

400mg twice daily 14 days

Drugs should cover gonococcal , chlamydial, aerobic and anaerobic infections

Re assess after 48-72 hoursIn adequate response – hospital admission

Indications for Admission to hospitalSurgical emergencies cannot be ruled out No response to OP oral treatmentPresence of Tubo-ovarian abscessClinically severe disease with nausea,

vomiting and high feverPID in pregnancy

Inpatient Management of PIDRest IV Fluids

Dehydration Vomiting Electrolyte imbalance

Analgesics Antibiotics at the earliest

DRUG DOSE DURATIONREGIMEN A

CEFOTETAN 2g IV every 12hrs (or) Upto 24 hours after patient

becomes afebrileCEFOXITIN 2g IV every 6 hrs

+DOXYCYCLINE

100mg oral/ IV every 12hr

Continue oral BD * 14days

REGIMEN BCLINDAMYCIN 900mg IV every 8hrs 24 hrs after

patient become afebrile, 450mg oral QID * 14days

+ GENTAMICIN 2mg/kg IV or IM loading dose

1.5mg/kg every 8 hr maintenance dose

Or single daily dose

Alternative RegimensDRUG DOSE

OFLOXACIN 400mg IV every 12hrs (or)

LEVOFLOXACIN 500mg Iv OD

With/ withoutMETRONIDAZOLE

AMPICILLIN/ SULBACTAM500mg IV every 8 hrs (or)

3g IV every 6hr

Plus DOXYCYCLINE 100mg oral / IV every 12hrs

Azithromycin 500mg IV 6th hourly x 2 days , followed by oral therapy -for Chlamydia

Placentrex Aqueous extract of fresh placenta2ml IM daily/ alternate days10 injectionsAnti inflammatory / tissue regeneration/ wound

healing /significant immunotropic action

Actinomyces PIDAnaerobic gm positive organism Associated with IUCD – 7% higher incidenceFever , abdominal pain, bleeding , dischargePenicillin 2,50,000units/kg IV daily x 4 doses

for 2-6 weeksFollowed by oral penicillin 100mg/kg daily x

3- 12 monthsTetracycline/ Erythromycin/Clindamycin/

Chloramphenicol

Surgical InterventionsUltrasound guided aspiration

Pelvic abscess – 70% successSubdiaphragmatic collectionMay cause rupture/ pelvic vein thrombosis/ C/c

infectionPosterior colpotomy

Incision on posterior vaginal fornix to drain pelvic abscess

Minimal Invasive Surgery Laparoscopic

aspiration/drainage/adhesiolysisTubo-ovarian abscess

Size of abscess > 10cm Failure to respond to antibiotics in 48 -72 hrs Abscess ruptures Pyo peritoneum

Pelvic abscessComplications : recurrence / chronic PID /

tubal blockage / chronic pelvic pain

Dilatation and evacuation:Post abortal sepsis

Laparotomy Rupture of tubo-ovarian abscessMultiple intra abdominal collections

Salpingo – oophorectomy Tubo-ovarian mass / abscess

Management of sexual partnersContact partners within 6 months of ondet of

diseaseScreen for gonococcal/ chlamydial infectionsIf screening not possible start empirical

treatmentAvoid intercourse till the partner completes

treatment

CounsellingPractice safe sex , prevent re infection &

sequelaeEarly treatment reduces the risk not

eliminate Barrier contraception Recurrence increases risk of infertilityTreatment of sexual partner

Follow upAfter 6 – 8 weeks Ensure adequate response to therapyCompliance Counselling

Management of Chronic PIDSurgical treatment Depends on

AgeParitySymptoms and pelvic pathology

LaparoscopyAdhesiolysis - by laser or electro cauterySalpingo - oophorectomy

Laparotomy AdhesiolysisSalpingo-oophorectomyHysterectomy with BSO

TuboplastyTubal lumen blocked Hysteroscopic falloposcopy assess extent of

damageLaparoscopic salpingoscopy

Prognosis Boer – Meisel system of prognostic evaluation

Extent of adhesionsNature of adhesions : flimsy/ denseSize of hydrosalpinxMacroscopic condition of hydrosalpinxThickness of tubal wall

End ResultsDecreased mortality ratesConsiderable Morbidity persists :

Chronic pelvic painMenorrhagiaEctopic pregnancyInfertilityBack ache, dyspareunia, vaginal discharge

15% •Fail to respond to chemo therapy

20% •At least one recurrence•Chronic pelvic pain

15% •Infertility

8% •Of those who conceive have ectopic pregnancy

Prophylaxis

Hospital delivery Trained dais Reduce puerperal infection

Contraception Barrier method Minipills / OCPs

Sex education Risk of STD Femshield use