Download - Diagnosis and management of PID
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