PID

By Dr. Nadia AL.Assady F.I.B.O.G C.A.B.O.G

Pelvic inflammatory diseases Def : is infection of the upper genital tract. Causes : its most commonly caused by ascending infection from the endocervix or may occur from descending organ such as the appendix ,the most common organism are Chlamydia & gonococcus but an aerobes also involved.

Pathophysiology: Once the infection has ascended to the uterus , the fallopian tubes are commonly damaged, there is inflammation of the mucosa which if progressive will destroy cilia followed by scarring in the lumen & this can cause pocketing with partial obstruction of tubes this may predispose to ectopic pregnancy*. in severe infection mucopurulent discharge exudes through the fimbrial end causing peritoneal inflammation , scarring & adhesion formation*.


*. It can affect the ovary & form tubo-ovarian abscess*. Infection are usually contained by omentum causing omental adhesion*. CT & GC can cause perihepatitis leading adhesion between liver & peritoneum this gives violin string appearance at laparoscopy & is called the Fitz-Hugh-Curtis syndrome.

Risk factors : 1-age < 25 years. 2-previous STDs. 3-IUCD. 4-multiple sexual partners. 5-TOP. 6-HSG. 7-IVF. 8-postpartum endometritis. 9-bacterial vaginosis. Protective factors : The use of barrier contraception, marina & COCP.

Sign & symptoms: a-may be asymptomatic diagnose during infertility investigation. b-lower abd, pain & dyspareunia . c-abnormal vaginal discharge & unscheduled vaginal bleeding . d-pyrexia > 38 C., cervical excitation & adnexal tenderness . investigations: 1-endocervical & HVS . 2-WBC & CRP may be elevated.3-U/S to detect adnexial mass.4- laparoscopy gold standard.

Treatment:1-rest is advised & PT is done to rule out ectopic pregnancy.2-an IUCD should be removed , adequate hydration & analgesia.3-sexual intercourse should be avoided during treatment & the partner should be treated. 4-most patients can be treated as outpatient but inpatient treatment may indicated in:a-surgical causes not excluded. b-severe infection & generalized sepsis .c- failure to response to outpatient treatment. d-severe pelvic & abdominal pain requiring strong analgesic.e-suspicion of tubo –ovarian abcess.

Outpatient treatment : *Oral ofloxacin (400mg)twice/day + oral metronidazole (400mg) twice/day for 14 days . *ceftrixone (250mg) single dose i.m + oral doxycycline (100mg) twice/day +oral metronidazole (400mg) twice/day for 14 days .

Inpatient treatment: *ceftriaxone (2gm i.v)+i.v or oral doxycycline (100mg)twice/day + i.v metronidazole (500mg) twice/day this continue until the patient improved usually within 24 hours, then changes to oral drugs for 14 days. *clindamycin (900mg i.v) three times /day+ gentamycin i.v (loading dose 2mg/kg followed by 1.5mg/kg three times /day) followed by oral ofloxacin (400mg)twice/day + oral metronidazole (400mg) twice/day for 14 days .



* i.v ofloxacin (400mg)twice/day + i.v metronidazole (400mg) three times/day for 14 days . 5-Surgical treatment in form of abscess drainage under U/S guidance or by laparoscopy. 6-Advise patient about used barrier contraception & seek early medical advice if pregnant due to risk of ectopic pregnancy.

Chlamydia :C.trachomatis its obligate intracellular parasite & it’s the commonest STDs it affect the columnar epithelium of the genital tract .there are several serovars of Chlamydia A_C infect the conjunctiva causing trachoma & D_K infect the genitourinary systems .other species infect the lung causing pneumonia & there is a lymphogranuloma venereum strain( L1_L2) causing rectal infection & proctitis.

Signs & symptoms : 1-asymptomatic with detrimental effect on tubal function . 2-vaginal discharge & mucopurulent cervical discharge . 3-postcoital bleeding & intermenstrual bleeding 4-dysuria &urethral discharge & lower abdominal pain . Diagnosis : 1-endocervical swabs & urethral swab & urine for PCR 2-nucleic acid amplification technique. 3-culture .

Treatment : 1-Avoid sexual intercourse & the partner should be treated. 2-Test of cure should be done 6 weeks after treatment . 3-drugs treatment . a-doxycycline (100mg) orally twice/day for 7days. b-azithromycin (1gm)orally single dose(recommended in pregnancy . c-ofloxacin (400mg) once/day for 7days.

complications : 1-PID 2-perihepatitis 3-tubal infertility 4-risk of ectopic pregnancy 5-Reiter s syndrome ( arthritis +urethritis + conjunctivitis). Implications in pregnancy : 1-PROM & preterm lobar . 2- low birth wt. 3-postpartum endometritis . 4-neonatal conjunctivitis . 5-neonatal pneumonia .

Gonorrhea :Its STDs caused gram –ve intracellular diplococcus Neisseeria gonorrheae its effect mucous membrane & the columnar epithelium in the endocervical & urethral mucosa , it also effect the rectal & oropharyngeal mucosa .

Signs & symptoms : 1-asymptomatic 2-greenish vaginal discharge & abd , pain . 3- mucopurulent endocervical discharge & contact bleeding . 4-dysuria & mucopurulent urethral discharge . 5-proctitis & rectal bleeding , discharge & pain .


Diagnosis : 1-triple swabs : ( endocervix , urethra ,rectum) for gram stain & culture also pharyngeal swab . 2-NAAT & NAHT . Treatment : 1-ceftriaxone (250mg) i.m single dose . 2-cefixime (400mg) oral dose . 3-spectinomycin ( 2gm) i.m single dose

Complications : 1-PID 2-bartholin' s abscess & skene's abscess . 3-disseminated gonorrhea which cause fever , pustular rash ,migratory poly arthralgia ,& septic arthritis . 4-tubal infertility . 5- risk of ectopic pregnancy .

Implications in pregnancy : 1-PROM & preterm lobar 2- chorioamnionitis . 3-postpartum endometritis . 4-ophthalmia neonatrum .