PELVIC INFLAMMATORY DISEASE

19 year old G1P0(0010) consulted at your clinic for a 1 week history of foul-smelling vaginal discharge
associated with fever and chills. No history of amenorrhea. She has had 3 sexual partners. BP = 80/60,
HR = 110, RR 24, Temp 40. (+) LLQ direct tenderness. No palpable mass. Pelvic: Normal external
genitalia, IE: smooth vagina with muco-purulent discharge, cervix smooth, closed, with wriggling
tenderness, corpus 6 weeks size and slightly tender, (+) 6 x 4 cm cystic, tender mass at the cul de sac.
What is your admitting impression?
What is the pathophysiology for your impression?
What are your diagnostics?
How will you manage her case?

Admitting impression would PELVIC INFLAMMATORY DISEASE with Tuboovarian Abscess; Sepsis
PID results from an ascending infection by cervicovaginal bacterial flora, or may be associated with
gonococcal and chlamydial infections.
Risk factors age below 25, history of sexual activity and multiple sex partners, concomitant STI.
Differentials: Acute Appendicitis, Ovarian New Growth with Complication, Ectopic Pregnancy, Pelvic TB
Laboratory and ancillary procedures I would request would include:
1. CBC with WBC diff count, Urinalysis; Pregnancy test
2. Liver and renal function tests
3. Work up for sepsis: Blood and urine CS; Cervical swab GS-CS
4. Transvaginal ultrasound
5. Screen for other STI (HBsAg, VDRL, HIV)
6. Screen and treat partner
Management:
Admit patient and start venoclysis for hydration.
Assess Airway, Breathing and Circulation.
Monitor accurate fluid balance, insert foley catheter
Start Intravenous Antibiotics:
1. Clindamycin 900 mg IV q8
2. Gentamicin 2mg/kg IV as loading dose, then 1.5 mg/kg IV q8 as maintenance dose
3. Ampicillin
Closely monitor/assess patient for the first 3-5 days: there should be no deterioration (increase pain or
tenderness, rising fever)
Upon stabilization of patient, prepare for exploratory laparotomy laparotomy with aspiration/drainage
of abscess. (Unilateral adnexectomy may be necessary) -- good exposure, sentinel packs, NSS lavage, In-
dwelling drainage, Smead-Jones fascial closure with monofilament suture, retention sutures
Post-operatively, continue IV antibiotics until 24 hours afebrile. May shift to oral doxycycline 100 mg
BID for 14 days.
Treatment of partner and abstinence until completion of treatment.

*If TOA is less than 6 cm, give Clindamycin and Gentamicin and minitor. Ampicillin may be added if
there is no immediate response or if you suspenct enterocci as pathogens.
Monitor for the first 3-5 days: There should be no clinical deterioration, there must be decrease in
pain/tenderness, repeat ultrasound (do not expect immediate decrease in size but there should be NO
INCREASE in SIZE, or the mass may have disappeared and replaced by fluid suggestive of rupture of the
abscess). Surgical aspiration/ drainage, if there is medical treatment failure.
*Pelvic clean up in older patients and those who are not desirous of future child-bearing.
*OUT PATIENT TREATMENT:
Ceftriaxone 250 mg IM PLUS Doxycycline 100 mg PO BID x 14 days, with or without MEtronidazole 500
mg BID x 14 days.
Patient should respond within 72 hours of oral antibiotics. If no response, admit for intravenous
antibiotics and reassessment.

*Indications for hospitalization:

Surgical emergencies cannot be excluded.
Patient is pregnant.
Does not respond clinically to oral antibiotics
Unable to comply to or tolerate oral outpatient regimen
The patient has a severe illness: nausea and vomiting, high grade fever
The patient has a TUBOOVARIAN ABSCESS.

*Indications for surgical management:

Large abscess (>/= 6 cm) abscess
Ruptured/leaking abscess
No response to antibiotics
Complete family size: try to spare ovarian function