PELVIC INFLAMMATORY DISEASE(PID)

and
ECTOPIC PREGNANCY
DR MUSANA ABDUSALAAMU KIZITO
MULAGO NATIONAL REFERRAL HOSPITAL
PATHOLOGY DEPARTMENT
 Case scenario

• A 16 year old female complained of 5 days history of

a severe RIF pain, associated with mild vaginal
bleeding, vomiting and low grade fever.
• Her last period was 5 weeks ago, otherwise it used to
be regular, of 5 days duration, with a severe pain
and vomiting sometimes.
• O/E patient look sick, severely anemic, but not jaundiced or
cyanosed.
• BP=80/50, PR 99/m, regular of low volume, RR 21/m
• Abdomen was slightly distended, with generalized tenderness
and rigidity.
• PV= minimal bleeding, marked tenderness and cervix is shifted
to the left
 Questions

What is the diagnosis?

What is your differential diagnosis?
What other information you would like to know?
What investigations would you request?
What is your plan of management?
PID is and inflammatory disorder involving both the
lower and upper female genital tract.
It is caused by the following microorganism:
 gonococci, chlamydiae, and enteric bacteria.
staphylococci, streptococci, and Clostridium
perfringens.
It usually begins in the Bartholin gland and other
vestibular glands or periurethral glands; cervix
involvement is common and frequently asymptomatic.
From any of these sites, the organisms may spread
upward to involve the tubes and tubo-ovarian region.
It is usually polymicrobial.
 Clinical features

Pelvic and lower back pain

Adnexal tenderness
 fever
Dyspareunia
 vaginal discharge and itching
 Complications
The complications of PID include:
 Peritonitis
 Intestinal obstruction due to adhesions between the small bowel and the pelvic
organs
 Bacteremia, which may produce endocarditis, meningitis, and suppurative
arthritis
 Infertility, one of the most commonly feared consequences of long-standing
chronic PID
 With the gonococcus acute suppurative
salpingitis, salpingo-oophoritis, tubo-ovarian
abscesses, and pyosalpinx are common
complications.
Increased risk of ectopic pregnancy.
A, Acute salpingo-oophoritis, with tubo-ovarian abscess. The fallopian tube
and ovaries have coalesced into an inflammatory mass adherent to the
uterus.
 Diagnosis

 Clinical:
History and examination
Investigations:
High vaginal swab ( gram stain, culture and sensitivity)
Pelvic ultrasound
 Ectopic pregnancy

Implantation of the blastocytes outside the endometrial

cavity.
The most common locations for ectopic pregnancy are:
Fallopian tube (tubal pregnancy) 95%, the remaining
5% of non-tubal pregnancy are, ovary, peritoneal
cavity, cervix and previous C/S scar.
The incidence of ectopic pregnancy is 1 to 2% of all
first trimester in USA.
The most frequent region involved in tubal
pregnancy in descending order is ampullary (70%),
isthmic (12%), fimbrial (11%), and interstitial (2-
3%).
 Risk factors
Abnormal fallopian tube anatomy underlies many cases of
tubal ectopic pregnancy.
Surgeries for prior tubal pregnancy, for sterilization, for
fertility restoration confer highest risk for tubal pregnancy.
 prior sexually transmitted diseases including salpingitis
and PID.
Peritubal adhesions following salpingitis,
appendicitis, or endometriosis also increases the risk
of tubal pregnancy.
Salpingitis isthmica nodosa is also a well
documented risk factor.
 Clinical manifestations
In early stage of the disease the signs and symptoms of
ectopic pregnancy is usually subtle or absence.
Later, the patient present with the classic triad of delayed
menstruation, pain, and vaginal bleeding.
With tubal rupture, there is a severe sharp lower abdominal
and pelvic pain which may radiate to the axilla or shoulder
especially on inspiration, why???
O/E patient is usually hemodynamically
unstable with severe palor, tachycardia, and
hypotension.
Abdominal examination reveals generalized
tenderness and PV examination causes a
severe pain with tender adnexa.
Outcomes include:
Tubal rupture
Tubal abortion, and
Pregnancy failure with resolution.
 Differential diagnosis
Uterine conditions: miscarriage, infections (endomeritis),
degenerating fibroid, and molar pregnancy.
Ovarian conditions: ectopic pregnancy, twisted ovarian
cyst, tubo-ovarian abscesses.
Surgical causes: acute appendicitis, renal and ureteric
stones, cystitis, diverticulitis, mesenteric infarction, etc.
Ruptured tubal pregnancy with marked hemorrhage (hematosalpinx).
The tiny embryo is identifiable in the center of the clot.
 Diagnosis

Clinical history and physical findings.

Serum or urine beta HCG.
Trans-vaginal ultrasound, and
Diagnostic surgery.
THANK YOU