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Upper female reproductive infection
Endometritis (infection of uterine endometrium) PID (fallopian tube ovaries peritoneum)
Tubo-ovarian abscess Toxic shock syndrome (TSS)
• Ascending tract may also lead to Toxic Shock Syndrome (TSS)* *TSS = colonization of staph. pelvis and abdomen. pelvic and abdominal infection affected women > men because of the absence of a mucosal lining or epithelium between these spaces and external body. • Presence of open tract btwen vagina. adnexa.• Upper reproductive tract. fallopian tube. the pelvis and abdomen leading to ascending infections of uterus. Aureus that produce epidermal toxin –toxic shock syndrome toxin .
• Results from ascending infection by microorganism from vagina/cervix. . • An infectious and inflammatory disorder of the upper female reproductive tract involving the fallopian tubes. • Incidence closely related to STD. uterus. ovaries and adjacent pelvic structures.Definition of PID • Acute salphingitis.
Causative agent • Perdominantly by Chlamydia trachomatis & Neisseria gonorrhoeae (40%) • Recenct study: polymicrobial in nature including Gardnerella vaginalis. Haemophilus influenzae and anaerobe such as Bacteroides species. (60%) .
Pelvic inflammatory disease (PID) is an infectious and inflammatory disorder of the upper female reproductive tract. including the vagina and cervix.Anatomy • Pelvic inflammatory disease may extend from infection of the lower female reproductive tract. Infection and inflammation may spread to adjacent pelvic structures in the pelvis and abdomen. . including the uterus and fallopian tubes. including perihepatic structures (Fitz-Hugh Curtis syndrome).
.Pathophysiology • Exact mechanism of ascent of microorganism: unknown • Cervical mucus should provide functional barrier against upward spread. but efficacy of this mechanism is decreased by hormonal changes occur during ovulation and menstruation.
. • + facilitated by : opening of cervix during menstruation and retrograde menstrual flow • Intercourse – due to rhythmic mechanical uterine contractions.• Alteration in cervicovaginal microenvironment from antibiotic treatment and sexually transmitted infections .disrupt balance of endogenous flora causing normally non pathogenic organism to overgrow and ascend.
Pregnancy-related factors • Pregnancy ↓ risk of PID: cervical os is protected by the mucos plug. • Rarely occurs in pregnancy – However. can occur at first 12 weeks of gestation. before mucos plug solidifies and seals off the uterus from ascending bacteria fetal loss .
.Risk factors • Multiple sexual partners • Sexual intercourse at a young age (<25 y/o) and doesn’t not use contraception • IUD • Lives in an area with a high prevalence of sexually transmitted infections (STIs) Women who have multiple sexual partners and who use an intrauterine device (IUD) for birth control have a higher rate of PID. Monogamous women using an IUD have no increased incidence of PID.
CLINICAL PRESENTATION .
ranging from clinically asymptomatic to present with toxic symptom. aching or crampy bilateral and constant. • Minimum criteria for empiric treatment: – Pelvic or lower abdominal pain • Dull. .• Depending of severity of the infection.. • Toxic symptoms – – – – Fever Nausea vomiting Severe pelvic and abdominal pain. • Begins few days after onset of the LNMP • Accentuated by motion and exercise History – pain with sexual intercourse (dyspareunia) • Additional diagnosis critieria – foul-smelling mucopuralent vaginal discharge – Fever – Vaginal bleeding (post coital) •Gonococcal PID – abrupt onset + more toxic symptoms than nongonococcal •Gonorrhea and chlamydia associated infection more likely to cause symptoms toward the end of menses and in the first 10 days following menstruation.
along with the other signs of lower abdominal tenderness and abnormal vaginal discharge. * Due to poor specificity( no precise hx. or fallopian tube can be enlarged or tender on bimanual pelvic examination. • An oral temperature of greater than 38.Physical Examination • Minimal criteria: ( abdminal pain + >1 of the minimal criteria) * – Cervical motion tenderness – Uterine tenderness – Adnexal tenderness • The uterus. PE. • Guarding peritonitis • Adnexal fullness/disproportiante unilateral adnexal tenderness may indicate the development of tubo-ovarian abscess. . • Right upper quadrant tenderness a/w jaundice indicate of Fitz-HughCurtis syndrome. CDC has establish minimal criteria for the Dx. and Ix found to be highly specific /sensitive for the disease) of clinical finding. ovary.3° C is indicative of infection.
• Endometriosis . but in young women in whom spaphingitis and tubal pregnancy may co-exist the distinction can be very difficult. Cyst should be palpable.Differential Diagnosis • Appendicitis – Mainly right sided pain. • Tubal pregnancy (ectopic pregnancy) – PID is the most common incorrect diagnosis in cases of ectopic pregnancy. and the menstrual cycle is undisturbed • Adnexal tumors • Diverticulitis – Older women and left sided pain • Torsion of pedicle cyst – History of intermittent pain over several months. – Through history. B-hCG aids diagnosis.
3. fluuid filled fallopian tube Indisctint endometrial borders Ovaries with multiple small cysts Moderate-to-large amount of free pelvic fluid in acure. fluid-filled tubes with/without free pelvic fluid or tuboovarian abscess (TOA) Endometrial biopsy (histological exam) showing endometritis FBC – elevated WBC in presence of infection (>10. 2. severe PID.000) High vaginal swab(HVS) and culture or DNA probe– look for causative organism (N gonorrhoeae or C trachomatis) Saline microscopy of vaginal secretions – abundant WBC in presence of infection ESR – elevated ESR C-reactive protein – elevated Pregnancy test – if +ve ectopic pregnancy must be addressed Urinalysis – to help exclude UTI however positive urinalysis does not exclude PID Hepatits and HIV screening Repid protein reagin (RPR) test for syphilis . • • • • Laparoscopic confirmation Thickened (>5cm). • • • • • • • • • Transvaginal ultrasonographic scanning or magnetic resonance imaging (MRI) showing thickened.Investigation • Definitive procedures used to increase the specificity of the diagnosis: 1.
2.—24-year-old woman with pelvic inflammatory disease and tuboovarian complex. U = uterus. Sagittal endovaginal sonogram reveals complex free fluid (FF). A. Coronal image of left adnexa reveals dilated fallopian tube (T) with echogenic fluid. B.Fig. Findings are consistent with those of pyosalpinx .
acute appendicitis. and diverticulitis. . Combination of hypoechoic (arrows) and hyperechoic (asterisks) fat surrounds pyosalpinx (pyosalpinx itself is not seen on this image). Degree of inflammation is usually indication of infection and is unusual in other causes of acute gynecologic distress. but may be seen with other inflammatory causes such as Crohn's disease.Sonographic features of pelvic inflammatory disease with pyosalpinx and surrounding inflamed fat.
B). Note elongated nature of thickened tube on sagittal view (arrows and crosshairs. .Sonographic features of pelvic inflammatory disease with thickened fallopian tubes in 38-year-old woman. Similar findings were present in left adnexa. Axial (A) and sagittal (B) transvaginal sonograms of right adnexa show normal ovary (OV) relatively close to thickened fallopian tube (arrows).
Complication • Tubo-ovarian abscess (TOA) • Pelvic peritonitis • Fitz-Hugh-Curtis syndrome – Perihepatitis from ascending infection resulting right upper quadrant pain and tenderness and liver function test elevations – “violin-string” adhesions .
Tubo-ovarian abscess complicating colonic diverticulitis-the left ovary and tube have been transformed into a multicystic mass with a yellow lining (AFIP) .
eradication of current infection and minimization the risk of long-term complication. • Removal of the uterus and fallopian tubes and perhaps the ovaries as well . cefoxitin. azithromycin or ampicillin • Laparotomy – if signs and symptoms persist • Clindamycin and gentamicin treatment of choice during pregnancy because tetracyclines and fluoroquinolones are avoided in pregnancy. • Laparoscopy • Remove any IUD • Broad spectrum cephalosporin antibiotics – due to polymicrobial nature – Doxycycline.Management • Objective: relief of acute symptoms.
or patients using immunosuppressive medications) – Failure to improve clinically after 72 hours of outpatient therapy . patients with HIV infection who have a low CD4 count.Admission criteria • Most patients with PID are managed as outpatient but hospitalization should be considered for: – – – – – – – Uncertain diagnosis Pelvic abscess on ultrasonographic scanning Pregnancy Failure to respond to outpatient management Inability to tolerate outpatient oral antibiotic regimen Severe illness or nausea and vomiting precluding outpatient treatment Immunodeficiency (eg.
In patient • Broad spectrum cephalosporin IV (cefoxitin) + doxycycline IV Outpatient • Ceftriaxone IM or cefoxitin IM +oral deoxycline .
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