1. Pelvic Inflammatory Disease

2. Does LEEP increase the risk of PTB before 37 weeks? Compared women with history of LEEP to Compared women with history of LEEP to 1. Women with no history of CIN or LEEP 2. Women with history of CIN but no LEEP History of LEEP verses Group 1 History of LEEP verses Group 1 RR 1.61 RR 1.61 History of LEEP verses Group 2 History of LEEP verses Group 2 RR 1.08 RR 1.08 Risks factors leading to CIN probably more important than the LEEP Risks factors leading to CIN probably more important than the LEEP

3. Pathophysiology Starts as cervicitis caused by GC, chlamydia, or mycoplasm Starts as cervicitis caused by GC, chlamydia, or mycoplasm In the presence of bacterial vaginosis, there is a breakdown of mucous and other natural barriers allowing an ascending infection In the presence of bacterial vaginosis, there is a breakdown of mucous and other natural barriers allowing an ascending infection Normal vaginal flora is the source of a polymicrobial infection. Normal vaginal flora is the source of a polymicrobial infection.

5. TOA

6. Causative Agents N. gonorrhea N. gonorrhea ▪ 20% of women with this cervicitis will develop acute PID ▪ Intense inflammatory reactions in the tubal mucosa ▪ Intense inflammatory reactions in the tubal mucosa

7. Causative Agents Chlamydia Chlamydia ▪ More prevalent than Neisseria ▪ More prevalent than Neisseria ▪ Clinically produces a mild for of salpingitis with an insidious onset ▪ Clinically produces a mild for of salpingitis with an insidious onset ▪ 30% of women with this cervicitis develop PID ▪ 30% of women with this cervicitis develop PID

8. Microorganisms Isolated from the Fallopian Tubes with Acute PID Type of Agent Type of Agent STD STD Endogenous agent aerobic or facultative Endogenous agent aerobic or facultative Anaerobic Anaerobic Organism Chlamydia trachomatis Neisseria gonorrhea Mycoplasma hominis Streptococcus sp. Staphylococcus sp. Haemophilus sp. Escherichia coli Bacteroides, Peptococcus, Clostridium, Actinomyces Weström L: Sex Transm Dis 11:439, 1984

9. Symptoms Abdominal pain Abdominal pain Abnormal discharge Abnormal discharge Postcoital spotting Postcoital spotting Fever Fever Low back pain Low back pain Nausea/vomiting Nausea/vomiting

10. How to approach the diagnosis? Does she have cervicitis? Does she have cervicitis? Is the cervix inflamed, tender, and/or friable? Is the cervix inflamed, tender, and/or friable? Is the there leukocytes in the wet mount? Is the there leukocytes in the wet mount?

11. Mucopurulent cervicitis Mucopurulent cervicitis caused by C. trachomatis (Holmes, 1999; reprinted with permission from McGraw Hill.)

13. Physical Findings Pelvic tenderness Pelvic tenderness Cervical, uterine, or adenexal Cervical, uterine, or adenexal Less than 1/3 have fever Less than 1/3 have fever WBC commonly normal WBC commonly normal Sed rate is generally elevated Sed rate is generally elevated

14. CDC recommends treating sexually active women 25 or less years old at risk for STD if they are having pelvic or low abdominal pain AND 1) cervical, uterine, or adenexal tenderness; 2) no other causes of pain

15. Presumptive Diagnosis of Cervicitis

16. Gonococcal Cervicitis Recommended Recommended Ceftriaxone 250 mg IM plus Azithromycin 1 gm po or doxycycline 100 mg po BID x 7days Ceftriaxone 250 mg IM plus Azithromycin 1 gm po or doxycycline 100 mg po BID x 7days Alternative regimen Alternative regimen Cefixime 400 mg po plus Azithromycin 1 gm po or doxycycline 100 mg po BID x 7days Cefixime 400 mg po plus Azithromycin 1 gm po or doxycycline 100 mg po BID x 7days If penicillin allergy If penicillin allergy Azithromycin 2 gm po Azithromycin 2 gm po

17. Cervicitis Treatment Azithromycin 1 gm po x 1 OR Doxycline 100 mg bid x 7d PLUS Ceftriaxone 125 mg IM OR Cefixime 400 mg po PLUS Treat for BV if present

18. Outpatient PID

19. Indications to hospitalize… Pregnancy Pregnancy Adolescents with unpredictable compliance Adolescents with unpredictable compliance Immunodeficient ( HIV with low CD4 counts) Immunodeficient ( HIV with low CD4 counts) Uncertain diagnosis Uncertain diagnosis Nausea and vomiting, high fever Nausea and vomiting, high fever Inadequate response to outpatient therapy Inadequate response to outpatient therapy TOA TOA CDC.Guidelines for Treatment of Sexually Transmitted Diseases 2002, MMWR 2002: 51: 1041

20. Inpatient PID

22. Post Hospitalization Doxycycline 100 mg orally twice a day for 14 days Doxycycline 100 mg orally twice a day for 14 days Clindamycin 450 mg orally four time s a day for 14 days Clindamycin 450 mg orally four time s a day for 14 days

23. Not sure what she has …

24. TOA Tubo-ovarian abscess (TOA) Tubo-ovarian abscess (TOA) collection of pus delimited by the adherence of the fallopian tubes, ovaries, and adjacent organs collection of pus delimited by the adherence of the fallopian tubes, ovaries, and adjacent organs serious manifestation of PID and generates 350,000 hospitalization/150,000 surgeries/yr serious manifestation of PID and generates 350,000 hospitalization/150,000 surgeries/yr 34% of PID cases hospitalized have TOA 34% of PID cases hospitalized have TOA TOA ruptured -mortality rate is as high as 9% TOA ruptured -mortality rate is as high as 9% 1-4% rupture at initial presentation or during conservative management 1-4% rupture at initial presentation or during conservative management Soper DE. Pelvic inflammatory disease. Infect Dis Clin North Am. 1994;8:821-840

25. Tuboovarian abscess Presenting symptoms and findings with TOA Presenting symptoms and findings with TOA Pelvic pain Pelvic pain Pelvic mass Pelvic mass Fever/chills Fever/chills Vaginal discharge Vaginal discharge Abnormal uterine bleeding Abnormal uterine bleeding Nausea/vomiting Nausea/vomiting Temp.>100°F Temp.>100°F WBC>10,000 WBC>10,000 Landers DV and Sweet RL: Rev Infect Dis 5:879, 1983 Pelvic inflammatory disease, proven chlamydial pyosalpinx. Right tube is swollen and tortuous (arrow) (Holmes, 1999; reprinted with permission from McGraw Hill.)

26. Diagnostic tests Ultrasound Ultrasound Complex cystic mass containing multiple septations and internal echoes Complex cystic mass containing multiple septations and internal echoes correctly identified TOA in 94% of pt. confirmed by surgery correctly identified TOA in 94% of pt. confirmed by surgery Bulas DI. Radiology. 1992;183:435 Bulas DI. Radiology. 1992;183:435

27. Criteria for treatment success: Clinical improvement may take 72 hours Clinical improvement may take 72 hours Resolution of abdominal pain, defervescence, decreased WBC, stabilization or decrease in mass size. Resolution of abdominal pain, defervescence, decreased WBC, stabilization or decrease in mass size. clinically deterioration or development of an acute abdomen should prompt surgical intervention clinically deterioration or development of an acute abdomen should prompt surgical intervention

28. Post Hospitalization for TO Clindamycin 450 mg orally four times a day for 14 days Clindamycin 450 mg orally four times a day for 14 days

29. Surgery TAH/BSO TAH/BSO Laparoscopy with endoscopic drainage, irrigation, lysis of adhesions Laparoscopy with endoscopic drainage, irrigation, lysis of adhesions Ultrasound guided percutaneous drainage Ultrasound guided percutaneous drainage

30. Sequelae Chronic pelvic pain Chronic pelvic pain Ectopic pregnancy Ectopic pregnancy Infertility Infertility