PID Flashcards
list the causes of PID
STI- chlamydia, gonorrhoea, Mgen
BV organsims - anaerobic bacili, anaerobic cocci
anaerobes and organisms that make up the vaginal flora - gardnerella,
what are the symptoms associated with pid/
lower pelvic pain, recent onset and often bilateral change to vaginal discharge fever abnormal bleeding - IMB/PCB, deep dyspareunia
What are the signs of PID on clinical examination
lower pelvic tenderness - usually bilaterally adnexal tenderness CME fever purulent discharge
IUD insertion can cause PID?
true or false
False - IUD/IUS insertion increases the risk of developing PID in the next 4-6 weeks (risk is highest in women with pre-existing CT/GC/Mgen at the time of insertion)
Lydia presents to your GUM clinic with acute onset bilateral lower abdominal pain associated with a change in her vaginal discharge. You suspect PID. What investigations would you carry out assuming you are working in a level 3 GUM service?
- observations - check HR and temp especially
- STI screen - HIV and STS bloods + CT/GC vaginal swab
- examination - palpate abdomen, bimanual examination to elicit any adnexal tenderness or CME,
- microscopy : wet and dry microscopy and cervical microscopy + GC culture plate
+/- Mgen if evidence of PID on examination - UPT
Lydia has >20 WBC on cervical and vaginal microscopy, no evidence of GC, UPT negative,
she had bilateral lower abdominal tenderness with CME. Observations were stable.
She is not allergic to anything and has the implant in situ.
How would you treat her?
Rx for PID
stat dose IM 1gram ceftriaxone, 100mg BD doxycycline and 400mg BD metronidazole for 14 days
no sex until her and partner completed RX and symptoms are better
Lydia was treated for PID and her STI screen including Mgen has come back negative. What is the empirical Rx that her partner should be offered?
doxycycline 100mg BD for 7 days
What is the PPV of cervical microscopy demonstrating raised WBC in the diagnosis of PID?
PPV of 17% (i.e. if WBC are present this does not mean it is it PID, lots of other reasons why women may have WBC on cervical microscopy- lacks specificity )
what is the NPV of determining PID in a patient with no WBC on cervical microscopy
95% NPC - high sensitivity for ruling PID out if no WBC on microscopy
A GP rings to ask your advice. She has diagnosed PID in a 23 year old female who is known to have chlamydia. She is worried as the patient has a mirena coil in situ. She is unsure as to whether or not to remove it. Her observations are stable. The last UPSI was 2 days ago.
What would your advice be?
a) remove ASAP
b) watch and wait, review in 72 hours if symptoms improving then remove
c) watch and wait, review in 72 hours if symptoms not improving then remove.
d) watch and wait, review in 72 hours, if symptoms not improving then remove, and consider the need for EC
d - watch and wait, review in 72 hours, if symptoms not improving consider remove but this needs to be balanced against the risk of patient needing emergency contraception.
in a patient whom you suspect PID what would other differential diagnoses that you need to consider be?
ectopic pregnancy appendicitis IBS endometriosis ovarian accident/cyst functional pain
when should you consider admission for IV treatment of PID
Pregnancy
signs of sepsis - pyrexial, tachycardia +/- hypotensive
severe symptoms not improving with oral treatment
surgical cause needs exclusion
Emily has signs and symptoms of PID., You feel she can tolerate outpatient oral treatment but last time she took doxycycline for chlamydia it made her feel very nauseous and she was unable to complete the course.
what is the second line management option?
- ofloxacin 400mg BD + metronidazole 400mg BD for 14 days
You treated Emily for PID with ofloxacin 400mg BD and metronidazole 400mg BD, when you review her symptoms 5 days later they are no better or worse. On reviewing her results you notice her mycoplasma genitalium result has subsequently come back positive.
How would you treat her and what advice should be given for PN?
stop current antibiotic regime, switch to moxifloxacin 400mg OD for 14 days.
No sex until her and partner have been treated and symptoms improved.
advise current RMP to have testing for MGen and only if positive does he require treatment.
TOC for Mgen at 5 weeks (no sooner than 3 weeks)
Emily was treated for Mgen PID. She is worried about future complications especially the risk of infertility. This is the first time she has ever had an STI or been treated for PID.
What are the future complications and what is the risk of infertility?
reassure that the risk of complications usually result from undiagnosed and untreated cases of PID. with prompt treatment the risk of complications can be reduced
risk of infertility is 8% (with 1 epsiode of PID), 20% with 2 episodes and 40% with 3 episodes.
increased risks of ectopic pregnancy in the future and chronic pelvic pain.
Lucy is on Rx for PID. She is currently on day 4 of oral doxycycline and metronidazole having received a stat dose of ceftriaxone in the GUM clinic. She is admitted to hospital with severe RUQ and feeling generally unwell.
Admission bloods demonstrate deranged LFTs with raised CRP and WBC.
What is the name of the complication Emily is experiencing?
Fitz-Hugh Curtis : peri-hepatitis from lymphatic or peritoneal spread of GC/CT
what is the loopback period for PN in PID
6 months (but sexual history and symptoms may guide you otherwise)
Laura is 8 weeks pregnant with her first baby. She presents to early pregnancy assessment unit with LIF and the team performed a TV USS to rule out ectopic pregnancy and ovarian cyst. This was all negative but did demonstrate a left sided tubo-ovarain abscess. She has had pain in the life for some time but over the past few days it has become much worse and she noticed a change in her discharge.
what investigations should you perform now and how would you treat Laura?
offer STI screen including Mgen
admission as pregnant and cover for PID with discussion with obs and gynaecology team
- IV ceftriaxone 2g daily + Iv erythromycin + IV metronidazole (avoid doxycycline) 400mg BD; consider oral switch once clinically improving and apyrexial for 24 hours. Complete a total of 2 weeks
what is the most common organism to cause PID
chlamydia trachomatis (up to 35%)
where might a pelvic abscess develop if it has spread as a result of endometritis and endosalpingitis
rector-vaginal pouch
what type of immune response does chlamydia produce to cause PID
th 2 type immune response this damages tubal endothelium
what reaction does Neisseria gonorrhoea cause on the epithelium in PID
complement mediated necrosis of ciliated epithelium
out of the list below which organisms are anaerobic bacilli
A- gardnerella vaginalis
B - mycoplasma hominis
C- Prevotella
D - Bacteriodes spp
E - alpha haemolytica
F- non haemolytic streptococci
C - prevotella and bactericides spp (bacili)
Gardenerella vaginalisis is a
A - anaerobic bacilli
B- anaerobic cocci
B - anaerobic cocci
what enzyme is thought to weaken the cervical mucous barrier making it easier for anaerobic bacilli to ascend the genital tract
sialidase
how can mycobacterium tuberculosis spread to cause PID
when should you consider this a potential cause?
haematological spread - in high risk countries
can you list potential complications of PID
- fitz hugh curtis = perihepatitis
- tube-ovarian abscess and pelvic abscess (likely to be associated with anaerobic bacteria)
- Infertility = 8% with 1 episode, rate doubles with every episode of PID
- chronic pelvic pain
- increased risk of ectopic pregnancy ( 7 fold increase in the risk of ectopic pregnancy)
- peri-appendicitis - direct spread from the right fallopian tube
describe how fitz hugh curtis develops in PID
complication of PID due to peritoneal or lymphatic spread of PID of pelvic gonorrhoea or chlamydial infection.
Leads to inflammation go the hepatic capsule with ‘violin string’ adhesions between anterior surface of liver and abdominal wall.
quoted to occur 10-20% of PID
what is the gold standard investigation to diagnose PID
A )USS
B) ct.gc naat
C- microscopy
D - MRI
E - laparoscopy
laparoscopy (rarely performed)
if a patient has symptoms of PID and coil insitu what would you advice in terms of management of the coil?
keep coil in for now, review in 72 hours if no improvement then remove and consider need to cover with EC if they have had UPSI in preceding 7 days
if improving - keep coil in situ
