uninteded pregnancy/PID

Question 1

Elective abortion vs Therapeutic Abortion

Answer 1

Elective abortion
Interruption of pregnancy before viability at the request of the woman, but not for medical reasons
Also referred to as voluntary abortion

Therapeutic abortion
Termination of pregnancy before viability for medical indications
> 50% of all pregnancies in the United States are unintended
>
Unwanted, unplanned, or mis-timed pregnancies
Most do not end in elective abortion

As medical providers you should:
Aid in the prevention of an unintended pregnancy
Provide unbiased, medically accurate information regarding options for women with unintended pregnancy

Question 2

Risk Factors for Unprotected Intercourse

Answer 2

Difficulty obtaining contraceptives
Less than a college education
Woman aged 20-24 years
Black race
Lack of social support
Depressive symptoms
History of intimate partner violence

Question 3

Options for Unintended Pregnancy

Answer 3

Three options:
Give birth and raise the child
Give birth and place the baby for adoption
End the pregnancy with an induced abortion

Discussion of the 3 options:
Nonjudgmental manner
Impartial and medically accurate characterization of the options
Respect the rights and decision of the patient

Question 4

Conscientious Refusal

Answer 4

Can be exercised by the medical provider
Not compelled to perform an act that violates his/her good judgment or personally held moral principles
Has to be consistent with good moral practices

Medical provider has 2 options:
Provide information
Financial and other assistance available to both her and the child
Availability of licensed or regulated adoption agencies if the patient chooses not to keep the child
Availability of safe, legal abortion services if she chooses not to continue the pregnancy
Identify resources where such information can be obtained

Question 5

uninteded pregnancy

Raising the Child

Answer 5

Role of the medical provider:
Provide prenatal care
Provide resources for the mother and family during the pregnancy and with subsequent care of the infant

Local public health agencies
Medical resources
Financial resources
Social resources
Spiritual resources

Question 6

unintended pregnancy

adoption

Answer 6

Voluntary placement of children is rare in the United States < 1%
Occurs through licensed private or state-run adoption agencies
Laws vary by states and can be complex

Who is likely to choose adoption?
White women
Unmarried
Women who expect little assistance with child care
Higher education levels
High career or educational aspirations

Question 7

Current elective abortion Laws

Answer 7

41 STATES HAVE ABORTION BANS IN EFFECT WITH LIMITED EXCEPTIONS

Most include exceptions to preserve a pregnant person’s life or health
14states have a total abortion ban
27states have abortion bans based on gestational duration
7states ban abortion at or before 18 weeks’ gestation
20states ban abortion at some point after 18 weeks

9 STATES AND THE DISTRICT OF COLUMBIA DO NOT RESTRICT ABORTION BASED ON GESTATIONAL DURATION

Question 8

1st trimester Medically Induced Abortion

Answer 8

1st trimester medical abortion
Preferred method in the 1st trimester
U.S. FDA approved regimen
Mifepristone (antiprogesterone) 600 mg PO followed by misoprostrol (prostaglandin E1 analog) 400 mcg PO
Infection after medical abortion is rare and prophylactic antibiotics are not indicated
Rh status of the mother must be known and RhoGAM administered if indicated

Question 9

Medically Induced Abortion

Answer 9

2nd trimester medical abortion
Multiple regimens
Patients usually require admission to the hospital
Duration of the abortion is variable and blood loss may be more significant
Account for all fetal parts
Infection after medical abortion is rare and prophylactic antibiotics are not indicated
Rh status of the mother must be known and RhoGAM administered if indicated

Question 10

Surgically Induced Abortion

Answer 10

1st trimester surgical methods
Vacuum aspiration
Dilation & Curettage
Require dilation of the cervix prior to the procedure
Perioperative antibiotics given to prevent upper genital tract infection
Equally effective
Similar complication rates

2nd trimester surgical methods
Same methods used as in the 1st trimester
Account for all fetal parts
Perioperative antibiotics given to prevent upper genital tract infections

Question 11

unintended pregnancy

Consequences

Answer 11

Recognize that elective abortion can have lasting consequences:
Physical Complications
Hemorrhaging, infection, cervical laceration, perforation of the uterus, uterine rupture, endotoxic shock, death
May require hysterectomy
Psychological Problems
Depression and despair are common after abortion
Women who abort have asix times higher rate of suicidethan those who carry their babies to term
Future Risks
Women who abort are more likely to experiencefuture ectopic pregnancy, infertility, stillbirth, miscarriage, and premature birth

Question 12

Pelvic Inflammatory Disease

general

Answer 12

Acute upper genital tract infection in women that affects theuterus, fallopian tube,ovaries, and possibly the adjacent pelvic organs
Often ascends from lower genital tract infection

Epidemiology
>1 million cases per year in the United States (CDC)
More common in women < 35 years old
Most cases occur in 15-25 year old females

Risk factors:
Unprotected sexual intercourse
Multiple sexual partners
History of STIs
Presence ofbacterial vaginosis

Question 13

PID

Etiology

Answer 13

STIs (85%):
Chlamydia trachomatis
Most common bacterialSTI
Neisseria gonorrhoeae
Mycoplasma genitalium
Trichomonas vaginalis

Other isolatedbacteria:
Gardnerella vaginalis
Cytomegalovirus
Streptococcusagalactiae
Enteric gram-negative bacilli
Ureaplasmaspecies
Instrumentation or trauma-related pelvic infection

Question 14

PID

patho of normal pelvic protection

Answer 14

Endocervical canal serves as a barrier between the sterile upper genital tract and the vaginal canal, which contains differentbacteria
Normal vaginal flora is predominantlyLactobacillus species mixed with a low amount of potentially harmfulbacteria

Question 15

PID

Patho of pelvic infection

Answer 15

Infection fromSTIor vaginal microorganisms (may be asymptomatic) → disruption of mucosal barrier → spread of infection to upper genital tract (usually symptomatic) → spread of infection to peritoneal cavity → inflammatory damage resulting in scarring, adhesions, and partial or total obstruction of the Fallopian tubes

Question 16

Infection Sites

Answer 16

Uterus/endometrium:endometritis
Fallopian tube: salpingitis
Ovaries:oophoritis
Surrounding area/peritoneum:peritonitis

Increased risk of PID from lower genital tractbacteriaoccurs:
Duringmenses
With an intrauterine device (IUD)

Question 17

PID

Clin Man

acute / chronic/ subclinical

Answer 17

Acute PID (duration ≤ 30 days):
Fever
Nausea and/orvomiting
Lower abdominal/pelvicpain
Purulent vaginal discharge
Abnormal uterine bleeding
Dyspareunia -painful sex
Dysuria

Chronic PID (duration > 30 days):
Milder symptoms than acute presentation
Higher association with complications

Subclinical PID:
Signs and symptoms can be absent or mild (Chlamydia trachomatis or Mycoplasma genitalium)
Somepatientspresent with infertility
Adhesions
Distal fallopian tube occlusion

Question 18

PID

PE Findings

Answer 18

Physical exam
Mucopurulent cervical discharge
Cervical friability
Cervical motion tenderness → Chandelier sign
Unpleasant sensation or response elicited on pelvic examination with movement of the cervix by the medical provider
Guarding or rebound tenderness
Uterine and/or adnexal tenderness
Adnexalmass

Question 19

PID

Dx and Labs

Answer 19

Primarily clinical
PID should be considered in any sexually active young woman with pelvic or low abdominal pain and evidence of genital tract tenderness on exam

Laboratory tests:
Pregnancy test (to rule out ectopic pregnancy)
CBC shows leukocytosis in 50% ofpatients
Presence of > 10 WBCs per high-powerfield on wet prep of vaginal discharge
PCRdetection ofN. gonorrhoeae and C. trachomatis
Consider testing for other STIs – HIV and syphilis (Treponema pallidum)
Lactic acid (lactate) and blood cultures x 2 for patients with symptoms of sepsis

Question 20

PID

imaging

Answer 20

Imaging:
Transvaginal ultrasound
Obtained if clinical and laboratory findings are inconclusive or complications suspected
May show thickenedfallopian tube, free pelvic fluid, or indistinct endometrial borders
In cases of tubo-ovarianabscess: complex adnexal collection with multiple fluid levels

Question 21

PID

indications for hospitalization

Answer 21

Most patients will be managed on an outpatient bases

Indications for hospitalization:
Pregnancy
Severe clinical illness: high fever, nausea and vomiting
PID with pelvic abscess
Failed outpatient treatment
If appendicitis or alternative Dx cannot be ruled out

Question 22

PID

Recomended IM/oral Tx

Answer 22

Recommended Intramuscular or Oral Regimen for Pelvic Inflammatory Disease

IM or oral therapy can be considered for women with mild-to-moderate acute PID
Ceftriaxone500 mg IM (1 g for patient >150 kg) in a single dose PLUS
Doxycycline100 mg orally 2 times/day PLUS
Metronidazole500 mg orally 2 times/day
OR
Cefoxitin2 g IM in a single dose andProbenecid1 g orally administered concurrently in a single dose PLUS
Doxycycline100 mg orally 2 times/day for 14 days PLUS
Metronidazole500 mg orally 2 times/day for 14 days
OR
Other parenteral 3rd generationcephalosporin(ceftizoxime or cefotaxime) PLUS
Doxycycline100 mg orally 2 times/day for 14 days PLUS
Metronidazole500 mg orally 2 times/day for 14 days

Question 23

PID

Recommended Parenteral Tx

Answer 23

Empiric antibiotic therapy aimed to cover aerobic and anaerobic infection
Recommended Parenteral Regimen for Pelvic Inflammatory Disease
Ceftriaxone1 g IV every 24 hours PLUS
Doxycycline100 mg orally or IV every 12 hours PLUS
Metronidazole500 mg orally or IV every 12 hours
OR
Cefotetan 2 g IV every 12 hours PLUS
Doxycycline100 mg orally or IV every 12 hours
OR
Cefoxitin 2 g IV every 6 hours PLUS
Doxycycline100 mg orally or IV every 12 hours

Doxycycline should be administered orally when possible due to pain associated with IV infusion

After clinical improvement with parenteral therapy, transition to oral therapy to complete 14 days of therapy:
Doxycycline 100 mg 2 times/day PLUS
Metronidazole 500 mg 2 times/day

Question 24

PID

Treatment of Sex Partners

Answer 24

Sexual contact with a partner with PID during the 60 days preceding symptom onset should be evaluated, tested, and presumptively treated for chlamydia and gonorrhea, regardless of the PID etiology or pathogens isolated

Abstain from sexual intercourse until the patient and their sex partners have been treated and symptoms have fully resolved

All patients treated for PID should have a follow-up visit in approximately 3 months for repeat STI testing

Question 25

PID

complications

Answer 25

Chronic pain
Tubo-ovarianabscess:
Presents as an adnexalmass
Ectopicpregnancy (70,000 cases – CDC)
Hydrosalpinx
End portion of the fallopian tube becomes fluid-filled and swollen
Infertility (100,000 women – CDC)
Fitz-Hugh-Curtis syndrome (peri-hepatitis orinflammationof thelivercapsuleand peritoneal surfaces)