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Pelvic Inflammatory Disease Evaluation and Management INFECTION PRACTICE POINTS PELVIC INFLAMMATORY DISEASE EVALUation AND MANAGEMENT Dear FOGSIANs, The theme of FOGSI this year is “We for Stree”. I would like to thank every FOGSIAN who has helped making every woman Safer, Stronger and Smarter. Through various academic and social programs FOGSI aims to uplift the quality of care that is given to every woman who comes to us. TOG IPP (Infection Practice Points) is one such conclave that brings to light some of challenging health issues like Vaginitis, Pelvic inflammatory disease (PID) and Urogenital infections. I would like to thank Zuventus for their contributions towards the TOG IPP Conclave. We, as clinical practitioners are always busy, therefore the TOG IPP that is released has been a quick and easy way to update you with the latest evidence in the field of Infections. This year we ask all FOGSIANs to focus on the Stree and help make them safer, smarter and stronger. Select FOGSIANs across India came together to deliberate and create these practice points. I am sure that you will appreciate the efforts which has gone into preparing the Infection Practice Points and find them useful in your day to day practice. Best wishes! Dr. Nandita Palshetkar MD, FCPS, FICOG President 2019 - Federation of Obstetrics & Gynecological Societies of India (FOGSI) 1 PELVIC INFLAMMATORY DISEASE EVALUation AND MANAGEMENT FOGSI President : Dr. Nandita Palshetkar Moderators : Dr. Rishma Dhillon Pai, Dr. Pratik Tambe Panelists : Dr. Nozer Sheriar, Dr. Dibyendu Banerjee, Dr. Shyamal Sett, Dr. Madhuri Patel, Dr. Anshu Jindal, Dr. Seema Mehta, Dr. Adarsh Bhargava, Dr. Rakhi Singh, Dr. Pragya Mishra, Dr. Arun Nayak, Dr. Parzan Mistry, Dr. Bipin Pandit, Dr. Nita Mishra Clinical Reporter : Dr. Ritu Hinduja From left to right: Dr. Nita Mishra, Dr. Pratik Tambe, Dr. Rakhi Singh, Dr. Parzan Mistry, Dr. Rishma Dhillon Pai, Dr. Nandita Palshetkar, Dr. Anshu Jindal, Dr. Shyamal Sett, Dr. Pragya Mishra, Dr. Madhuri Patel, Dr. Ritu Joshi This is an independent publication owned by Science Integra®. The advice, opinion, statements, materials and other information expressed and contained in this book are solely those of the experts in the relevant field. The contents including text, graphics and images of the book are meant for educational and informational purposes only. Although great care has been taken in compiling and checking the information, neither Zuventus © 2020 or Science Integra shall be responsible/ liable in any way for the present and/or continued accuracy of the information or for any errors, omissions or inaccuracies in this publications whether arising from negligence or otherwise howsoever, or for any consequences arising therefrom. Opinions expressed do not necessarily reflect the views of Zuventus. The information in this book is meant only to supplement and not to replace the practice guidelines set by International, National Associations and Government bodies. The author/s, Doctors, sponsor and publisher advise readers to take full responsibility before practicing any of the suggested guidelines described in this book, be sure not to take risks beyond your level of experience, aptitude, training, and comfort level. These of course are only opinions of our experts and not recommendations or guidelines and are only meant to give the readers a systematic flow 2 chart to follow, using your own expertise to make final judgements. Any unauthorized reproduction or distribution of this publication is illegal. PelvIC Inflammatory DIsease Evaluation and Management Definition • C. trachomatis is the commonest identified cause accounting for 14%–35% of cases, Pelvic inflammatory disease (PID) refers to acute whilst Gardnerella vaginalis, anaerobes and infection of the upper genital tract structures other organisms commonly found in the in women, involving any or all of the uterus, vagina may also be implicated fallopian tubes and ovaries and may involve the neighboring pelvic organs.1 • Mycoplasma genitalium has been associated with upper genital tract infections in women Mild-to-moderate PID is defined as the absence and is a very likely cause of PID of a tubo-ovarian abscess. Severe disease is • Genital tuberculosis is one of the causes of defined as severe systemic symptoms or the PID in India5 presence of tubo-ovarian abscess.2 Introduction • The insertion of an intrauterine device (IUD) increases the risk of developing PID • Pelvic infection is one of the most common, but only for 4–6 weeks after insertion. This serious infections in non-pregnant women risk is probably highest in women with pre- or reproductive age3 existing gonorrhoea or C. trachomatis3 • Pelvic infection are usually the result of infection ascending from the endocervix Causes causing endometritis, salpingitis, • Neisseria gonorrhea and Chlamydia parametritis, oophoritis, tubo-ovarian trachomatis are identified as the causative abscess and/or pelvic peritonitis3 agents of PID • PID is reported to occur in 1% of the 15- • Gardnerella vaginalis, anaerobes and 25 year age group of young adults around the world and affects around 24%–32% of other organisms commonly found in the women in India4 vagina may also be implicated • In developed countries, the annual incidence • Mycoplasma genitalium has been is estimated to be 10–13 per 1000 women, associated with upper genital tract with 20 per 1000 women being in the age infections in women and is a very likely group of 20–24 years4 cause of PID 3 Cause of PID • Insertion of an IUD increases the risk and • Neisseria gonorrhea and Chlamydia is highest in women with pre-existing trachomatis (C. trachomatis) have been gonorrhoea or C. trachomatis identified as the causative agents 3 4,6,8,9 risk factors figure 1. Flow diagram of causes of primary and secondary pelvic inflammatory disease7 • Instrumentation of the uterus / interruption of the cervical barrier Pelvic inflamatory disease » Termination of pregnancy, insertion of IUD within the past 4 months, hysterosalpingography, In vitro Primary Secondary fertilization, intrauterine insemination Typical (IUI), hysteroscopy infections • C. trachomatic Genito- Colonic IUD • N. gonorrhoea urinary • Young < 25 years • Menstruating women Diverticulitis Atypical Appendicitis infection Actino- • Multiple sexual partners Crohn’s eg- TB mycosis disease Infected Salmonella Colorectal endomet- Preforation • Recent new partners Carcinoma rioma • Past history of sexually transmitted TB: tuberculosis; IUD: intrauterine device. infections (STIs) in the patient or their • Infection of the fallopian tubes initially partner affects the mucosa, but inflammation • No h/o of contraception use may rapidly become transmural. This • Living in an area of high prevalence of PID inflammation, which appears to be mediated by complement, may increase in intensity • Tampons use (forgotten) with subsequent infections • Poor menstrual hygiene • Inflammation may extend to uninfected • Bacterial vaginosis parametrial structures, including the • However, in Indian scenarios the common- bowel est causes are abortions, puerperal sepsis • Infection may extend via spillage of and IUD insertions purulent materials from the fallopian tubes Pathogenesis of PID4,6,8,9 or via lymphatic spread beyond the pelvis to produce acute peritonitis and acute • Ascending perihepatitis (Fitz-Hugh−Curtis syndrome) • Hematogenous Other factors responsible for influencing • Local spread occurrence of PID are: Most cases of PID occur in 2 stages. • Cervical mucus provides a functional 1. Acquisition of a vaginal or cervical infection, barrier against upward spread, but vaginal which is often sexually transmitted and may inflammation and hormonal changes that be asymptomatic occur during ovulation and menstruation decrease the efficacy of this barrier 2. Direct ascent of microorganisms from the vagina or cervix to the upper genital tract, • Antibiotic treatment of sexually transmitted with infection and inflammation of these infections can also disrupt the balance of structures endogenous flora in the lower genital tract, 4 causing normally nonpathogenic organisms • Fever (>38°C) in moderate to severe to overgrow and ascend disease • Opening of the cervix during menstruation, A recent study conducted in Indian women along with retrograde menstrual flow, may with PID demonstrated signs and symptoms as also facilitate ascent of microorganisms shown in Figure 2 below.10 • Intercourse may contribute to the ascent figure 2. Signs and symptoms in studied cases of infection through rhythmic uterine contractions occurring during orgasm. 68 70 58 Bacteria may also be carried along with 60 52 50 48 38 sperm into the uterus and fallopian tubes 40 30 3,9 22 20 12 Clinical features % of patients 10 PID should be considered in a patient with the 0 clinical signs and/or symptoms as below. Malaise Infertility 3 Dyspareunia symptoms Low backache Low grade fever Vaginal discharge PID may be symptomatic or asymptomatic. The Lower abdominal pain following features are suggestive of a diagnosis of PID: Centre for Disease Control and 11 • Lower abdominal pain which is typically Prevention (CDC) Criteria for PID bilateral (but can be unilateral) Table 1. PID diagnostic criteria per 2015 CDC guidelines Minimal • Cervical motion tenderness • Abnormal vaginal or cervical discharge clinical • Uterine tenderness which is often purulent criteriaa • Adnexal tenderness • Deep dyspareunia particularly of recent • Oral temperature greater than 101°F (38.3°C) • Abnormal cervical mucopurulent discharge onset or cervical friability •
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