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Flashcards in PID Deck (49)
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1
Q

What is PID?

A

Pelvic inflammatory disease- acute and subclinical infection of the upper genital tract in women. It comprises a spectrum of inflammatory diseases involving any combo of the uterus, fallopian tubes, ovaries. Often accompanied by involvement of neighboring pelvic organs

2
Q

what does PID result in?

A

Results in endometritis, salpingitis, oophoritis, pelvic peritonitis, perihepatitis, and/or tubo- ovarian abcess (TOA)

3
Q

Acute PID hard to diagnose because of the wide variation in s/s, which are?

A
unilateral or bilateral lower abdominal or pelvic pain
fever
vomiting
abnormal vaginal discharge
irregular vaginal bleeding
pain with intercourse
4
Q

*many episodes of PID go undiagnosed and untreated because ??

A

the patient and/or practitioner fails to recognize the implications of mild or nonspecific signs and symptoms

5
Q

Silent PID

A

term that can be applied to women with very minimal or no symptoms, represents a large portion of all PID cases

6
Q

what is happening in subclinical PID

A

mild inflammation is occurring within the reproductive tract at a very low level, yet damage to the fallopian tubes or surrounding structures is occurring

7
Q

important for clinicians to recognize the implication of mild/ non specific findings, especially

A

in young female patients who might give an incomplete or inaccurate sexual history

8
Q

how can PID occur (less likely)

A

can be blood- borne, ie. TB or result from an intra- abdominal process or gyn procedures that disrupt the protective cervical barrier

9
Q

how does PID usually occur

A

most often develops when bacteria ascend from the vagina or cervix into the endometrium, fallopian tubes, and pelvic peritoneum. majority (85%) of cases caused by sexually transmitted pathogen or bacterial vaginosis- associated pathogens

10
Q

risk factors for PID

A
a previous h/o of PID
higher numbers of lifetime sex partners
douching
h/o bacterial STD
age younger than 25
having a partner with an STI
11
Q

gyn procedures that disrupt the protective cervical barrier

A
pregnancy termination
IUD insertion
dilation and curettage
hysterosalpingography
- all elevate the risk of PID and may lead to PID in the absence of the classic sexually transmitted pathogen
12
Q

time course of presentation of PID

A

typically acute over several days but can be weeks to months

13
Q

clinical diagnosis remains..

A

the most important practical approach

14
Q

15% of cases of PID are NOT sexually transmitted and instead are associated with..

A

enteric pathogens (E.coli, bacteroides fragilis, group B strep, and campylobacter spp) or respiratory pathogens (h. influenzae, strep pneumoniae, group A strep, and staph aureus) that have colonized in the lower GI tract

15
Q

what other things can produce a similar clinical picture

A

post- op pelvic cellulitis and abscess, pregnancy- related pelvic infection, injury or trauma- related pelvic infection, and pelvic infection secondary to spread of another infection

16
Q

who is at risk?

A

any sexually active female is at risk for STI associated PID

-those w/ multiple partners at higher risk

17
Q

PID during pregnancy rare because

A

the mucus plug and decidua seal off the uterus from ascending bacteria.

18
Q

PID rare during pregnancy but possible

A
  • can occur within first 12 weeks of gestation before the mucus plug seals off the uterus
19
Q

our level of suspicion should always be high, especially

A

in adolescents

20
Q

what is the goal of the initial evaluation of women with suspected PID?

A

to establish a presumptive diagnosis of PID

  • assess for additional findings that increase the liklihood of that diagnosis
  • evaluate for other potential causes of pelvic pain
21
Q

issues pertaining to high- risk sexual behavior and acquisition of STI are common to both adolescents and adults but

A

are intensified among adolescents because of both behavioral and biological predispositions

22
Q

behavioral factors that put adolescents and young women at high risk for STI’s and PID are

A

inconsistent use of barrier protection
douching
greater number of current/ lifetime sexual partners
use of ETOH and other substances that may impair judgement while engaging in sexual activity

23
Q

what to use to reduce risk of PID

A

latex condoms

24
Q

use of oral contraceptives

A

may also reduce risk of PID (associated with a decrease in the severity of inflammation)

25
Q

what will your PID pt possible look like? exam findings vary but may include:

A

oral temp >101F
lower abdominal tenderness w/ or w/o peritoneal signs
cervical or vaginal discharge
tenderness with lateral motion of the cervix
uterine tenderness
unilateral or bilateral adnexal tenderness and adnexal fullness
pyuria- abundant WBCs on saline microscopy of vaginal fluid
elevated c- reactive protein
and/ or adnexla mass demonstrated by abdominal or transvaginal US

26
Q

where does PID come from/ most common pathogens

A

studies from europe and US from the 80’s found its caused by C trachomatis and N. gonorrhoeae or both about 50% of cases

27
Q

M. genitalium has been associated with

A

endometritis and PID

28
Q

Actinomyces israelli is a cause of

A

PID in women with IUDs

29
Q

most common pathogens of PID

A

neisseria gonorrhoeae and chlamydia trachomatis

30
Q

other organisms from upper genital tract that can cause PID

A

anaerobes such as bacteroides species and peptostreptococcus species
facultative anaerobes such as gardnerella vaginalis, haemophilus influenzae, strep species, actinomyces
enteric gram negative bacilli and
cytomegalovirus

31
Q

genital mycoplasms also associated with PID including

A

mycoplasma genitalium, mycoplasma hominis, and ureaplasma urealyticum

32
Q

etiology of PID

A

polymicrobial common, but in more than half the cases, no organism is identified in the specimen

33
Q

complications of PID

A

perihepatitis (fitz- hugh- curtis syndrome) and tubo- ovarian abscess/ complex formation

34
Q

long term sequelae

A

tubal scarring that can cause
- infertility in 20% of females
- ectopic pregnancy in 9%
chronic pelvic pain in 18%

35
Q

factors that may increase the likelihood of infertility

A

delay in diagnosis or initiation of antimicrobial therapy
younger age at time of infection
chlamydial infection
PID determined to be severe by laparoscopic exam

36
Q

*perihepatitis aka fitz- hugh- curtis syndrome

A

occurs in setting of PID when there is inflammation of the liver capsule and peritoneal surfaces of the anterior right upper quadrant

  • there is generally minimal stromal hepatic involvement
  • was first associated with gonococcal salpingitis in 1920 and subsequently C trachomatis
37
Q

perihepatitis aka fitz- hugh- curtis syndrome cont

A

occurs in approximately 10% of women with acute PID and is chracterized by RUQ abdominal pain with a distinct pleuritic component, sometimes referred to as the right shoulder

  • marked tenderness at RUQ on exam
  • the severity of pain in this location may mask PID and lead to concerns of cholecystitis
  • aminotransferase are usually normal or only slightly high
  • on laparoscopy or visual inspection, it manifests as “violin string”- patchy purulent and fibrinous exudate, most commonly affecting the anterior surfaces of the liver (not the liver parenchyma)
38
Q

ABX of choice for coverage of c. trachomatis

A

1st choice doxycycline. azithromycin has shown activity against this pathogen too

39
Q

has moderate in vitro activity against n. gonorrhoeae and c. trachomatis

A

the combo clindamycin and gentamicin

40
Q

have excellent in vitro activity against n. gonorrhoeae and c. trachomatis

A

second generation cephalosporin (cefoxitin, cefotetan) plus doxy

41
Q

what do you NOT give to treat gonorrhea or associated conditions

A

fluoroquinolones bc of increased resistance

42
Q

if you suspect PID

A

you should treat- even if you are not sure

43
Q

CDC recommends initiating treatment of PID in who?

A

all sexually active young women with adenexal tenderness or cervical motion tenderness (these criteria are sensitive but not specific)

44
Q

treatment against PID directed at what?

A

c. trachomatis, n. gonorrhoeae, gram negative facultative anaerobes, vaginal anaerobes, and stretococci

45
Q

2 most important sexually transmitted organisms associated with acute PID

A

c. trachomatis, n. gonorrhoeae- these should be the target of tx. However negative endocervical screeening for either of these pathogens does not rule out upper tract infection

46
Q

diagnosis of PID difficult to make because

A

studies have been unable to identify any single clinical finding or constellation of findings that allow accurate identification of women with PID

47
Q

most cases of PID

A

probably go undiagnosed

48
Q

when PID diagnosis is made clinically

A

might not be supported by laparoscopic evidence/ surgical findings

49
Q

treatment guidelines from CDC 2015

A

make chart on paper!