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CASE 12 Dr.
Trinidad
Vinluan. Joseph David
Villegas, Jose Bernabe
Wong, Deo Adiel
Yague, Glenn
Yang, Caprice
A 24 year old G4P1 (1030) complained of fever and moderate hypogastric pain
which has been increasing in severity since yesterday. LMP- August 17-20, 2007. PE:
BP-110/70 PR-94,full RR-19 T-38.9C. There was direct tenderness over the hypogastric
and both iliac areas without rebound tenderness. On speculum examination, the cervix
was congested, with moderate muco-purulent discharge from the os. On IE, the cervix
was long, firm, and closed, with minimal tenderness on motion. The uterus was normal
in size, movable retroflexed, and slightly tender. There was bilateral adnexal tenderness
but no masses were appreciated; fornices were deep.
Aside from the questions mentioned under the sexual history, the patient’s age of
first sexual intercourse, number of partners, and sexual practices. Women with multiple
sexual partners and those who engage in unusual sexual practices are prone to myriad
of sexually transmitted diseases. A recent sexual exposure to a male with symptoms of
urethritis or any STD should be asked. This should be done to identify and cure the
potentially infected partner and prevent recurrence of the infection. We should ask
about the her occupation, if it involves any sexual activities that could place her at risk
for STDs.
The patient should be asked about recent intrauterine procedures like use of
intrauterine device (IUD), dilatation and curettage, surgical abortion, cesarean section,
or hysterosalpingography. The presence of a recently fitted IUD ( <3 months) increases
the risk of developing PID by three- to five- fold ( Danakas GT, 1999), because insertion
facilitates the upward migration of cervical and vaginal bacteria. The onset of IUD-
associated PID typicall is gradual and may be preceded by a malodorous vaginal
diacharge. There is also an increased risk of ascending infection after D & C, surgical
abortion, hysterosalpingography, or cesarean section.
It is also pertinent to ask if the patient uses vaginal douching. In a study done by
Scholes et al in 1998, he found that women aged 18 to 34 years old who douched were
at increased risk for acquiring a cervical chlamydial infection. This risk was even greater
for those who douched four or more times per month. Vaginal douching alters the
vaginal pH and hence affecting the normal vaginal flora making the patient prone to
infection.
Any accompanying symptoms should also be asked such as, anorexia, nausea,
or vomiting, unilateral pain limited to the right lower quadrant suggests acute
appendicitis. Missed periods, morning sickness, unilateral pelvic pain is suggestive of
ectopic pregnancy. Unilateral pain with signs and symptoms of peritonitis suggests
ruptured ovarian cyst. Presence of dysuria and an abnormal urinalysis result suggest
urinary tract infection. Constant pain that begins a week before menses suggests
endometriosis. Severe unilateral pain and hematuria is suggestive of renal calculus.
Adnexal torsion and hemorrhaging corpus luteum both present with unilateral pain.
Proctocolitis presents with anorectal pain, tenesmus, rectal discharge or bleeding.
The patient complained of fever and moderate hypogastric pain with increasing
severity and on physical exam there was direct tenderness over the hypogastric and
both iliac areas without rebound tenderness; on internal exam, IE, the cervix was long,
firm, and closed, with minimal tenderness on motion. The patient may be suffering from
pelvic inflammatory disease (PID). It is an infection of the female upper genital tract that
encompasses a broad category of diseases, including endometritis, salpingitis,
salpingo-oophoritis, tubo-ovarian abscess (TOA), and pelvic peritonitis. Prompt
diagnosis and treatment of this condition are critical because the complications of PID
can be life and fertility threatening. Traditionally, the diagnosis of PID has been based
on a triad of symptoms and signs, including pelvic pain, cervical motion and adnexal
tenderness, and the presence of fever. It is now recognized that there is wide variation
in many symptoms and signs among women with this condition, which makes the
diagnosis of acute PID difficult.
PID most commonly occurs as a result of Chlamydia trachomatis or Neisseria
gonorrhoeae infection of the cervix or vagina that then spreads into the endometrium,
fallopian tubes, ovaries, and adjacent structures. Less commonly, direct spread from a
nearby infection such as appendicitis or diverticulitis may occur. Hematogenous
infection is a rare cause of PID except in cases of tuberculous PID.
At least 4 factors could contribute to the ascent of these bacteria and/or be
associated with the pathogenesis of upper-genital- tract infection. First, uterine
instrumentation (e.g., the insertion of an intrauterine device facilitates upward spread of
vaginal and cervical bacteria. Second, the hormonal changes during menses, as well as
menstruation, leads to cervical alterations that may result in loss of a mechanical barrier
preventing ascent. Also, the bacteriostatic effect of cervical mucus is lowest at the onset
of menses. Third, retrograde menstruation may favor ascent to the tubes and
peritoneum. Finally, individual organisms may have potential virulence factors
associated with the pathogenesis of acute chlamydial and gonococcal PID.
Platt et al.found evidence of adnexal involvement in about half of women who
had recently been infected with N. gonorrhoeae. Similarly, Stamm et al. noted evidence
of upper genital tract infection in 6 of 20 women (30 percent) infected with both
gonococci and chlamydiae who were treated with antibiotics active only against N.
gonorrhoeae.
Risk factors include young age, multiple sexual partners, and certain methods of
contraception. Sexually experienced teenagers are three times more likely to have
pelvic inflammatory disease than sexually experienced women who are 25 to 29 years
of age. Women with multiple sexual partners are at increased risk of acquiring causative
organisms such as N. gonorrhoeae and C. trachomatis. Barrier methods of
contraception (condoms and diaphragms) and oral contraceptive agents, protect against
upper genital tract infection. Most studies have implicated intrauterine devices as a
predisposing factor, especially for nongonococcal, nonchlamydial pelvic inflammatory
disease. Most of the increased risk occurs during the first few months after the insertion
of the device. Recent studies have suggested that vaginal douching may be a
predisposing factor. Cigarette smoking has also been implicated and may be an
indication of risk-taking behavior.
Lower abdominal pain, usually bilateral, is the most common presenting
symptom. Pain may be associated with an abnormal vaginal discharge, abnormal
uterine bleeding, dysuria, dyspareunia, nausea, vomiting, fever, or other constitutional
symptoms. Gonococcal pelvic inflammatory disease tends to have a more abrupt onset
and more dramatic symptoms of fever and peritoneal irritation than nongonococcal
disease. Both gonococcal and chlamydial disease are more likely to begin during the
first half of the menstrual cycle than later in the cycle.
Tubal damage and scarring result in important long-term complications, such as
recurrent disease, chronic pelvic pain, ectopic pregnancy, and infertility. In a prospective
study by Westrom et. al, chronic pelvic pain was found in about 18 percent of women
after pelvic inflammatory disease had resolved. Similarly, ectopic pregnancy occurred
about six times more often among women who had had the disease than among
comparable women who had not.
3. Give the differential diagnosis
The following are entities that may present clinically similar to PID:
c. Endometriosis- is the presence of endometrial tissue (stroma and glands) outside the
uterus, usually the pelvic viscera and the peritoneum. Endometrial foci are under the
influence of ovarian hormones and therefore undergo cyclic menstrual changes with
periodic bleeding. The pain that occurs with endometriosis begins usually begins 2 to 3
days before menses and worsens during menstruation. The pain may be due to local
peritoneal inflammation, deep infiltration with tissue damage, adhesion formation,
fibrotic thickening, and collection of shed menstrual blood in endometriotic implants,
producing pain whenever tissues are moved. Aside from dysmenorrhea, there may also
be dyspareunia and pain on defacation although endometriosis can be asymptomatic.
Tender nodules along the uterosacral ligament (which in this case was found in the
patient during the rectal examination), a posteriorly fixed uterus, and enlarged cystic
ovaries are characteristic findings.
d. Torsion of the Adnexa- results in ischemia and rapid onset of acute pelvic pain. The
onset of the torsion and the symptoms of abdominal pain frequently coincide with lifting,
exercise, or intercourse. Autonomic reflexes such as nausea, emesis, and apprehension
are usually present. On examination, there is the presence of large pelvic mass, the
abdomen is very tender, and localized rebound tenderness in the lower quadrants. Mild
temperature elevation and leukocytosis may accompany the infarction.
PID can be alleviated with the use of numerous types of antibiotics. However,
antibiotics do not reverse any damage that has already occurred to the reproductive
organs. Speedy antibiotic treatment can prevent severe damage to reproductive organs.
The longer a woman delays treatment for PID, the more likely she is to become infertile
or to have a future ectopic pregnancy because of damage to the fallopian tubes.
Regimen B
• Clindamycin 900 mg IV every 8 hours PLUS Gentamicin loading dose IV or
IM (2 mg/kg of body weight), followed by a maintenance dose (1.5 mg/kg) every
8 hours. Single daily dosing may be substituted.
Oral therapy can be considered for women with mild-to-moderately severe acute
PID, as the clinical outcomes among women treated with oral therapy are similar to
those treated with parenteral therapy. The following regimens provide coverage against
the frequent etiologic agents of PID. Patients who do not respond to oral therapy within
72 hours should be reevaluated to confirm the diagnosis and should be administered
parenteral therapy on either an outpatient or in-patient basis.
Regimen B
• Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg orally
twice a day for 14 days WITH OR WITHOUT Metronidazole 500 mg orally
twice a day for 14 days
• Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered
concurrently in a single dose PLUS Doxycycline 100 mg orally twice a day for
14 days WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14
days
• Other parenteral third-generation cephalosporin (e.g., ceftizoxime or
cefotaxime) PLUS Doxycycline 100 mg orally twice a day for 14 days WITH
OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days
Reference:
Novak’s Gynecology 14th ed.
Current Medical Diagnosis and Treatment 2006
www.newenglandjournalofmedicine.com
http://www.cdc.gov/std/treatment/2006/pid.htm#pid2