Diploma in Midwifery

Pelvic Inflammatory Disease

Table of Contents

Pelvic Inflammatory Disease (PID) encompasses infections affecting the female reproductive organs, the pelvic peritoneum, and the pelvic vascular system.
The reproductive organs involved include the fallopian tubes, ovaries, cervix, and endometrium (uterine lining).

Causes of PID

PID can arise from different pathways:

  1. Ascending Infections: This is the most common route, where bacteria move upwards from the vagina or cervix into the upper reproductive organs, such as the fallopian tubes and ovaries.

  2. Hematogenous Infections: These occur when pathogens are carried via the bloodstream to the pelvic organs.

  3. Direct Spread: Infections can spread directly from nearby infected organs, such as an infected appendix, into the pelvic region.

Several microorganisms can cause PID, including:

  1. Neisseria gonorrhoeae

  2. Chlamydia trachomatis

  3. Haemophilus influenzae

  4. Escherichia coli (E. coli)

 Factors increase the risk of developing

  1. History of STIs: Previous or current sexually transmitted infections, especially gonorrhea and Chlamydia.

  2. Bacterial Vaginosis: An imbalance in the normal bacteria present in the vagina.

  3. Multiple Sexual Partners: Having multiple sexual partners increases the risk of STI exposure.

  4. Douching: Disrupting the normal vaginal flora by douching can increase risk.

  5. Previous PID: A history of PID increases the likelihood of recurrent infections.

  6. IUD Use: Use of intrauterine devices (IUDs), particularly shortly after insertion, can increase risk.

  7. Surgical Procedures: Certain procedures, such as dilation and curettage, can increase risk.

  8. Obstetric Factors: Complications of pregnancy like abortion, ectopic pregnancy rupture, and postpartum infections (puerperal sepsis).

Pathophysiology

PID is frequently caused by multiple types of microorganisms, with gonorrhea and Chlamydia being most commonly seen.
The infection typically begins in the vagina and ascends through the cervical canal to affect the fallopian tubes and ovaries.
During menstruation, the cervical canal is more open, allowing bacteria to enter the uterus. Once in the reproductive tract, the pathogens multiply rapidly and can spread to the fallopian tubes, ovaries, and the peritoneal cavity and abdominal organs.

The clinical presentation of PID 

It can vary widely, but common symptoms and signs include:

  1. Severe Lower Abdominal Pain: Approximately 70% of women with PID experience intense lower abdominal pain. It may be localized or diffuse and can be aggravated by movement or sexual activity.

  2. Acute Fever: About 40% of PID cases involve a fever, indicating a systemic response to the infection.

  3. Purulent Vaginal Discharge: Approximately 90% of PID patients have a pus-like vaginal discharge, which may be foul-smelling and appear yellowish or greenish.

  4. Menstrual Changes: PID can disrupt the menstrual cycle, leading to various irregularities such as dysmenorrhea (painful periods), menorrhagia (heavy or prolonged periods), or oligomenorrhea (infrequent or light periods).

During physical examination, the following may be observed:

  1. Signs of Inflammation: Redness, warmth, and swelling may be seen in the pelvic region.

  2. Peritoneal Signs: Examination may reveal signs of peritonitis like guarding (muscle tensing), abdominal distension (swelling), and rebound tenderness (increased pain upon release of pressure), indicating a spread of infection.

  3. Vaginal Examination: A pelvic exam is critical for assessing the reproductive organs:

    • Vaginal Changes: The vaginal walls may appear red, inflamed, and dry due to inflammation.

    • Tender Fornices: Palpation of the vaginal fornices (around the cervix) can reveal tenderness, particularly in cases of pyosalpinx (pus accumulation in fallopian tubes).

    • Purulent Discharge: The presence of purulent discharge may be noted.

Cervicitis

Cervicitis is an inflammation of the cervix, the lower portion of the uterus that opens into the vagina. It is usually caused by sexually transmitted infections, such as Chlamydia and Gonorrhea.

  1. Redness of the Cervix: The cervix may appear red and swollen upon examination by a healthcare provider.

  2. Slight Bleeding on Intercourse: The cervix can be more prone to bleeding because of inflammation, especially during or after sexual activity.

  3. Itching and Burning: Individuals may experience itching or a burning sensation in the vaginal area.

  4. Vaginal Discharge: An abnormal vaginal discharge, may be watery, yellow, or green in color.

  5. Pelvic Pain: Mild pelvic discomfort or pain may be experienced.

Salpingitis is the inflammation of one or both fallopian tubes, often resulting from infections moving upwards from the vagina and uterus. Untreated or undertreated STIs, particularly Chlamydia and Gonorrhea, are common causes.

  1. Abdominal or Back Pain: Salpingitis can cause lower abdominal or back pain, ranging from mild to severe.

  2. Dyspareunia: Pain during sexual intercourse (dyspareunia) may occur.

Oophoritis is the inflammation of one or both ovaries, which can occur independently or alongside other pelvic infections, such as salpingitis.

  1. Abdominal or Back Pain: Similar to salpingitis, oophoritis can cause lower abdominal or back pain.

  2. Dyspareunia: Pain during sexual intercourse may also be a symptom.

 Endometritis

 Endometritis refers to the inflammation of the endometrium, the inner lining of the uterus. This condition can manifest as either acute (sudden onset) or chronic (long-term) and is typically triggered by bacterial infections. These infections are most frequently observed following events such as childbirth, abortions, or the insertion of intrauterine contraceptive devices (IUDs).

Signs and Symptoms of Endometritis

  1. Fever: An elevated body temperature is often present as the body’s response to infection.

  2. Abdominal Pain: Patients commonly experience pain or discomfort in the lower abdominal region.

  3. Uterine Enlargement: The uterus might appear larger than its typical size upon physical examination.

  4. Vaginal Discharge: An abnormal vaginal discharge may occur, often characterized by a foul odor and varying colors.

Hospital Management

AIMS:

  • Preventing complications associated with endometritis.

  • Alleviating the patient’s pain and discomfort.

  • Limiting the spread of the infection within the patient’s body.

Admission:

  • The patient should be admitted to a clean, well-ventilated gynecological ward, where complete bed rest can be ensured.

  • Establish an intravenous (IV) line promptly to prevent dehydration and actively encourage the intake of oral fluids.

Position:

  • Position the patient comfortably, with a semi-Fowler’s position particularly useful in promoting the drainage of discharge.

Histories and Examination:

  • Obtain a thorough patient history and conduct a detailed general physical examination.

Observations:

  • Regularly monitor vital signs (temperature, pulse, respiration, and blood pressure).

  • Closely observe and record the color, amount, and smell of any vaginal discharge each day.

  • Keep track of the patient’s overall condition.

Investigations:

  • Perform a high vaginal swab for culture and sensitivity testing to pinpoint the specific bacteria causing the infection.

  • Conduct a urinalysis with culture and sensitivity to identify any urinary tract involvement.

  • Rule out malaria with a blood smear analysis.

  • Collect a blood sample for culture and sensitivity to check for bloodstream infections that may originate from the uterus or surrounding areas.

  • Perform an ultrasound scan of the pelvic area to exclude other potential causes of abdominal pain.

Diet:

  • Advise the patient to consume a highly nutritious diet and drink plenty of fluids orally to support the body’s natural healing process.

Elimination:

  • Provide a bedpan or urinal and instruct the patient to urinate whenever necessary.

  • Closely observe and document the color, amount, and smell of the urine.

  • Ensure proper disinfection of urine and feces using an appropriate disinfectant before disposal to prevent infection spread.

Hygiene:

  • Ensure the bed is made daily, with wrinkles removed, to help maintain a clean environment.

Exercise:

  • Encourage the patient to engage in mild physical activity, such as walking around, as their condition allows. Psychotherapy can be beneficial for some patients.

Care of Mind:

  • Offer reassurance to both the patient and their family members.

  • Provide access to distractions such as newspapers, television, and radio.

Medical Treatment:

  • Initiate treatment immediately while awaiting results from culture and sensitivity tests.

  • Start with broad-spectrum antibiotics (e.g., chloramphenicol 2 gm stat, then 1 gm every 6 hours for 5 days, gentamicin 160 mg once daily for 5 days, ceftriaxone 2 gm daily for 5 days). If the discharge lessens, transition to oral antibiotics.

  • Administer additional drugs as indicated by sensitivity results (e.g., metronidazole 500 mg three times daily intravenously, azithromycin 1g as a single dose, ciprofloxacin, tetracycline, doxycycline, Septrin).

Analgesics:

  • Use narcotics for severe pain. Other alternatives include medications like acetaminophen (Panadol), ibuprofen, or diclofenac to manage pain and inflammation.

Advice on Discharge:

  • Provide instructions on safe sexual practices, such as reducing the number of sexual partners and consistently using condoms.

  • Advise against the use of intrauterine contraceptive devices (IUDs) in certain cases

  • Emphasize the importance of seeking early treatment for sexually transmitted infections.

  • Educate on maintaining good personal hygiene and consistently adhering to the prescribed medications.

  • Instruct the patient to return for a follow-up visit if any problems such as pain, abnormal discharge, or itching arise.

Complications

When endometritis is not treated or poorly managed, it can result in the following complications:

  1. Pelvic Abscess: An accumulation of pus in the pelvic region.

  2. Infertility: Inflammation and scarring can impair the function of the fallopian tubes, reducing fertility.

  3. Ectopic Pregnancy: A pregnancy occurring outside the uterus, usually in the fallopian tubes.

  4. Chronic Pelvic Pain: Persistent pelvic pain lasting for an extended period.

  5. Pelvic Adhesions: The formation of scar tissue causing organs to stick together.

  6. Salpingitis: Inflammation of the fallopian tubes.

  7. Peritonitis: Inflammation of the abdominal lining.

  8. Tubal Ovarian Mass: The formation of masses involving the fallopian tubes and ovaries.

  9. Intestinal Obstruction: A partial or complete blockage of the intestines.

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