Obstetrics & Gynaecology
Question 65 of 180
A 21 year old woman presents to the Emergency Department with a 1 week history of pelvic pain and fever. She notes that she has been experiencing pain during sex. She has also had some breakthrough bleeding despite being on the combined oral contraceptive pill. What is the most likely causative organism for this patient's condition?
Answer:
The patient has features of pelvic inflammatory disease. Many types of bacteria can cause PID, but gonorrhea (2–3% of cases) or chlamydia infections (14–35% of cases) are the most common.Pelvic Inflammatory Disease
Obstetrics & Gynaecology / Sexual Health
Last Updated: 12th February 2021
Pelvic inflammatory disease is a general term for infection of the upper genital tract. Infection typically ascends from the endocervix causing one or more of endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscess or pelvic peritonitis.
Causes
Chlamydia trachomatis (14–35% of cases) and Neisseria gonorrhoeae (2–3% of cases) have been identified as causative organisms for PID. Mycoplasma genitalium has been associated with upper genital tract infection in women and is a common cause of PID. Organisms in normal vaginal flora (such as anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus agalactiae) have also been implicated.
Risk factors for developed pelvic inflammatory disease include:
- Factors relating to sexual behaviour e.g.
- Young age (younger than 25 years)
- Early age of first coitus
- Multiple sexual partners
- Recent new partner (within the previous 3 months)
- History of STI in the woman or her partner
- Recent instrumentation of the uterus or interruption of the cervical barrier e.g.
- Termination of pregnancy
- Insertion of intrauterine device
- Hysterosalpingography
- In vitro fertilisation and intrauterine insemination
Clinical features
- Symptoms:
- Pelvic or lower abdominal pain (usually bilateral but can be unilateral).
- Deep dyspareunia particularly of recent onset.
- Abnormal vaginal bleeding (intermenstrual, postcoital, or 'breakthrough') which may be secondary to associated cervicitis and endometritis.
- Abnormal vaginal or cervical discharge as a result of associated cervicitis, endometritis, or bacterial vaginosis. This is often very slight and may be transient, especially with chlamydial infection.
- Right upper quadrant pain due to perihepatitis (Fitz–Hugh–Curtis syndrome).
- Secondary dysmenorrhoea.
- Signs:
- Lower abdominal tenderness (usually bilateral).
- Adnexal tenderness (with or without a palpable mass), cervical motion tenderness, or uterine tenderness (on bimanual vaginal examination).
- Abnormal cervical or vaginal mucopurulent discharge (on speculum examination).
- A fever of greater than 38°C, although the temperature is often normal.
Investigations
A diagnosis of pelvic inflammatory disease (PID) should be made on clinical grounds. Do not delay making a diagnosis and initiating treatment whilst waiting for the results of laboratory tests. Negative swab results do not rule out a diagnosis of PID.
- Offer a pregnancy test to all sexually active women who are potentially fertile, to exclude ectopic pregnancy.
- Consider taking a high vaginal swab to exclude other vaginal infections, such as bacterial vaginosis and candidiasis.
- Test for the following:
- Chlamydia.
- Gonorrhoea.
- Mycoplasma genitalium.
- If possible, look for endocervical or vaginal pus cells under a microscope on a wet-mount vaginal smear.
- If absent, a diagnosis of PID is unlikely.
- Excess leucocytes are associated with PID, but they are also found in women with lower genital tract infection.
- Consider performing the following tests (which if elevated support the diagnosis of PID but are non-specific):
- Erythrocyte sedimentation rate (ESR).
- C-reactive protein.
- Leucocyte count.
- Offer blood tests for the following:
- HIV.
- Syphilis.
- Consider other investigations, as appropriate.
- Ultrasound scanning is of limited value for uncomplicated PID but is helpful if an abscess or hydrosalpinx is suspected. Doppler ultrasound can detect increased blood flow associated with pelvic infection and may be useful, but it cannot differentiate between PID and other causes of increased vascularity, such as endometriosis.
- MRI or CT scanning of the pelvis may be helpful in differentiating PID from alternative diagnoses, but they are not indicated routinely.
Differential diagnosis
- Ectopic pregnancy.
- Threatened abortion.
- Ruptured corpus luteal cyst.
- Acute appendicitis.
- Endometriosis.
- Gastrointestinal disorders, including irritable bowel syndrome, acute bowel infection, or diverticular disease.
- Complications of an ovarian cyst, such as rupture, torsion, or haemorrhage.
- Urinary tract infection.
- Mittelschmerz pain.
- Functional pain (that is of unknown physical origin).
Management
- Provide pain relief with ibuprofen or paracetamol.
- Antibiotic therapy:
- Start empirical antibiotics as soon as a presumptive diagnosis of PID is made clinically.
- Broad spectrum antibiotic therapy is required to cover N. gonorrhoeae, C. trachomatis and a variety of aerobic and anaerobic bacteria commonly isolated from the upper genital tract in women with PID. e.g. ceftriaxone plus doxycycline plus metronidazole.
- Outpatient therapy is as effective as inpatient treatment for patients with clinically mild to moderate PID.
- Intravenous therapy is recommended for patients with more severe clinical disease e.g. pyrexia > 38°C, clinical signs of tubo-ovarian abscess, signs of pelvic peritonitis. Intravenous therapy should be continued until 24 hours after clinical improvement and then switched to oral.
- Admission for parenteral therapy, observation, further investigation and/or possible surgical intervention should be considered in the following situations:
- a surgical emergency cannot be excluded
- a lack of response to oral therapy
- clinically severe disease
- presence of a tubo-ovarian abscess
- intolerance to oral therapy
- pregnancy
- Patients should be advised to avoid unprotected intercourse until they, and their partner(s), have completed treatment and follow-up.
- Current partners and recent partners (within the last 6 months) of women with pelvic inflammatory disease (PID) should be contacted and offered advice, screening, treatment, and contact tracing.
- Surgical management
- Laparoscopy may help early resolution of the disease by dividing adhesions and draining pelvic abscesses but ultrasound guided aspiration of pelvic fluid collections is less invasive and may be equally effective.
- It is also possible to perform adhesiolysis in cases of perihepatitis although there is no evidence whether this is superior to using only antibiotic therapy.
Complications
Complications of pelvic inflammatory disease include:
- Tubal infertility
- Ectopic pregnancy
- Chronic pelvic pain
- Tubo-ovarian abscess
- Fitz-Hugh–Curtis syndrome (a rare complication characterised by right upper quadrant pain associated with peri-hepatitis which occurs in some women with PID, especially by Chlamydia trachomatis)
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
