Uterine and pelvic infections

Endometritis

This is an infection confined to the uterus which, left untreated, will spread to the pelvis. This is usually the result of instrumentation of the uterus (i.e. terminations, evacuations of retained products of conception, dye tests, IUCD), as a complication of pregnancy or both. Miscarriage, abortion (particularly with retained products of conception) and Caesarean section are risk factors for this infection. Chlamydia and gonorrhoea or are the usual causative pathogens and are both sexually transmitted. E.coli, staphylococci and some clostridia have also been implicated.

Clinical features are heavy bleeding, pain, uterine tenderness and commonly an open cervical os. Fever maybe absent initially. Investigations are FBC (WCC↑); vaginal and cervical swabs; USS is unreliable. Management is broad-spectrum antibiotics. If this fails, it is followed by evacuation of retained products of conception (ERPC).

Acute Pelvic Inflammatory Disease

Definition

PID (aka salpingitis) is infection of female reproductive organsbut usually means sexually transmitted infection.

Epidemiology

Around 2% of women are affected.

Pathophysiology

Ascending infection from bacteria and the virus, 80% sexually transmitted.

Risk Factors

• Young
• Poor
• Sexually active (80% sexually transmitted)
• Nulliparous (no previous births)
• Uterine instrumentation (any operation involving the uterus or IUCD)
• Complications during childbirth
• Miscarriage

Clinical Features

Often asymptompatic, subfertility and menstrual problems are also features though these often come later on in the disease. Bilateral lower abdominal pain and deep dyspareunia (internal pain during intercourse) are hallmarks of the disease and are often accompanied by discharge/abnormal bleeding.

On examination, when severe, there is fever, tachycardia, peritonism with bilateral adnexal tenderness and cervical excitation. If an abscess has formed, there maybe a palpable mass. Often however, the diagnosis is confused with appendicitis, ovarian cysts or ectopic pregnancy.

Investigations

• Swabs from vagina and cervix
• FBC (WCC↑)
• CRP↑
• USS - excludes abscess or cyst
• Laparoscopy with biopsy of fimbriae - gold standard of diagnosis

Management

Analgesics can be used to deal with pain. There are two combinations of antibiotics.

• Parenteral cephalosporin; doxycycline and metronidazole
• Ofloxacin and metronidazole

In febrile disease - IV therapy is indicated. Laparoscopy should be performed if after 24h the disease has not subsided.

Prognosis

Ectopic pregnancy is 6 times more likely after a pelvic infection. Subfertility and tubal obstruction may develop. The main complication is the formation of a pyosalpinx (abscess).