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Pelvic Inflammation Disease (PID) 骨盆腔炎

 

 

General Consideration:

1.   骨盆腔炎症的產生,主要是由於群聚在endocervix的微生物由下往上傳染(endometritis-salpingitis-peritonitis)所致。

2.   骨盆腔炎症包括各種的上生殖道發炎感染,如:endometritis, salpingitis, peritonitis, tubo-ovarian abscess (TOA)等。

3.   經臨床症狀而診斷(Clinical diagnosis)。

4.   病因(Pathogens):

1)  sexually transmitted microorganisms: 大部分的病原,如:淋病雙球菌(Neisseria gonorrhoeae)佔50%,砂眼披衣菌(Chlamydia trachomatis)佔20%。

2) respiratory pathogens: 少部分的病原,如:Haemophilus influenzae, Group A streptococci, pneumococci。

3) endogenous microorganisms: Prevotella, Gardnerella vaginalis。

 

Risk Factor:

1.   性伴侶多。

2.   低社會知識水準。

3.   使用IUD。

4.   接受過陰道手術(如:D & C)

 

Symptoms/Signs and Diagnosis:

PID大多數發生於經期中或經期剛結束時,最常見的症狀是下腹疼痛(屬鈍痛),有時伴隨著發冷發熱,陰道分泌物增加,觸診時有下腹壓痛,內診時有cx lifting pain。

 Triad of symptoms and signs: 傳統上常見的症狀有pelvic pain, cervical motion tenderness (即cx lifting pain), adnexal tenderness and fever。

 Genitourinary tract symptoms indicating PID: 如lower abdominal pain, excessive vaginal discharge, menorrhagia, metrorrhagia, fever, chills, and urinary symptoms

(註:有些病人雖然發生PID,但確沒有任何症狀)

 

Differential diagnosis:

Acute appendicitis, Ectopic pregnancy, Septic abortion, Endometriosis, Internal GI bleeding, GI infection, Corpus luteal bleeding, Pelvic adhesion, Renic colic, Lower lobe pneumonia, Torsion of adnexal structure, Acute pyelonephritis

(註:診斷困難時,可考慮採行Diagnostic laparoscope) 

 

Basic Lab Work-up:

CBC, D/C, CRP, ESR, beta-hCG, U/A, Blood culture, Cx culture, Grain stain and ultrasonography 

 

Hospitalization:

一般PID若能正確診斷與治療,在給藥後24-48小時,症狀便會改善,約70%的病人在門診追蹤治療即可,但有以下情況時,便須考慮住院治療:

 

Indication: (住院)

1.   診斷有疑問(diagnosis is uncertain)。

2.   疑有Pelvic abscess。

3.   疑有appendicitis, ectopic pregnancy。

4.   懷孕。

5.   病情嚴重(clinical disease is severe),門診治療失敗。

6.   病人配合度差(compliance with an outpatient regimen is in question)。

7.   無法追蹤至48-72小時。

 

Discharge: (出院)

1.   退燒24小時以上(fever totally lysed (< 37.5℃) for more than 24hr)。

2.   感染指標趨於正常(WBC count, ESR, CRP are normal)。

3.   反彈壓痛消失(rebound tenderness is absent)。

4.   重覆的理學檢查顯示骨盆腔壓痛現象有明顯改善(repeat examination shows marked amelioration of pelvic organ tenderness)。

5.   TOA (tubo-ovarian abscess)的病人除了以上所述,另外可佐以超音波報告TOA有明顯變小。 

 

Treatment:

1.  Medical Tx:

1)   治療PID以抗生素治療為主,治療前應先做blood culture及endocervical culture,給藥則先以予經驗療法(詳見下表),待culture結果出來再決定是否要改藥。

2)   Therapy regimens for PID must provide empiric, broad-spectrum coverage of likely pathogens including Neisseria gonorrhoeae, Chlamydia trachomatis, gramnegative facultative bacteria, anaerobes, and streptococci.

 

 **治療PID的用藥方法

 

CDC Guidelines for Treatment of PID

Outpatient treatment (門診病人)

 Regimen A:

  Cefoxitin 2g im, plus probenecid, 1g orally, or

  Ceftriaxone, 250mg im, or

  Equivalent Cephalosporin

    <PLUS>

  Doxycycline 100mg orally Bid* 14 days

 Regimen B:

  Ofloxacin 400mg orally Bid* 14 days

    <PLUS>

  Clindamycin 450mg orally Qid, or

  Metronidazole 500mg orally Bid* 14 days

Inpatient treatment (住院病人)

 IV form antibiotics至少要給4天,直到退燒達48小時才可改口服

 Regimen A:

  Cefoxitin 2g iv Q6h, or

  Cefotetan 2g iv Q12h

    <PLUS>

  Doxycycline 100mg iv or orally Q12h

 Regimen B:

  Clindamycin 900mg iv Q8h

    <PLUS>

  Gentamicin iv or im (2mg/kg) st, and (1.5mg/kg) Q8h

 

 # Cefoxitin, Ceftriaxone及Cefotetan皆為Cephalosporins, Ofloxacin為Quinoloone, Doxycycline為Tetracycline, Gentamicin則屬於Aminoglycoside。

 # 科內常用的three-combined antibiotics如下:

  Cefamezine 1 Vial (500mg) iv Q6hr

  Gentamicin 80mg im/ivf st & 60 mg im/ivf Q8hr

  SABS 1 bottle (500mg) ivf Q8h

  (註:Cefamezine為第一代Cephalosporin, SABS為Metronidazole)

 PID病人的性伴旅若懷疑有chlamydia or gonorhea的urethral infection,可依下表給予治療 (Sexual partners of women with PID should be evaluated and treated for urethral infection with chlamydia or gonorhea)。

 

Treatment Regimens for Gonococcal and Chlamydial Infections

 Neisseria gonorrhoeae endocervicitis

  Ceftriaxone 125mg im (single dose), or

  Ofloxacin 400mg orally (single dose), or

  Cefixime 400mg orally (single dose), or

  Ciproflooxacin 500mg orally (single dose)

 Chlamydia trachomatis endocervicitis

  Doxycycline 100mg orally Bid* 7 days, or

  Azithromycin 1gm orally (single dose), or

  Ofloxacin 300mg orally Bid* 7 days, or

  Erythromycin base 500mg orally Qid* 7 days, or

  Erhthromycin ethylsuccinate 800mg orally Qid* 7 days

 

 

2.  Surgcal Tx:

=抗生素治療失敗,有時會產生TOA (an end-stage process of acute PID),此時仍以抗生素治療(75% respond to antimicrobial therapy alone);但若治療72小時後,fever未退或abscess未消,便應考慮採用surgical exploration (laparotomy或laparoscopy) 做手術引流(drainage of abscess)。

=本科常用之引流方式:放置sump drain irrigation,用L/R當沖洗液,以low pressure,速度從150ml/hr®120®100®80®60ml/hr®dry drain逐日遞減,總計約5天,當然實際上仍視臨床情況而定。

=當TOA rupture產生peritoneal sign則必須立刻手術治療;若未能於24小時內手術,死亡率可達100%。手術包括切除有TOA之adnexa並做abscess引流。(因USO有17% reoperation rate,所以若評估可行,可採行ATH + BSO)。

 

Sequele:

1.  infertility

2.  recurrent inflammation

3.  ectopic pregnancy