by Group 8 PID & EP edited.pptx

College of Health and Medical Science
School of Nursing and Midwifery
Master of Science in Maternity and Neonatal Nursing
Pelvic Inflammatory Disease and Ectopic pregnacy
Done by Group 8 (Eight)
Gadissa Tolosa
Gemechu Alemayehu
Asanti Jiregna
Submitted to.Dr. Addisu A.( MD, pathologist, Ass’t Proffesor)
9/24/2023 Pathology Group Assignment by GT,GA, & AJ 1

PELVIC INFLAMMATORY DISEASE (PID)
AND
ECTOPIC PREGNANCY

Outline of presentation
At the end of this presentation the participants will
able to, Know Definition of Pelvic inflammatory
disease and Ectopic pregnancy
Able to list etiology of Pelvic inflammatory disease
Identify pathophysiology, pathogenesis and
diagnosis of PID and Ectopic pregnancy
9/24/2023 3
Pathology Group Assignment by GT,GA, & AJ

PELVIC INFLAMMATORY DISEASE (PID)
• PID is an infection of the upper female genital tract.
• It is an infection that spreads upward to involve
the uterus, fallopian tubes, and ovaries and also
involvement of the neigh boring pelvic organs (pelvic
peritoneum)
• The bacterial infection can lead to an abscess in a
fallopian tube or ovary
9/24/2023 4

What is PID
• An infection of
⁻ Vagina (colpitis)
⁻ Cervix (endocervicitis)
⁻ Uterus (endometritis)
⁻ Fallopian tube
(salpingitis)
⁻ Ovaries (oorphatis)
⁻ Pelvic peritonitis
Resulting in pelvic pain,
adnexal tenderness, fever,
and vaginal discharge.

Figure of Female reproductive organ and PID
9/24/2023 6

Etiology of PID
The most common etiologic agents in PID are:
 Neisseria gonorrhea,
 Chlamydia trachomatis
 common cause of PID = 1/3rd each;
 PID also can be caused by infections that are not
sexually transmitted, such as bacterial vaginosis
(BV).
9/24/2023 7

Pathway of Ascending infection
Cervicitis
endometritis
Salpingitis
oorphatis
peritonitis

Pathophysiology of PID
• The vaginal flora of most normal, healthy women includes a
variety of potentially pathogenic bacteria (Srinivasan et al.,
2012)
• This vaginal flora which is non-pathogenic (most
commonly Klebsiella spp, Escherichia coli, and a variety of
anaerobes) are present in low numbers, and
• Flow under the influence of hormonal changes (eg,
pregnancy, menstrual cycle), contraceptive method, sexual
activity, and other as yet unknown forces.
9/24/2023 10

• The endocervical canal functions as a barrier
protecting the normally sterile upper genital tract
from the organisms of the dynamic vaginal ecosystem.
• The initial infection most commonly involves the endo
cervical mucosa
• Endo-cervical infection with sexually transmitted
pathogens can disrupt this barrier.
9/24/2023 11
Pathophysiology of PID con’t…

• Disturbance of this barrier provides vaginal
bacteria access to the upper genital organs,
• Infecting the endometrium, then endosalpinx,
ovarian cortex, pelvic peritoneum, and their
underlying stroma.
• The resulting infection may be subclinical or
manifest as the clinical entity of pelvic
inflammatory disease (PID).
9/24/2023 12

• The Iatrogenic events (non-gonococcal bacterial infections)
that follow
⁃ Induced abortion and D&C
⁃ Other surgical procedures (IUD insertion or use,
Hysterosalpingography)
• Which facilitates spread upward from the uterus through the
lymphatic or venous channels rather than on the mucosal
surfaces
• It produces more inflammation within the deeper layers of the
organs than gonococcal infections.
9/24/2023 13

• Gonococcal infection is characterized by marked acute
inflammation of involved mucosal surfaces.
• The tubal mucosa becomes congested and diffusely infiltrated by
neutrophils, plasma cells, and lymphocytes, resulting in
epithelial injury and sloughing of the plicae.
9/24/2023 14

• The tubal lumen fills with purulent exudate that may leak
out of the fimbriated end.
• The infection may then spread to the ovary to create a
salpingo-oophoritis.
• Collections of pus may accumulate within the ovary and tube
(tubo-ovarian abscess) or tubal lumen (pyosalpinx).
• Scarring process that forms gland like spaces and blind
pouches, referred to as chronic salpingitis
9/24/2023 15

Pathogenesis of PID
• Patients with PID can present with clinical disease at any
point along a continuum from endometritis (with normal
tubes, ovaries, and peritoneum) to salpingitis (with
inflammation of the fallopian tubes and adjacent pelvic
structures).
9/24/2023 16

Risk factors of PID
- women with longstanding monogamous relationships rarely
develop PID
- Any sexually active female is at risk for sexually transmitted
infection (STI) associated pelvic inflammatory disease (PID),
but those with multiple sexual partners are at the greatest
risk.
- The clinical status of the partner (Having a symptomatic like
dysuria, urethral discharge) male partner greatly increases a
woman's risk of PID.
9/24/2023 17

Risk factor con’t…
⁃ A sex partner who has sex with others
⁃ Women who undergo Gynaecological procedures
favouring ascend of infection (e.g. termination of
pregnancy)
⁃ Past Hx of PID
9/24/2023 18

Clinical manifestations of PID
• Acute symptomatic PID is characterized by .
the acute onset of lower abdominal or pelvic
pain,
pelvic organ tenderness, and
evidence of inflammation of the genital tract
9/24/2023 19

Some women with PID have only mild symptoms or
have no symptoms at all.
⁃ Abnormal vaginal discharge
⁃ Pain in the lower abdomen (often a mild ache)
⁃ Abnormal menstrual bleeding
⁃ Fever and chills
⁃ Painful urination
⁃ Nausea and vomiting
⁃ Painful sexual intercourse

Diagnosis of PID
• PID is difficult to accurately diagnose, in part, because
manifestations range from mild to severe
• All young, sexually active women presenting with lower
abdominal pain should be carefully evaluated for the
presence of salpingitis and endometritis.
• Routine bimanual and abdominal exams should be done
on all women with an STD, since some women with
salpingitis or endometritis will not complain of lower
abdominal pain
9/24/2023 21

Criteria for diagnosis
Major Criteria:-
Cervical motion tenderness or
Lower abdominal / uterine tenderness or
Adnexal tenderness
Minor criteria:-
Oral temperature >101 °F ( >38.3°C)
Abnormal cervical or vaginal mucopurulent
discharge
Presence of abundant numbers of WBC on saline
microscopy of vaginal secretions
9/24/2023 22

Diagnosis PID
Elevated ESR
Elevated C-reactive protein
Laboratory documentation of cervical infection
with N. gonorrhoeae or C. trachomatis
 Endometrial biopsy with histopathologic evidence
of endometritis
 Transvaginal sonography or MRI
 Laparoscopy (Gold Standard) – to see sign of
acute inflammation
9/24/2023 23

Complications of PID
Acute complications of PID:
 Peritonitis and bacteremia,
Endocarditis, meningitis, and suppurative arthritis.
The chronic complication of PID:
 Infertility and tubal obstruction,
ectopic pregnancy, Chronic pelvic pain, and
intestinal obstruction due to adhesions between the
bowel and pelvic organs.
9/24/2023 24

DDX:-
• Acute appendicitis
• Endometriosis
• Torsion or rupture of an adnexal mass
• Ectopic pregnancy
9/24/2023 25

Treatment
• Based on the consensus that PID is polymicrobial in
cause.
• Empirical antibiotic protocols should cover a wide
range of bacteria
• Oral therapy can be considered for women with mild
to moderately severe acute pid
9/24/2023 26

Ectopic pregnancy
• is a pregnancy in which the developing blastocyst
becomes implanted at a site other than the
endometrium of the uterine cavity.
Or
• Is implantation of a fertilized ovum in any site other
than the uterus.
• The most common extra-uterine location is the
fallopian tube
9/24/2023 27

Ectopic pregnancy
• The mechanisms responsible for ectopic implantation are
unknown. But
• The four main possibilities are
An anatomic obstruction to the passage of the zygote
An abnormal conceptus
Abnormalities in the mechanisms responsible for
tubal motility, and Trans-peritoneal migration of the
zygote
9/24/2023 28

An anatomic obstruction to the passage of the
zygote
⁃ Anatomic distortion and obstruction of the fallopian tube
are widely believed to be responsible for most ectopic
implantations.
⁃ Obstruction could result from PID, salpingitis tubal
endometriosis, or postsurgical fibrosis and isthmica
nodosa.
⁃ Scarring of the endosalpinx could lead to diverticuli
formation, in which the zygote could be trapped, or to simple
obstruction of the tubal passage
9/24/2023 29

Pathophysiology
Histopathology
oLack of a submucosal layer within the fallopian
tube wall provides easy access for the fertilized
ovum to burrow through the epithelium and
allow implantation within the muscular wall.
oAs the rapidly proliferating trophoblast erodes the
subjacent muscularis layer, maternal blood pours
into the spaces within the trophoblast or the adjacent
tissue.
oThe lack of resistance allows early penetration by
trophoblasts
oThe anatomic location of a tubal pregnancy may
predict the extent of damage.

Pathophysiology
• Inflammation
Acute inflammation has been implicated in the role
of tubal damage that predisposes to ectopic
pregnancies.
• Recurrent chlamydial infection causes intraluminal
inflammation and subsequent fibrin deposition with
tubal scarring .

Risk factors for ectopic pregnancy
 Previous ectopic px
⁃ Highest risk for recurrence
⁃ Rational
⁃ underlying tubal disorder that led to the initial
ectopic pregnancy and to the choice of treatment
procedure.
⁃ History of salpingostomy for ectopic pregnancy is
a risk factor for recurrent ectopic pregnancy
9/24/2023 32

Risk factors for EP
Tubal pathology and surgery
Disruption of normal anatomy of tube by
• Infection, surgery, Congenital anomally, Tumors
Anatomic distortion can be accompanied by functional
impairment due to damaged cilliary activity
Reconstructive surgery
• Occurrence depend on condition of tube, type of surgery
and surgeons expertise
9/24/2023 33

Risk factors for EP
In utero DES exposure
Women with a history of in-utero diethylstilbestrol (DES)
exposure have a 4x increased risk of ectopic pregnancy
- due to abnormal tubal morphology and, possibly, impaired
fimbrial function
IUC
• All contraception decrease pregnancy(both IUP and
ectopic)
• But if pregnancy occurs, the risk of EP is high
9/24/2023 34

Risk factors for EP
PID and recurrent infection, is a major cause of
tubal pathology and increases the risk of ectopic
pregnancy.
Pelvic infection may alter tubal function and may
also cause tubal obstruction and pelvic adhesive
disease
9/24/2023 35

Risk factors for EP
Previous genital infection(salpingitis by
gono,chlamydia)
Infertility
Multiple sexual partners (increase PID)
Smoking (dose dependent)
• Mechanism:
• Impair immunity and so increase PID or
impair tubal motility
Previous pelvic or abdominal surgery
9/24/2023 36

PATHOGINESIS OF ECTOPIC PREGNANCY
37
Almost all (more than 95%) occur in FT
(A) Ampullary, 80% ; (B) Isthmic, 12%; (C)Fimbrial, 5%;
(D) Cornual/Interstitial, 2%
(E) Abdominal, 1.4%; (F) Ovarian, 0.2% (G) Cervical, 0.2%.

PHATOGENESIS IN TUBAL PREGNANCY
• Factors involved in pathogenesis
• Delay or prevent passage of fertilized ovum in to
Uterus cavity
• Inherent in embryo leading to premature implantation
• Tubal condition which impair tubal transport
1.Chronic salpingitis
• Seen in 90% of ectopics
• 6x more in tubes of ectopic than normal tubes
9/24/2023 38

• Tubal conditions which impair tubal transport
2.Chronic isthmica nodosa(nodular scaring of FT)
• Seen in 10% of ectopic
• Gross: bilateral nodularities in isthmus
• Etiology:unknown
3.Other factors may cause premature implantation in tube
PATHOGENESIS IN TUBAL PREGNANCY
9/24/2023 39

Complication of EPx
• The most common complication is rupture with
internal bleeding which may lead to hypovolemic
shock.
• In the first trimester, ectopic pregnancy is the most
common cause of pregnancy-related deaths and
10% of maternal deaths may be due to ectopic
pregnancy.

Summary
• PID is an infection that begins in the vulva or vagina and
spreads upward to involve the uterus, fallopian tubes, and
ovaries and also involvement of the neigh boring pelvic organs
(pelvic peritoneum)
• The bacterial infection can lead to an abscess in a fallopian tube
or ovary
• EP is implantation of a fertilized ovum in any site other than the
uterus.
• The most common extra-uterine location is the fallopian tube

Reference
• Robbin & Cotran Pathologic Basis of Disease 10th Ed
• Uptodate 2018.
• American College of Obstetricians and Gynecologists:
Pelvic Inflammatory Disease ,August 2019
• Srinivasan, S., Hoffman, N. G., Morgan, M. T., Matsen, F.
A., Fiedler, T. L., Hall, R. W., . . . Fredricks, D. N. (2012).
Bacterial communities in women with bacterial vaginosis:
high resolution phylogenetic analyses reveal relationships of
microbiota to clinical criteria. PLoS One, 7(6), e37818.
doi:10.1371/journal.pone.0037818

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