Chlamydia trachomatis infection, 079.98
Ectopic pregnancy, 633.90
Gonorrhea, 098.0
Herpes, 054.9
Pelvic inflammatory disease (PID salpingitis), 614.9
Syphilis, 097.9
I. Definition
A. Implantation of the fertilized ovum in tissue other than the endometrium.
B. The most common implantation site is the fallopian tube.
II. Etiology/incidence/predisposing factors
A. Any condition that prevents or retards passage of the fertilized ovum into the uterus, such as
1. Pelvic inflammatory disease, sexually transmitted infections (STIs), especially Neisseria gonorrhoeae and Chlamydia trachomatis salpingitis
2. History of endometriosis
3. Prior tubal or uterine surgery related to adhesions
4. Use of a contraceptive intrauterine device (IUD)
5. Congenital anomalies associated with diethylstilbestrol (DES)
6. Tubal tumors
7. Infertile women treated with ovulation-inducing drugs, such as clomiphene citrate (Clomid)
8. Postabortal and puerperal infections
10. Previous tubal sterilization
11. Cigarette smoking
B. Most common cause of maternal mortality in the first trimester
C. Leading cause of maternal mortality in the U.S. Two of every 100 women who were known to conceive had an ectopic pregnancy.
III. Subjective findings
A. Early
1. Missed or delayed menses, followed by continuous intermittent vaginal bleeding, typically dark in color
2. The nature, duration, and intensity of pain vary considerably.
3. Sudden, sharp, and stabbing abdominal pain, diffuse pelvic pain, referred neck or shoulder pain
B. Late
1. Fainting, vertigo, dizziness
2. Nausea, vomiting, diarrhea
3. Right or left pelvic pain
IV. Physical examination findings with rupture and intra-abdominal hemorrhage
A. Signs of hypovolemic shock—hypotension, skin pallor, tachycardia
B. Temperature may or may not be changed.
C. Ecchymotic blueness around umbilicus (Cullen’s sign)
D. Uterine size is generally normal; uterus is sometimes displaced to the side.
E. Palpation of adnexal mass
F. Bimanual examination is very painful with cervical motion tenderness.
G. Unilateral abdominal tenderness with rebound
V. Laboratory findings/diagnostic findings
A. Decreased hemoglobin and hematocrit with mild leukocytosis
B. Absence of an intrauterine gestational sac with human chorionic gonadotropin (beta-hCG) concentration of 1500 mIU/ml or greater is suggestive of ectopic pregnancy.
C. Culdocentesis (aspiration of the cul-de-sac) when ultrasonography is not available. Aspiration of nonclotting blood is considered positive.
D. Pregnancy test: Beta-hCG radioimmunoassay is usually decreased in ectopic pregnancies.
VI. Management
A. Thinking “ectopic” in any woman of childbearing age with an acute abdomen should be a major priority concern for the acute care nurse practitioner.
B. Salpingectomy: per outpatient laparoscopy
C. Linear salpingostomy: unruptured tube greater than 2 cm
D. Outpatient nonsurgical treatment with methotrexate (amethopterin) therapy. Methotrexate is a folic acid antagonist.
2. Pretreatment medical workup should consist of baseline laboratory values and diagnostic tests:
a. Transvaginal ultrasound to determine the presence or absence of extrauterine gestational sac
b. Quantitative: beta-hCG level
c. Liver function (serum glutamic-oxaloacetic transaminase [SGOT])
d. Renal function (BUN) creatinine
e. Blood type Rh factor and presence of antibodies
f. CBC
g. Bone marrow function tests
3. Contraindications
a. Unstable or noncompliant patient
b. History of renal disease
c. History of hepatic disease
d. Current thrombocytopenia
e. Hemodynamically unstable
4. Dosage of methotrexate: 50 mg/m2 IM single dose, follow up on days 4 and 7, then weekly
5. Additional management
a. Central venous line if unstable hemodynamically for Ringer’s lactate or normal saline; run at rate appropriate for patient’s hemodynamic condition
b. Blood transfusions, packed RBCs as indicated for low hemoglobin/hematocrit
c. Maintain urinary output at 30 ml/hour.
d. Iron dextran (InFeD) IV 2 ml (100 mg) test dose. Use cautiously in patients with a history of allergies or asthma. Give 0.5 ml (25 mg) epinephrine at bedside for anaphylaxis.
e. Cefoxitin (Mefoxin) 2 g IV single dose
f. Oxycodone/acetaminophen (Percocet) every 4 to 6 hours as needed for pain. Give morphine, 15 mg, to a hospitalized patient through high-dose patient-controlled analgesia (PCA) pump.
g. NPO
h. Rho(D)-negative unsensitized patient to receive IM injection of Rho(D) immune globulin (RhIG), 300 mcg
i. Biweekly hCG is required (with a drop in hCG after 7 days); 1500 mIU/ml beta-hCG is considered normal. Monitor until beta-hCG levels become undetectable.
k. Avoid sun exposure.
PELVIC INFLAMMATORY DISEASE (PID) SALPINGITIS
I. Definition
Acute or chronic bacterial inflammation of the upper female genital tract caused by infection
II. Etiology/incidence/predisposing factors/morbidity
A. 1 million cases of PID reported annually in the U.S.
B. Polymicrobial causation
C. Most common causative organisms are N. gonorrhoeae and C. trachomatis (exogenous).
D. Other etiologic agents
1. Normal vaginal flora (anaerobes)
a. Such as H. influenzae, Gardnerella
b. Streptococci
c. Enteric Gram-negative rods
d. Mycoplasma hominis
2. Trauma
3. Surgery
E. Predisposing risk factors
1. Sexually active women with multiple partners
2. Younger than age 25
3. Reduced socioeconomic status
4. Sexual exposure to a partner with urethritis
5. Low educational attainment
6. Use of contraceptive intrauterine device (e.g., IUD)
7. Douching
8. Menses: Incidence increases with onset or cessation of menses.
9. Smoking: alters the protective nature of cervical mucus
10. Substance abuse
11. Pelvic surgery
12. Prior history of PID or cervicitis
F. Complications
1. Infertility
2. Tubal pregnancy
3. Chronic pelvic pain due to adhesions
4. Recurrent PID
5. Tubo-ovarian abscess
6. Pelvic abscess and rupture
G. Infectious perihepatitis (Fitz-Hugh–Curtis syndrome)
H. Morbidity
III. Subjective findings
A. Early (up to 1 week)
1. Clinical presentation varies widely; many women have atypical or no symptoms.
2. Lower abdominal pain
3. Menstrual cramping
4. Low-grade fever
5. Malaise
B. Late symptoms
1. Severe lower abdominal pain
2. Temperature greater than 101.4° F (38.6° C)
3. Increased foul, purulent vaginal discharge
4. Dyspareunia and painful defecation
IV. Physical examination findings
A. Mucopurulent cervical or vaginal discharge
B. Friable cervix (bleeding)
C. Uterine and cervical motion tenderness (Chandelier’s sign: marked tenderness of the cervix, uterus, and adnexa)
D. Abdominal rebound tenderness or guarding
E. Infectious perihepatitis, Fitz-Hugh–Curtis syndrome (i.e., right upper quadrant abdominal pain)
V. Laboratory findings/diagnostic findings
A. Assessment of last normal menstrual period (LNMP), sexually transmitted infection (STI) history, contraceptive use, sexual history, pregnancy test, drug allergy
B. Centers for Disease Control and Prevention (CDC) Diagnostic Criteria for PID
1. Minimum criteria for diagnosing PID in any sexually active female with one of the following:
a. Uterine/adnexal tenderness
b. Cervical motion tenderness
2. Additional criteria
a. Oral temperature above 101° F (38.3° C)
b. Abnormal cervical/vaginal mucopurulent discharge; WBCs noted on vaginal microscopy
c. Elevated erythrocyte sedimentation rate (ESR)
d. Elevated C-reactive protein
e. Laboratory evidence of gonococcal or chlamydial infection
f. Leukocytosis (WBC count greater than 10,000/mm3)
3. Definitive criteria for diagnosing PID
a. Histopathologic evidence on endometrial biopsy
b. Tubo-ovarian abscess on transvaginal sonography
VI. Management
A. Early detection and aggressive treatment of STIs and lower genital tract infections essential in prevention of PID
B. CDC guidelines for treatment of acute PID
1. Parenteral inpatient treatment
a. Regimen A
i. Cefotetan 2 g IV every 12 hours, or cefoxitin sodium (Mefoxin) 2 g IV every 6 hours, or cefotetan disodium (Cefotan) 2 g IV every 12 hours plus
ii. Doxycycline (tetracycline) 100 mg IV or orally every 12 hours for 10 to 14 days
b. Regimen B
i. Clindamycin hydrochloride (Cleocin) 900 mg IV every 8 hours plus
ii. Gentamicin sulfate (Garamycin) loading dose IV or IM (2 mg/kg body weight) followed by a maintenance dose (1.5 mg/kg every 8 hours until discharge)
c. Regimens are continued until at least 48 hours after significant clinical improvement. Then, follow up with doxycycline (tetracycline) 100 mg PO every 12 hours for 10 to 14 days, or clindamycin 450 mg PO 4 times a day for 10 to 14 days.
2. CDC-recommended regimens for outpatient treatment of PID
a. Regimen A
i. Ofloxacin (Floxin), 400 mg PO twice daily for 14 days or Levofloxacin 500 mg PO twice daily for 14 days with or without
ii. Metronidazole (Flagyl), 500 mg PO twice daily for 14 days
b. Regimen B
i. Cefoxitin sodium (Mefoxin), 2 g IM plus probenecid (Benemid), 1 g PO in a single dose concurrently; or ceftriaxone sodium (Rocephin), 250 mg IM, or other parenteral third-generation cephalosporin (e.g., ceftizoxime sodium [Cefizox] or cefotaxime sodium [Claforan]) plus
ii. Doxycycline (tetracycline), 100 mg PO twice daily for 14 days (include this regimen with one of the above regimens)
C. CDC recommendations for hospitalization:
1. Surgical emergencies: Rule out ectopic pregnancy or appendicitis.
2. Coexisting pregnancy
a. HIV infected with low CD4 counts
b. Adolescent
c. Immunosuppressed
d. Nausea, vomiting, fever
e. Dehydration
f. Pelvic and tubo-ovarian abscess suspected
3. Unable to tolerate or follow an outpatient regimen
4. Failed to respond clinically to oral antimicrobial therapy within 72 hours
D. Additional considerations
1. Notification and prompt treatment of sexual partners
2. Counseling on safer sex practices and high-risk behaviors
3. Screening for other STIs
4. Testing for cure within 7 days of completion of therapy
5. Rescreening in 4 to 6 weeks for C. trachomatis and N. gonorrhoeae
6. Removal of IUD
7. Testing for HIV
8. In-hospital treatment only with parenteral antibiotics for pregnant women
E. Other treatments
1. Warm sitz baths for 10 to 15 minutes as needed for pain
2. No douching
3. Use of sanitary napkins
4. Avoidance of sexual intercourse for 7 days
5. Bed rest in a semi-Fowler’s position
6. Over-the-counter pain medications, such as acetaminophen (Tylenol)
7. Adequate hydration (6-8 glasses of water daily)
8. Condoms
CHLAMYDIA TRACHOMATIS INFECTION
I. Definition
Chlamydia is a parasitic sexually transmitted infection that produces serious reproductive tract complications in persons of either sex.
II. Etiology/incidence/complications
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A. Etiology
1. Causative organism, Chlamydia trachomatis
a. An obligate, intracellular parasite
b. This organism can live only inside of cells; therefore, transfer of body fluids is necessary for transmission.
2. Incubation period thought to be 10 to 30 days
B. Incidence
1. More than 3 million new cases annually
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