PELVIC INFLAMMATORY

DISEASE WITH ENDOMETRIAL

HYPERPLASIA WITH ATYPIA

PRESENTED BY :
Jammula Mounika
Reg No: 18Q0411
5th pharm D
Bapuji Pharmacy College, DVG
Pelvic Inflammatory Disease (PID)
• PID is a clinical syndrome associated with ascending spread of microorganisms from the vagina or cervix
to the endometrium, fallopian tubes, ovaries and contiguous structures.
Symptoms
 Pain in lower abdomen and pelvis – ranging from mild to severe
 Unusual or heavy vaginal discharge that may have an unpleasant odor
 Fever, sometimes with chills
 Painful, frequent or difficult urination
 Unusual bleeding from vagina
 Irregular periods

Etiology
• 85% of cases, the infection is caused by sexually transmitted bacteria [Neisseria
gonorrhoeae or chlamydia trachomatis]
Complications
• Ectopic pregnancy
• Infertility
• Chronic pelvic pain
Endometrial hyperplasia
• It is a precancerous condition in which there is an irregular thickening of the uterine lining
• Hyperplasia usually develops in the presence of continuous estrogen stimulation unopposed by
progesterone
Clinical presentation
 Uterine bleeding, whether in the form of menorrhagia, metrorrhagia, or post menopausal bleeding
 Vaginal discharge
 Low abdominal pain

Risk factors
 Most frequently diagnosed in postmenopausal women
 Nulliparity
 Delayed menopause
 PCOS
 Obesity
 Previous radiation therapy

Complications
 Anemia
 cancer
Patient demographics
Name : QRS
Age : 50 years
Gender : female
Consultant : OBG unit -1
DOA : 13/02/2023
DOD : 22/02/2023
IP no : IP2302130166
Problem list
• Pelvic inflammatory disease
• Endometrial hyperplasia with atypia

Symptoms
C/O irregular bleeding PV since 3 months
C/O lower abdominal pain
C/O abnormal vaginal discharge
 SOAP ANALYSIS
• Subjective evidences
C/O irregular bleeding PV since 3 months
C/O lower abdominal pain
C/O abnormal vaginal discharge
Objective evidences

History of present illness

P2L2 Non tubectomized postmenopausal C/O irregular bleeding PV since 3 months .
Bleeding associated with clot and dysmenorrhea + with abnormal vaginal discharge

Menstrual history
Present irregular bleeding for 15-20 days ( heavy flow), H/O clots present , dysmenorrhea present

Obstetrics history
P2L2 A9-10
P1L1 – male , FTND /23 years of age
A1-2MOA A2 , A3 -2MOA , A4-2MOA
P2L2 – female / LSCS /22years of age
A6 –A9 medical (D and C)
Past medical history :NIL
Past medication history :NIL

Personal history :
• Diet :veg
• Sleep : adequate
• Appetite : normal
• Bowel and bladder : normal

Family history : H/O mother died of endometrial malignancy

General physical examinations

PR: 82BPM
BP : 120/80 mmHg
Temp : afebrile
RR : 18cpm
Patient is conscious , co operative and is oriented to time , place and person
Systemic examinations
• CVS : S1S2 heard , no murmurs
• RS : B/L NVBS heard , no added sounds , B/L breast normal , thyroid , spine – normal
• PER ABDOMEN :

Palpation : all findings confirmed on palpation , soft , non tender , no masses , no organomegaly
Auscultation : bowel sounds heard
Per speculum : cervix –soft
BME : uterus A/V , bulky , tenderness +
Relevant previous investigation report

• 30/12/2022 – Bulky uterus with thickened endometrium cystic spaces seen in the endometrium .
• 13/01/2023- Negative intraepithelial neoplasia / malignancy
• 18/01/2023 – Hyperplasia with atypia
LABORATORY INVESTIGATIONS

PARAMETER RESULT REFERENCE RANGE

Hemoglobin 11.6 g/dl 12-16 g/dl

Lymphocyte 38% 25-33%

Monocytes 8% 3-7%

PCV 34.6% 42±5%

 ASSESSMENT
Based on subjective like irregular bleeding PV since 3 months, lower abdominal pain, abnormal vaginal discharge
and objective evidences like
• Bulky uterus with thickened endometrium cystic spaces seen in the endometrium .
• Hyperplasia with atypia , the patient was diagnosed to have Pelvic Inflammatory Disease with Endometrial
hyperplasia with Atypia

PLANNING
Goals of therapy
 To reduce the symptoms associated with the disease like bleeding and dysmenorrhea
 To inhibit the further progress of infection
 To prevent complications associated with disease condition
 To improve patients quality of life
 MEDICATION CHART

BRAND NAME GENERIC NAME DOSE ROUTE FREQUENCY DURATION

Inj. TT Tetanus toxoid 0.5 ml IM STAT 14/02.2023

Tab. Bandy plus Albendazole + Ivermectin 400mg +12 mg P/O STAT 14/02/2023

Inj. Arixone SB Ceftriaxone +Sulbactam 1000mg + 500 mg IV 1-0-1 5 Days

Inj. PAN Pantoprazole 40 mg IV 1-0-1 5 Days

Inj. Metrogyl Metronidazole 100 ml IV 1-1-1 7 Days

16/02/2023
Inj. Ondem Ondansetron 4mg IV SOS 16/02/2023

Inj. Dynapar AQ Diclofenac sodium 75 mg IV 1-0-1 16/02/2023 –

17/02/2023
Inj. Tramadol Tramadol 100ml IV SOS Start on
16/02/2023
Inj. Phenergan Promethazine 25 mg IM STAT 16/02/2023

Tab. Combiflam Ibuprofen + Paracetamol 400mg+ 325 mg P/O 1-0-1 17/02/2023

5 days
Tab. Oflox Ofloxacin 400mg P/O 1-0-1 17/02/2023
7 days
Tab. Limcee Ascorbic acid 500 mg P/O 1-0-1 17/02/2023
6 Days
Inj. Pethidine Meperidine 50 mg IM SOS 16/02/2023
STAT
IV FLUIDS 5ʘ 2ʘ DNS 5ʘ IV 17/02/2023
2ʘ RL
1ʘ 5% DEXTROSE
1 ʘ PCV transfusion 17/02/2023
Inj. Metrogyl
• Generic name: Metronidazole
• Category: Nitroimidazole
• Indication: pelvic inflammatory disease
• MOA: inhibits nucleic acid synthesis by disrupting DNA and causing strand breakage
• Dose: 500mg PO
• ADR: dizziness, xerostomia
• Assessment: the given dose does not comply with CDC recommendation and indication is appropriate
• Justification: wiesenfeld and colleagues conducted a randomized, placebo-controlled double blind trial
comparing the use of single dose, 250mg ceftriaxone and doxycycline for 14 days with or without
metronidazole in 233 women with acute PID. Anaerobic organisms were recovered less frequently from
the endometrium in women in the metronidazole group than in the placebo group and cervical
Mycoplasma genitalium also was reduced in the metronidazole group
Inj. Arixone SB
• Generic name: ceftriaxone + sulbactam
• Category: 3rd gen cephalosporin antibiotic and beta lactamase inhibitor
• Indication: pelvic inflammatory disease
• MOA: ceftriaxone inhibits bacterial cell wall synthesis and sulbactam inhibits beta lactamase enzyme thus
prevents the degradation of ceftriaxone
• Dose: 250 mg IM
• ADR: rash, eosinophilia
• Assessment: the given dose does not comply with treatment recommendation of PID according to CDC
and indication is appropriate
• Justification: according to study conducted by Wiesenfeld H C and Meyn L A . Treatment of acute pelvic
inflammatory disease with ceftriaxone, doxycycline, and metronidazole is associated with significant less
frequent recovery of anaerobic organisms from the upper genital tract and improved clinical response was
observed
Inj. Phenergan
• Generic name: promethazine
• Category: antihistamines
• Indication: relax and sedate patient before surgery
• MOA: blocks histamine 1, post synaptic mesolimbic dopamine, alpha adrenergic, mascurnic and NMDA
receptors
• Dose: 25mg IV
• ADR: Confusion, blurred vision
• Assessment: the given dose and indication is appropriate
Tab. Limcee
• Generic name: ascorbic acid
• Category: antioxidants
• Indication: faster wound healing after surgery
• MOA: necessary for collagen formation and tissue repair and also protects against oxidative stress induced
cellular damage by scavenging of reactive oxygen species
• Dose: 500mg PO
• ADR: flushing , dyspepsia
• Assessment: the given dose and indication is appropriate
• Justification: according to study conducted by Fukushima R et al. vitamin C requirement is increased in
surgical patients, and the potential advantage of supplementation is increased the plasma and tissue levels
of vitamin C and thereby reduction in oxidative stress and also was associated with reduced pain score
 ONCE ONLY DRUGS

BRAND NAME GENERIC NAME DOSE ROUTE FREQUENCY DAY

Tab PAN D Pantoprazole + Domperidone 40 mg + 30mg P/O 1-0-1 15/02/2023

Tab. Anxit Alprazolam 0.25 mg P/O 0-0-1 15/02/2023

Inj. Pipensia Piperacillin + Tazobactam 4 gm + 500 mg IV 1-0-1 16/02/2023

Soup water enema 200 ml P/R 12 AM 16

4 AM /02/2023
 DAILY FOLLOW UP

14 /02 /2023 O/E

BP : 120 /80 mm HG
PR : 80 BPM
P/A : soft and non tender
CVS : S1 S2 Heard
RS : NVBS Heard
VVE : NAD
Advice : monitor vitals

O/E
15 /02 / 2023 BP : 120/80 mmHg
NBM from 10:00 PM PR: 82 BPM
Tab. Anxit 0.025mg 0-0-1 CVS : NAD
Tab. Pan D 40mg + 30 mg 1-0-1 RS : NAD
P/A : Soft and non tender
VVE : NAD
Advice : monitor vitals
 16/02/2023 Surgical procedure :
TOTAL ABDOMINAL HYSTERECTOMY WITH
BILATERAL SALPINGOOPHORECTOMY
O/E
BP : 130/80 mmHg
PR : 66 BPM POST OPERATIVE INSTRUCTION :
CVS : NAD NPO : 6hrs for solids and 2 hrs. for liquids
RS : NAD Pain management :
P/A : Wound dressing dry , no leakage Inj. Paracetamol 1gm TID
VVE : No bleeding Epidural top up :
Advise : monitor vitals Inj. Bupivacaine 0.1% 7CC Q8h
Soap water enema @ 12:00AM & 4:00AM Inj. Morphine 2mg 0-0-1 + Inj. Bupivacaine 0.1% 5CC
1ʘ RL @ 6:00AM
Inj. Pipensia 4.5gm @ 8:00 AM
Inj. PAN 40mg @ 8:00 AM
Inj. Ondem 4mg SOS
 O/E
17/02 /2023
BP : 130/80mmHg
PR : 90 BPM
SPO2 : 100%
Intake : 1900 ml
Output : 1300 ml
P/A : wound dressing dry , no leakage
VVE : NAD
Advice : monitor vitals
Coffee
5ʘ IV fluids [ 2ʘ DNS + 2ʘ RL + 1ʘ 5%
Dextrose]
1ʘ PCV Transfusion
 DISCHARGE MEDICATION

BRAND NAME GENERIC NAME DOSE ROUTE FREQUENCY DURATION

Tab. Irentia XT Ferrous ascorbate + Folic 60mg +1.5mg P/O 0-0-1 30 days
acid

Tab. Carecal C Cholecalciferol + Zinc + 0.25mg + 4mg+ P/O 0-1-0 30 days

calcium carbonate 500mg

Nutrensia 5ml P/O 1TS-0-1TS 30 days

protein powder
 PHARMACIST INTERVENTION

DRUG – DRUG INTERACTION

SERIOUS
• Ofloxacin + Ondansetron
Ofloxacin and Ondansetron both increase QTc interval
ECG monitoring is recommended
Type: pharmacodynamic interaction

MONITOR CLOSELY
• Promethazine + Meperidine
Promethazine and Meperidine both increase sedation . Use caution /monitor
Type : pharmacodynamic interaction

• Promethazine + Ofloxacin
Promethazine and Ofloxacin both increase QTc interval
Type : pharmacodynamic interaction

• Promethazine + Tramadol
Promethazine and Tramadol increase sedation .use caution / monitor
• Meperidine + Tramadol
Meperidine and Tramadol both increase sedation
Type : pharmacodynamic interaction

• Diclofenac + Ibuprofen
Diclofenac and Ibuprofen both increases anticoagulation and serum potassium .Use caution /monitor
Type : pharmacodynamic interaction

MINOR
• Metronidazole + Acetaminophen
Metronidazole will increase the level or effect of diclofenac by affecting hepatic enzyme CYP2C9/10 metabolism
Type : pharmacokinetic interaction

• Metronidazole + Diclofenac
Metronidazole will increase the level or effect of diclofenac by affecting hepatic enzyme CYP2C9/10
Type : pharmacokinetic interaction
• Diclofenac + Ibuprofen
Diclofenac will increase the level or effect by acidic (anionic) drug competition for renal tubular clearance

PATIENT COUNSELLING
DISEASE RELATED

 Pelvic Inflammatory Disease [ PID ] : An infection of the female reproductive organ

 Endometrial hyperplasia with atypia : It is a precancerous condition in which there is an irregular thickening of
the uterine lining
DRUG RELATED
• Ferrous ascorbate + Folic acid
 Advise patient to take the drug 1 hour before or 2 hours after meals on an empty stomach . If stomach is
disturbed , then take the drug along with food
 Before or after this drug , stop taking antacids , dairy products , tea or coffee within 2 hours as they can reduce
their efficacy
 Tell patient not to worry , that after taking this drug , stool may appear black

• Cholecalciferol + zinc + calcium carbonate

 Advice patient to take the drug along with food , because stomach acid helps in absorption of drug and food
prevents gastric irritation
 Tell patient not to consume drug along with milk , as it decreases the absorption of calcium

• Nutrensia protein powder

 Advice patient to mix 1TS of protein powder in 1 glass of lukewarm water ,dissolve well and consume
immediately
 LIFE STYLE MODIFICATION
1. Do not lift heavy weights (>4kg) until 6weeks after surgery
2. Rest well if you feel tired
3. Try to walk and stretch each day
4. Include proteins such as fish , eggs , milk , yoghurt , nuts and beans in the diet which help with healing after
surgery
5. Drink about 8-10 glasses of fluids a day , to keep your body well hydrated
6. Avoid foods like butter , fried foods , sweets
7. Keep the wound clean and pat dry
8. Wear loose fitting clothing that will not rub or irritate the incision area
9. Increase your fiber intake like apple , carrots , bananas , oats , brown rice to avoid constipation
THANK YOU