What is the treatment for Pelvic Inflammatory Disease (PID) during pregnancy?

From the Guidelines

Treatment of pelvic inflammatory disease (PID) during pregnancy requires hospitalization and intravenous antibiotics due to increased risks to both mother and fetus. The decision to hospitalize is based on the discretion of the healthcare provider, considering factors such as the patient's pregnancy status, severity of illness, and ability to tolerate oral therapy 1.

Key Considerations

• The recommended regimen includes cefotetan 2g IV every 12 hours or cefoxitin 2g IV every 6 hours, plus doxycycline 100mg IV or orally every 12 hours, providing anaerobic coverage as suggested by the Centers for Disease Control and Prevention 1.
• Alternative regimens include clindamycin 900mg IV every 8 hours plus gentamicin loading dose of 2mg/kg IV followed by 1.5mg/kg every 8 hours.
• Treatment should continue for at least 24-48 hours after clinical improvement, then transition to oral therapy to complete 14 days total.
• Doxycycline should be avoided in the third trimester due to risk of dental staining in the infant.

Monitoring and Follow-up

• Close monitoring with serial ultrasounds is essential to assess for tubo-ovarian abscess formation, which may require surgical drainage.
• PID during pregnancy increases risks of preterm labor, maternal sepsis, and fetal loss, making prompt diagnosis and aggressive treatment crucial.
• The antibiotics target common causative organisms including Neisseria gonorrhoeae, Chlamydia trachomatis, and anaerobic bacteria.
• After treatment, follow-up cultures should be obtained to ensure cure, and partners should be treated to prevent reinfection.

From the FDA Drug Label

Gynecological infections, including endometritis, pelvic cellulitis, and pelvic inflammatory disease caused by Escherichia coli, Neisseria gonorrhoeae (including penicillinase-producing strains), Bacteroides species including B. fragilis, Clostridium species, Peptococcus niger, Peptostreptococcus species, and Streptococcus agalactiae Cefoxitin for Injection, USP, like cephalosporins, has no activity against Chlamydia trachomatis. Therefore, when Cefoxitin for Injection, USP is used in the treatment of patients with pelvic inflammatory disease and C. trachomatis is one of the suspected pathogens, appropriate anti-chlamydial coverage should be added Gynecologic Infections caused by Staphylococcus aureus (methicillin susceptible), Staphylococcus epidermidis (methicillin susceptible, Streptococcus species, Streptococcus agalactiae, E coli, Proteus mirabilis, Neisseria gonorrhoeae, Bacteroides fragilis, Prevotella melaninogenicaBacteroides vulgatus, Fusobacterium species*, and gram-positive anaerobic cocci (including Peptococcus niger and Peptostreptococcus species). Cefotetan, like other cephalosporins, has no activity against Chlamydia trachomatis Therefore, when cephalosporins are used in the treatment of pelvic inflammatory disease, and C. trachomatis is one of the suspected pathogens, appropriate antichlamydial coverage should be added.

Treatment of Pelvic Inflammatory Disease (PID) during pregnancy should be done with caution.

• Cefoxitin and Cefotetan can be used to treat PID caused by susceptible organisms.
• However, since both Cefoxitin and Cefotetan have no activity against Chlamydia trachomatis, appropriate anti-chlamydial coverage should be added when C. trachomatis is suspected as one of the pathogens.
• The choice of antibiotic should be based on the severity of the infection, the patient's condition, and the results of susceptibility studies 2 3.
• It is essential to note that the use of antibiotics during pregnancy should be carefully considered, and the benefits should outweigh the potential risks.
• The treatment regimen should be individualized, and the patient should be closely monitored for any adverse effects.

From the Research

Treatment of Pelvic Inflammatory Disease During Pregnancy

• The treatment of pelvic inflammatory disease (PID) during pregnancy is crucial to prevent severe health consequences, including infertility, chronic pelvic pain, and ectopic pregnancy 4.
• A systematic review of the literature found that PID during pregnancy is a rare and understudied occurrence, with potential negative outcomes, including nonviable births and neonatal deaths 4.
• The diagnosis of PID during pregnancy should be made promptly, and treatment should not be delayed if there is a high enough suspicion 4.
• Risk factors for PID development during pregnancy include maternal pelvic structural anomalies, a history of sexually transmitted infections, recent pelvic surgery, and in vitro fertilization or oocyte retrieval 4.
• The treatment of PID during pregnancy may involve exploratory laparotomies, unilateral salpingo-oophorectomies, and appendectomies, as well as antibiotic therapy 4.
• Broad-spectrum antibiotic regimens that adequately cover the polymicrobial etiology of PID, including Neisseria gonorrhoeae, Chlamydia trachomatis, and anaerobic and facultative bacteria, are recommended for the treatment of PID 5, 6.
• The choice of antibiotic regimen should be based on the severity of the disease, the patient's medical history, and the potential for resistance patterns among PID pathogens 7.
• Outpatient treatment of mild-to-moderate PID may include tolerated antibiotic regimens consisting of an extended-spectrum cephalosporin in conjunction with either azithromycin or doxycycline, while clinically severe PID should prompt hospitalization and imaging to rule out a tubo-ovarian abscess 5.