High temperature after delivery. Infection
in the postpartum period. Modern ideas.
Classification, the spread of infection.
Modern ideas of the infectious agent.
Diagnostics. Principles of treatment.
Obstetrical peritonitis, causes, diagnosis,
treatment. Prevention. High-risk groups,
prevention in the outpatient setting.
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The agents of pre-and postnatal
infections may be microorganisms. Many
of them are normal flora of the female
genital tract. Postpartum infection
pathogens may also be pathogens,
sexually transmitted diseases (gonorrhea
and chlamydia).
Postpartum endometritis
 Postpartum
endometritis usually been mild
and ends in recovery, but every 4th
parturients he has a severe course, while
there is purulent resorptive fever and, in
addition, there is a real threat to the
generalization of infection.
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Mild form of the disease is characterized by relatively late
onset (5-12th day postpartum), raising the temperature to
38-38 degrees C, the absence of fever, a mild increase in
erythrocyte sedimentation rate (30-55 mm / h), leukocytosis
in the range 9.12 . 10 9 per liter, a slight alteration of the
formula neutrophil white blood cells. The general health of
patients does not change, sleep and appetite remain
good, no headaches. Somewhat enlarged uterus, lochia
long are blood. The total protein content of blood, residual
nitrogen remains unchanged. In order to establish the
severity of the patient's condition must be continuous
monitoring of respiration, hemodynamics, urine output, the
dynamics of laboratory data on the background of
complex treatment within 24 h of light frme disease
condition of the patient per day did not significantly
deteriorate.
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In severe rapid improvement for the day, as a rule, is not
even possible negative dynamics of the process. Severe
endometriosis starts at 2 to 3 days after birth, every 4th
patient, he develops in the presence of chorioamnionitis.
Usually determined by uterine tenderness, purulent lochia
become, with ichorous smell.
Severe endometriosis is usually combined with other
purulent-septic diseases.
In recent years, more and more clinical picture does not
reflect the severity of the woman in childbirth. The time of
appearance of symptoms ranged from 1 to 7-days after
the birth. Moreover, clinical data and laboratory test results
indicates a mild current. Under this option, quickly comes
generalization of infection, as applied treatments (mostly
formally appointed) did not have the desired effect.
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Reduced immune reactivity in pregnant women is a
favorable background for the development of septic
complications in childbirth and the postpartum period. On
the other hand, the focus of inflammation are known to
serve as reservoir of germs and toxins, but also a source of
sensitization. Importantly, to the presence of abortive forms
of endometritis is not served as a basis for the "gentle"
treatment.
Endometritis after cesarean always be severe. Sick suffer
from headaches, fatigue, sleep disturbances, appetite,
pain in the lower abdomen. Characteristic tachycardia
(heart rate over 110 beats / min) temperature exceeds
39oS. In 3 of 4 patients with fever is an additional increase in
body temperature. The number of leukocytes ranges from
14 to 30. 10 ^ / l in all patients the neutrophil white blood
shift formula. Anemia develops in every third patient.
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Endometritis after cesarean always occurs with
signs of intoxication and intestinal paresis. Most
often, they have been reported in patients who
underwent surgery during the excessive bleeding,
loss of fluid and electrolytes. In patients after
surgery are determined signs of hypovolemia,
hypoproteinemia and hypokalemia. The clinical
picture is characterized by weakness, headache,
dry mouth, flatulence, decreased urine output.
Determined marked leukocytosis, neutrophilic shift
formula of white blood leukocytes toxic
granularity.
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Against the background of prophylactic
antibiotics, infusion-transfusion therapy and other
methods of influence clinical endometritis after
cesarean delivery is changing. Reduced
symptoms of inflammation (not determined
marked leukocytosis, no shift leukocyte counts, no
hectic rise in temperature, chills). No clear signs of
local inflammation, is not determined by uterine
tenderness, increasing its size by bimanual
examination.
Specific component of Intensive Care
Endometritis.
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The first step is to focus on the impact of the site of infection - the
uterus. This requires an accurate and early diagnosis, one of the
options, it is an ultrasound. It allows you to set the degree of
involution of the uterus, the presence of residues of the ovum in its
cavity, the walls of the uterus.
In identifying the contents of the uterus (about 70% of women in
childbirth) is preferable to produce a vacuum aspiration, which is a
safer intervention than curettage curette. Aspiration should be
performed under the general anesthesia in combination with
components of intensive care unit (atibakterialnaya, infusiontransfusion, detoxification, etc.). Possible and curettage subject to
certain safeguards.
In the absence of a significant amount of content in a limited
expansion of the uterus cervix under anesthesia) to create a robust
outflow to reduce absorption of the products of decay and toxins
shown uterine lavage solutions of antiseptics and antibiotics.
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Our experience shows that it is better to apply
the solution was cooled and the duration of
the perfusion solution at a temperature of 12
degrees C without autonomic defense
against hypothermia should not exceed 30
minutes. With prolonged washing of the
uterine cavity must use double-barreled
catheter. Perfusion pressure should not
exceed 20 cm of water column, the usual
solution temperature - +12 - 15 degrees C.
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Active effect on the uterus with endometritis can significantly
reduce toxicity, prevent the generalization of infection, keep NATK.
However, in advanced endometrial (in puerperal state, which is
regarded as moderate to very severe), you must also conduct a set
of common components of the intensive care unit.
Common components INTENSIVE CARE ENDOMET Rita. Antibiotic
therapy.
In our daily work using the principle of early administration of
antibiotics broad spectrum.
To prescribe antibiotics at the same time a combination of at least
two antibiotics in the highest dose level taking into account the
sensitivity of the microflora, released from the blood and wounds,
sometimes in combination with Dioksidin, solution furatsillina,
metronidazole. In a combination of antibiotics include ceftriaxone
1.0 2 times a day, 400mg Abaktal / in 5-10% glucose solution,
tsefamezin by 3.0 grams a day, efloran 100ml / drip.
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Almost all NSAIDs inhibit the formation of prostaglandins, acting synergistically
on other mediators of inflammation, which reduces the effect of bradykinin,
histamine, serotonin and other
The special features of obstetric tactics with endometritis were the following:
1. Once the diagnosis or vakuumaspiratsiyu scraping the uterus should be
done only on the background of general anesthesia and continuing intensive
therapy.
2. Effectively describe the complex intensive therapy should be evaluated no
later than one day of treatment. With a decrease in uterine volume,
stabilization clinical and laboratory parameters and improving the health of
patients should consider the impact on the primary site is sufficient. In case of
failure of the treatment, even against the background of the satisfactory
condition of patients, but the remaining clinical and laboratory signs of
inflammation should raise the issue of hysterectomy - than later, removal of
the uterus, the worse the prognosis and the greater the risk of sepsis and
infectious-toxic shock.
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Postpartum ulcer (chronic inflammatory process in the perineum, vulva,
vagina, cervix). Unlike postpartum endometritis in postpartum ulcer likelihood
of generalization process is much smaller, but it is not excluded. Patients with
postpartum ulcers are a source of infection for healthy childbirth.
In the presence of an inflammatory infiltrate in the joints and perineum wound
should be open and allow free flow of wound. With festering necessary
drainage of purulent cavities and thorough washing of antiseptic liquids.
Impregnated with purulent and necrotic tissue should be excised past. To
stimulate the formation of granulation tissue, it calls for full proteolytic enzymes
(trypsin and chymotrypsin) and providing hyperbaric oxygenation. For this 1020 mg diluted in 25-50 silt 0.25% solution of novocaine. Gauze pads soaked
with a solution injected into the wound. Proteolytic enzymes in the third to
reduce the healing time of postpartum ulcer and allow earlier deferred to
impose the secondary seams.
Antibiotic and fluid therapy for postpartum ulcer shown with symptoms of
intoxication and fever. The principles of the treatment is the same as in the
treatment of postpartum endometritis.
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INFECTION of the wound after cesarean section. Clinical presentation during
infection of the wound is characterized by both local and general symptoms.
The patient has weakness, loss of appetite, pain in the wound, the body
temperature is taken to 38-38, 5 degrees C are defined infiltration of the
wound the skin redness and soreness. Increased white blood cell count,
increased S0E. Every 7th patient has not expressed enteroplegia may be
single vomiting, intestinal peristalsis is preserved.
When suppuration of the wound tissue is removed and stitches provide
outflow of wound, pus cavity should be drained. In auditing the wounds to
exclude eventration, as it is a sign of peritonitis, and calls for the production of
hysterectomy with uterine tubes.
In the treatment of the wound festering known principles guided surgery
(Kuzin MK Kostichenok BM, 1981): excision of tissue, providing drainage, the
suppression of inflammation and swelling, flushing and physical active
antiseptic). Shows antibiotic treatment, restorative, infusion therapy, the
appointment of proteolytic enzymes. Treatment is carried out on the same
principles.
OBSTETRIC Peritonitis
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Obstetrical peritonitis - one of the most serious complications in
slerodovogo period. The source of infection is the most uterus
(horiamnionit in childbirth, postpartum endometritis, uterine
dehiscence after cesarean section). The important role of the
uterus as a portal of entry is determined by the presence in it of
blood clots and the remnants of the ovum, is an excellent medium
for the growth of microorganisms. In addition, the pregnant uterus
has a large surface area for bacterial and tissue resorption of toxins,
and promote blood circulation particularly its massive flow of
bacterial flora and toxins in the bloodstream. Infection with
peritonitis develops in the sensitization during pregnancy and
changes her hormonal homeostasis (primarily iatrogenic), and
secondary immunodeficiency. Obstetrical peritonitis often has
slack, worn over, especially after C-section, in which there is no
damage to the integrity of the bowel or other organs of the
gastrointestinal tract
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The leading role in the genesis of pathophysiological reactions in peritonitis
belongs intoxication caused by bacterial toxins, tissue proteases, biogenic
amines (histamine, serotonin, kinin) and hypovolemia ("no return" fluid loss
from krovyanosnogo riverbed deposits and sequestration of blood in the
vessels of the abdominal and part of the chest cavity), paralysis (paresis) of
the gastrointestinal tract.
The nature and severity of changes in peritonitis defined different
combination of factors such as the type, virulence, number of infiltrators into
the abdominal cavity of microbes, the prevalence of the duration of the
pathological process, the immune system of the body
In most cases with peritonitis show a mixed microbial flora, however, has a
leading role, E. coli, and Staphylococcus aureus, Pseudomonas aeruginosa
and Proteus vulgaris.
Proteinaceous toxins (polypeptides, tissue proteases, bacteria and their waste
products), toxins - crystalloids (ammonia), biogenic amines (histamine,
serotonin, heparin), soaked in blood, cause profound changes in the body.
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The source of infection of the abdominal cavity after
caesarean section may also be due to increased
permeability of the intestinal wall paresis for toxins
and bacteria "This phenomenon was established
almost 100 years ago and repeatedly confirmed by
subsequent research" However microbial invasion
into the abdominal cavity is accompanied by the
development of the typical pattern of peritonitis with
massive exudation, severe functional disturbances
and metobolicheskimi only under certain conditions.
The third and most common version of peritonitis
caused by infection of the abdominal cavity due to
lack of seams in the womb.
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The clinical picture of peritonitis midwifery consists of
a series of general and local symptoms. When
obstetric peritonitis local manifestations are less
pronounced and the reactive phase quickly moves
into a phase of intoxication.
Thus, in the "early" form of obstetrical peritonitis, signs
of intoxication, psychomotor agitation, thirst, dry
mucous membranes, tachycardia, weakness. The
severity of the patient is determined by a
combination of virulence of the infection and the
rate of development of multiple organ failure, in
particular, the degree of hypovolemia due to
prolonged labor, excessive blood loss during surgery,
a large loss of electrolytes and fluids.
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The clinical picture of the second form of midwifery at the onset of
peritonitis dominates enteroplegia, symptoms of postpartum
endometritis sidelined. The severity of the patient is determined by
the growing phenomena of intoxication. which occurs as a result of
violation of the barrier function of the intestine. and due to
resorption of toxic products from the uterus.
According to the third form of peritonitis due to lack of seams on
the uterus and receipt of the infectious agent into the peritoneal
cavity in the clinical picture more clearly reflected local symptoms.
On the background of marked enteroparesis determined positive
symptom SHCHetkina-Blumberg, "muscular defense", vomiting,
loose stools and frequent with a pungent odor, clear local
tenderness on palpation. However, given the complex intensive
care clinical peritonitis may obscured and Recognition is only
possible when a "return" of symptoms.
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During the operation, the surgeon must clarify the nature of the form of
peritonitis exudate (serous, fibrinous or purulent), and the prevalence of
abdominal lesions (limited, diffuse or full). In most cases, after 4 days from the
time of the cesarean observed purulent exudate, the defeat of the
peritoneum is most often diffuse. Clarification forms of peritonitis necessary to
address the application of the "abdominal dialysis" indication for the meeting
is the total peritonitis or disease, with intoxication.
Along with the local therapy of peritonitis after cesarean (removal of the
uterus, abdominal drainage, stomach, and some patients bowel or ileostomy)
is necessary and general medicine. The purpose of general medicinecompensation pathophysiological disturbances and fighting infection and
intoxication.
Considering the provisions defining the general therapy, one must pay
attention to the sequence of therapeutic measures, In peritonitis after
cesarean section when there is no destruction of any portion of the
gastrointestinal tract, surgical treatment is carried out on urgent indications.
However, it is not limited to a few hours, as the surgical peritonitis, caused
destructive appendicitis, perforated gastric ulcer, intestinal, etc.
Consequently, the total therapy should precede surgical treatment
performed or simultaneously with it.
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Peritonitis caused by the anaerobic flora, it is appropriate
we used a hyperbaric oxygen possessing, powerful
hypoxic, antipareticheskim and detoxifying effects.
Thus, the tactics of the patient depends on the form of
peritonitis, the severity of her condition and hemodynamic
disturbances occurred, fluid and electrolyte, protein
metabolism, disorders of microcirculation, tissue
metabolism, damage to internal organs. Integrated
intensive therapy solves all questions correct disability.
Properly conducted therapy peritonitis can in some cases
(the "early" peritonitis) avoid traumatic and disabling
operations (hysterectomy), and mortal danger that it
possible to represent a peritonitis.
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Thus obstetrical peritonitis - is a dangerous complication of
cesarean delivery, abortion is rarely (if the perforation of the uterus),
late diagnosis and inadequate treatment of which is fatal.
Characteristic of the flow is the virulence of this disease
infection, polymicrobial landscape, bacterial resistance to many
antibiotics, reducing the body's defenses. Effacement of symptoms,
poor flow, undulating course amid intensive care cause delay in
diagnosis and surgery, leading to maternal mortality.
To prevention are healthy women of reproductive age,
readjustment of foci outside and during pregnancy, strict
accounting contraindications cesarean population, adherence to
the operating mode sanepid generic unit, increased attentive
management of patients exposed to / from the intensive care and
rehabilitation units.
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Thus purulent-septic diseases after birth
represent ugpozy mother's life. In order to
prevent them should be treated with foci of
chronic infection in women before
pregnancy: dental caries, chronic tonsillitis,
purulent sinusitis, pyelonephritis, colpitis,
cervicitis, cervical erosion, enterocolitis.
During pregnancy should also conduct health
and sanitation of medical therapies foci of
latent infection, increase the protective
properties of the female organism.
Thank
you for
attention