Postpartum purulent-septic diseases - Diagnosis

Laboratory data show pronounced leukocytosis, left shift in the formula, anemia, and increased ESR. Changes in the protein-forming function of the liver are noted (decrease in total protein, dysproteinemia with albumin deficiency, a sharp decrease in the albumin-globulin coefficient - to 0.6). The level of medium molecules is 3-4 times higher than normal.

The prolonged course of the purulent process affects kidney function - almost all patients have proteinuria (up to 1%), leukocyturia (up to 20 in the field of vision), hematuria, and cylindruria.

One of the most informative diagnostic methods for complications after cesarean section is ultrasound. Analysis of echograms in patients with late complications of cesarean section allowed us to identify a number of common characteristic signs in all patients, indicating the presence of endometritis and disruption of reparation processes in the area of the suture or scar on the uterus:

• subinvolution of the uterus;
• enlargement and expansion of the uterine cavity;
• the presence of inclusions of varying size and echogenicity in the uterine cavity (intracavitary serous fluid, pus); the presence of linear echo-positive structures on the walls of the uterus (in the form of an intermittent or continuous contour), reflecting the deposition of fibrin;
• heterogeneity of the myometrium (in the area of the scar, anterior and posterior walls of the uterus);
• local changes in the structure of the myometrium in the area of the sutures in the form of areas of reduced echogenicity in the shape of a butterfly or cone (infiltration zone);
• local circulatory disorder in the scar area, expressed in a decrease in volumetric blood flow and an increase in vascular resistance indices.

The main indicator of the ultrasound examination, typical only for patients with an incompetent uterine suture, was the deformation of the cavity in the area of the scar (both external and internal contours), local retraction was determined, and a “niche” was visualized in the area of the postoperative scar.

In patients with purulent complications of cesarean section, the following diagnostic complex has a favorable prognosis:

• enlargement and expansion of the uterine cavity from 0.5 to 1.0 cm;
• deformation of the cavity in the area of the scar (the presence of a local retraction no more than 0.5 cm deep);
• the presence of inclusions of varying size and echogenicity in the uterine cavity (intracavitary serous fluid, pus); the presence of linear echo-positive structures on the walls of the uterus (in the form of an intermittent or continuous contour) with a thickness of 0.2-0.3 cm, reflecting the deposition of fibrin;
• local changes in the structure of the myometrium in the form of areas of reduced echogenicity in the area of the sutures (infiltration zone) no more than 1.5) 4.5 cm in size;
• local circulatory disorder in the scar area, manifested by a decrease in volumetric blood flow and an increase in vascular resistance indices to S/D 3.5-4.0, IR 0.7-0.85 (signs of local ischemia) with S/D indices of 2.2-2.8, IR 0.34-0.44 in the area of the upper half of the anterior wall and the posterior wall of the uterus.

The following two sets of echographic data in patients with complications of cesarean section are prognostically unfavorable, indicating the presence of local or total panmetritis and the need for surgical treatment.

Local panmetritis is characterized by:

• subinvolution of the uterus;
• enlargement and expansion of the uterine cavity from 1.0 to 1.5 cm;
• deformation of the cavity in the scar area, the presence of a “niche” with a depth of 0.5 to 1.0 cm (partial tissue defect);
• the presence of multiple heterogeneous echo-positive inclusions (purulent contents) in the uterine cavity, the presence of linear echo structures 0.4-0.5 cm thick on the walls of the uterine cavity; local changes in the structure of the myometrium in the area of the scar in an area measuring 2.5X.5 cm in the form of multiple inclusions of reduced echo density with fuzzy contours;
• local circulatory disorder in the scar area - absence of the diastolic component of blood flow, which indicates a sharp disruption in the blood supply to the tissue, leading to its focal necrosis.

The following echographic diagnostic complex indicates total panmetritis:

• subinvolution of the uterus;
• expansion of the uterine cavity throughout its length by more than 1.5 cm;
• sharp deformation of the cavity in the area of the scar: a cone-shaped “niche” is determined, the apex of which reaches the outer contour of the anterior wall of the uterus (complete divergence of the sutures);
• multiple heterogeneous echo-positive structures are determined in the uterine cavity, on the walls of the uterine cavity - echo-positive structures with a thickness of more than 0.5 cm;
• there is a diffuse change in the structure of the myometrium of the anterior wall of the uterus in the form of multiple inclusions of reduced echogenicity with unclear contours (areas of microabscessing);
• in the area of the scar between the anterior wall of the uterus and the urinary bladder, a heterogeneous formation with a dense capsule (hematoma or abscess) can be determined;
• there is a sharp decrease in the blood supply to the anterior wall of the uterus (it is not possible to visualize the blood flow velocity curves) with an increase in blood flow in the area of the posterior wall S/D less than 2.2 and IR more than 0.5;
• Echographic signs of hematomas, abscesses or infiltrates in the parametrium, pelvis and abdominal cavity can be determined.

The method of additional contrasting of the uterine cavity during echography allows to supplement the echographic picture.

To conduct the examination, a catheter with a latex rubber balloon at the end is inserted into the uterine cavity. To straighten the uterine cavity, depending on its volume, 5-50 ml of any sterile solution is injected into the balloon through the catheter under ultrasound control. The method compares favorably with previously known ones (hysteroscopy, hysterosalytingography) in its simplicity, accessibility and safety, since the sterile fluid in the uterine cavity is in a closed space (in the balloon). If there is a defect in the postoperative suture, the reflux of fluid beyond the infected cavity is excluded, i.e. the possibility of infection generalization is prevented.

In the presence of suture failure on the uterus, a defect of the uterine wall in the area of the lower segment is determined with dimensions from 1.5x1.0 cm to total divergence of the sutures on the uterus due to the balloon protruding beyond the uterine cavity towards the bladder. It should be noted that the quality of the echograms is always better, since the "zone of interest" - the anterior wall of the uterus - is located between two aqueous media - a filled bladder and a balloon with liquid in the uterine cavity, while even individual ligatures in the area of the suture on the uterus are visualized. The method reliably allows determining the indications for surgery.

Hysteroscopy

If any clinical or echographic signs of endometritis are detected after spontaneous and especially operative delivery, all patients are recommended to undergo hysteroscopy. The informativeness of hysteroscopy in the diagnosis of postpartum and postoperative endometritis is 91.4% and is the highest of all research methods, excluding pathomorphological (100%).

A hysteroscopy technique has been developed that can be performed as early as the 2nd day of the postpartum period, regardless of the method of delivery. The examination is performed using a serial device using liquid sterile media (5% glucose solution, physiological solution).

Features of performing hysteroscopy in obstetric patients:

1. For better visualization of the anterior wall of the uterus, it is advisable to place the patient on a gynecological chair with the pelvic end raised by 40 degrees.
2. In order to maximally examine the postoperative suture on the uterus, it is necessary to use a hysteroscope with 70-degree beveled optics.
3. After treatment of the external genitalia under intravenous anesthesia, the cervix is fixed with bullet forceps, then the cervical canal (if necessary) is expanded with Hegar dilators (up to No. 9). Examination and manipulations are carried out under a continuous flow of liquid in the amount of 800-1200 ml. It is desirable, and if signs of inflammation are detected, it is mandatory to add an antiseptic - 1% dioxidine solution in the amount of 10 ml for every 500 ml of solution.

Advantages of hysteroscopy: during hysteroscopy, the diagnosis of endometritis and its form is clarified, the condition of the sutures on the uterus is assessed, careful surgical removal (preferably vacuum aspiration or targeted biopsy) of necrotic tissue, cut suture material, blood clots, remnants of placental tissue is performed, the uterine cavity is sanitized with antiseptic solutions (chlorhexidine, dioxidine).

The experience of leading domestic clinics, where patients with severe purulent-septic complications of cesarean section are concentrated, has shown that with total curettage of the walls of the uterine cavity, the protective barrier is violated - the granulation ridge in the basement membrane - and the way opens to the generalization of infection. The most gentle method at present should be recognized as targeted removal of destructive necrotic tissue, the remains of the ovum under the control of hysteroscopy.

The risk of fluid reflux from the uterine cavity through the fallopian tubes into the abdominal cavity is practically non-existent. This is due to the fact that fluid reflux into the abdominal cavity occurs under pressure in the uterine cavity exceeding 150 mm H2O. It is impossible to create such pressure during a hysteroscopic examination, since the outflow of fluid from the cervical canal significantly exceeds its inflow through the hysteroscope.

The hysteroscopic picture of endometritis is characterized by the following general signs:

• dilation of the uterine cavity;
• an increase in the length of the uterine cavity that does not correspond to the normal period of postpartum involution;
• presence of turbid wash water;
• the presence of fibrinous deposits not only in the area of the placental site, but also in other areas of the uterus, including in the area of the scar;
• forming adhesions in the uterine cavity.

There are characteristic hysteroscopic signs for various types of postpartum endometritis (endometritis, endometritis with necrosis of decidual tissue, endometritis caused by remnants of placental tissue).

Thus, with fibrinous endometritis, the hysteroscopic picture is characterized by the presence of a whitish coating on the walls of the uterus, most pronounced in the area of the placental site and the suture zone, as well as fibrin flakes in the washing waters (the “snowstorm” picture).

In purulent endometritis, the uterine cavity contains pus, the endometrium is loose, pale in color, and resembles a honeycomb from which pus oozes; the lavage water is cloudy and has an odor.

Endometritis with necrosis of decidual tissue is characterized by the presence of a small amount of hemorrhagic "ichorous" fluid in the uterine cavity; areas of the endometrium are dark or black in color, sharply contrasting with the rest of the endometrial surface.

Endometritis with retention of placental tissue differs from those described above by the presence in the area of the placental site of a volumetric formation of a bluish color, spongy appearance, hanging into the uterine cavity.

The following signs indicate the presence of suture failure on the uterus against the background of endometritis:

• the presence of general signs of endometritis (dilation of the uterine cavity, fibrinous plaque on its walls, formation of adhesions, cloudy or purulent nature of the lavage water) or specific (see above) signs of endometritis;
• swelling of the scar, bending of the uterus along the scar and, as a consequence, lochio or pyometra;
• attachment of a gas bubble in the area of the weld defect;
• sagging ligatures, hanging knots into the uterine cavity, free presence of threads in the uterine cavity and lavage waters;
• detection of dark or black areas of the endometrium in the suture area, sharply contrasting with the rest of the endometrial surface, which is a poor prognostic sign indicating irreversible purulent-necrotic changes in the lower segment associated with both a violation of the surgical technique (a very low incision without maintaining the nutrition of the lower part of the cervix, unsystematic hemostasis - the application of massive or frequent sutures, "pulling" the nodes when matching the edges of the wound, ligation of the uterine artery), and being the result of necrobiotic inflammation (anaerobic or putrefactive flora);
• visualization of the defect of the postoperative suture, which looks like a "niche" or "niches", i.e. a funnel-shaped "retraction" of varying size and depth; as a rule, the defect area is always "covered", i.e. delimited from the free abdominal cavity by the posterior wall of the bladder and the vesicouterine fold, therefore, when inserting a hysteroscope into the "niche", the posterior wall of the bladder or the vesicouterine fold can be visualized;
• sometimes a formed fistula tract is determined (in case of utero-vesical fistulas), in this case, when methylene blue is introduced into the bladder, the latter is determined in the uterine cavity (and vice versa); performing a cystoscopy specifies the location and size of the fistula opening in the bladder (as a rule, the posterior wall is injured) and its relationship with the mouths of the ureters.

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