Postpartum purulent-septic diseases: diagnosis

In the laboratory data - pronounced leukocytosis, shift of the formula to the left, anemia, increased ESR. There is a change in the protein-forming function of the liver (reduction of the total protein, dysproteinemia with albumin deficiency, a sharp decrease in the albumin-globulin coefficient - up to 0.6). The level of average molecules is 3-4 times higher than normal.

Prolonged course of the purulent process affects the function of the kidneys - practically all patients are diagnosed with proteinuria (up to 1%), leukocyturia (up to 20 in the field of vision), hematuria, cylinduria.

One of the most informative diagnostic methods for complications after cesarean delivery is ultrasound. The analysis of echograms in patients with late complications of caesarean section made it possible to reveal in all a number of common characteristic signs that indicate the presence of endometriometritis and violation of repair processes in the area of the suture or cicatrix on the uterus:

• subinvolution of the uterus;
• enlargement and expansion of the uterine cavity;
• presence in the uterine cavity of different in magnitude and echogenicity inclusions (intracavitary serous fluid, pus); presence on the walls of the uterus of linear echopositive structures (in the form of intermittent or continuous contours) reflecting the imposition of fibrin;
• heterogeneity of myometrium (in the area of the scar, anterior and posterior walls of the uterus);
• local change in the structure of the myometrium in the seam area in the form of areas of low echogenicity in the form of a butterfly or cone (infiltration zone);
• local circulatory disturbance in the scar area, expressed in a decrease in volume blood flow and an increase in indices of vascular resistance.

The main indicator of ultrasound, characteristic only of patients with an inconsistent suture on the uterus, was the deformation of the cavity in the scar area (both external and internal contours), local entrainment was determined, and a "niche" was visualized in the postoperative scar area.

In patients with purulent complications of cesarean section, the diagnostic complex is prognostically favorable:

• enlargement and expansion of the uterine cavity from 0.5 to 1.0 cm;
• deformation of the cavity in the region of the rumen (the presence of a local entrainment not more than 0.5 cm deep);
• presence in the uterine cavity of different in magnitude and echogenicity inclusions (intracavitary serous fluid, pus); presence on the walls of the uterus of linear echo-positive structures (in the form of a discontinuous or continuous contour) 0.2-0.3 cm thick, reflecting the imposition of fibrin;
• local change in the structure of the myometrium in the form of areas of reduced echogenicity in the seam area (infiltration zone) of not more than 1.5) 4.5 cm;
• local circulatory disturbance in the scar area, manifested by a decrease in the volume blood flow and an increase in the indices of vascular resistance to the S / D 3.5-4.0, IR 0.7-0.85 (signs of local ischemia) with C / D 2.2- 2,8, IR 0,34-0,44 in the region of the upper half of the anterior wall and the posterior wall of the uterus.

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

For local panmetritis are characteristic:

• subinvolution of the uterus;
• enlargement and expansion of the uterine cavity from 1.0 to 1.5 cm;
• deformation of the cavity in the rumen area, the presence of a "niche" with a depth of 0.5 to 1.0 cm (partial tissue defect);
• presence in the uterine cavity of multiple heterogeneous echospositive inclusions (purulent contents), presence on the walls of the uterine cavity of linear echostructures with a thickness of 0.4-0.5 cm; local change in the structure of the myometrium in the rumen area in a 2.5 2.5 cm site in the form of multiple inclusions of low echomodality with fuzzy contours;
• local circulatory disturbance in the scar area - lack of a diastolic component of the blood flow, which indicates a sharp violation of blood supply to the tissue leading to its focal necrosis.

The following echographic diagnostic complex testifies to total pan- metritis:

• subinvolution of the uterus;
• expansion of the uterine cavity all over more than 1.5 cm;
• a sharp deformation of the cavity in the rumen: a "niche" of a conical shape is defined, the vertex of which reaches the outer contour of the anterior wall of the uterus (complete divergence of the sutures);
• Multiple heterogeneous ehopozitivnye structures are defined in the uterus cavity, on the walls of the uterus cavity - echopositive structures more than 0.5 cm thick;
• 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 fuzzy contours (areas of microabseration);
• in the region of the scar between the anterior wall of the uterus and the bladder, a heterogeneous structure with a tight capsule (hematoma or abscess) can be determined;
• there is a sharp decrease in 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 region of the posterior C / D wall of less than 2.2 and greater than 0.5;
• can be determined by echographic signs of hematomas, abscesses or infiltrates in the parameter, small pelvis and abdominal cavity.

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

For the examination in the uterine cavity, a catheter with a balloon made of latex rubber on the end is inserted. To spread the uterine cavity, depending on its volume, a 5-50 mL of any sterile solution under ultrasound control is inserted into the balloon. The method favorably differs from the previously known (hysteroscopy, hysterosalytinography) by its simplicity, accessibility and safety, since the sterile liquid in the uterine cavity is in a closed space (in the balloon). In the presence of a defect in the postoperative suture, liquid is thrown out beyond its infected cavity, that is, the possibility of generalization of the infection is prevented.

If there is an inconsistency of the sutures on the uterus, a defect of the uterine wall is determined in the region of the lower segment with dimensions from 1.5x1.0 cm to the total divergence of the sutures on the uterus by protruding the balloon beyond the uterine cavity towards the bladder. It should be noted that the quality of the echogram is always better, because the "zone of interest" - the front wall of the uterus - is located between two aqueous media - filled with a bladder and a balloon with fluid in the uterine cavity, and even single ligatures are visualized in the area of the suture on the uterus. The method reliably allows you to determine the indications for the operation.

Hysteroscopy

If any clinical or echographic signs of endometritis are revealed after spontaneous and especially operative labor, all patients are shown hysteroscopy. The informative value of hysteroscopy in the diagnosis of postpartum and postoperative endometritis is 91.4% and is the highest of all methods of study, excluding pathomorphological (100%).

A technique for hysteroscopy has been developed, which can be done already on the second day of the postpartum period, regardless of the method of delivery. The study is performed by a serial device using liquid sterile media (5% glucose solution, physiological solution).

Features of performing hysteroscopy in obstetric patients:

1. To better visualize the anterior wall of the uterus, it is advisable to put the patient on a gynecological chair with a 40-degree raised pelvic end.
2. For the purpose of maximum inspection of the postoperative suture on the uterus, a hysteroscope with a 70-degree beveled optics is necessary.
3. After processing the external genitalia under intravenous anesthesia, the cervix is fixed with bullet forceps, then the cervical canal (if necessary) is expanded by Gegar dilators (up to No. 9). Under a continuous flow of liquid in an amount of 800-1200 ml, inspection and manipulation are carried out. It is desirable, and if signs of inflammation are detected, it is necessary to add antiseptic - 1% solution of dioxidine in the amount of 10 ml for every 500 ml of the solution.

Advantages of hysteroscopy: during the hysteroscopy, the diagnosis of the endometritis and its shape is made more precise, the condition of the uterus seams is evaluated, careful surgical removal (preferably vacuum aspiration or targeted biopsy) of necrotic tissues, suture material, blood clots, placental tissue residues, uterine cavity sanitized with solutions of antiseptics (chlorhexidine, dioxidine).

The experience of leading Russian clinics, in which patients with severe purulent-septic complications of Caesarean section are concentrated, showed that with total scraping of the walls of the uterine cavity, the protective barrier, the granulation shaft in the basal membrane, is broken, and the path to generalization of the infection opens. The most sparing method at present is to recognize the targeted removal of destructive necrotic tissue, the remains of the fetal egg under the control of hysteroscopy.

The risk of throwing fluid from the uterine cavity through the uterine tubes into the abdominal cavity is practically absent. This is due to the fact that the transfer of fluid into the abdominal cavity occurs under pressure in the uterus cavity exceeding 150 mm aq. Art. With a hysteroscopic examination, it is impossible to create such a pressure, since the outflow of fluid from the cervical canal significantly exceeds its flow through the hysteroscope.

For the hysteroscopic picture of endometritis, the following general symptoms are characteristic:

• expansion of the uterine cavity;
• an increase in the length of the uterine cavity, which does not correspond to the normal period of postpartum involution;
• presence of turbid wash water;
• presence of fibrinous overlays not only in the placental area, but also in other parts of the uterus, including in the scar area;
• Formed synechia in the uterine cavity.

For various types of postpartum endometritis (endometritis, endometritis with decidual tissue necrosis, endometritis due to the remnants of placental tissue), there are characteristic hysteroscopic features.

Thus, with fibrinous endometritis, the hysteroscopic picture is characterized by the presence of a whitish coating on the walls of the uterus, which is most pronounced in the placental area and the seam zone, as well as fibrin flakes in the washing waters (the "blizzard" picture).

With purulent endometritis, the uterine cavity contains pus, the endometrium is friable, pale in color, resembling honeycombs, from which pus oozes; washing water is cloudy, with a smell.

For endometritis with necrosis of decidual tissue, a small amount of hemorrhagic "ichoric" fluid is present in the uterine cavity; Areas of endometrium of dark or black color sharply contrasted with the rest of the endometrium.

Endometrite with delayed placental tissue differs from the above described by the presence in the placental area of the bulk formation of a bluish color, a spongy species hanging down into the uterine cavity.

The presence of insolvency of the sutures on the uterus against the background of endometriometritis is indicated by the following signs:

• presence of common signs of endometritis (widening of the uterine cavity, fibrinous plaque on its walls, formation of synechia, turbid or purulent character of the washing water) or specific (see above) signs of endometriometritis;
• edema of the scar, uterine flexion along the scar and as a consequence of this lochio or pyometra;
• attachment of a gas bubble in the region of the weld defect;
• sagging of ligatures, dangling of the nodes in the uterine cavity, free presence of threads in the uterine cavity and washing water;
• Identification of dark or black areas of the endometrium in the seam area that contrast sharply with the rest of the endometrium, which is a poor prognostic sign indicating irreversible purulent-necrotic changes in the lower segment that are associated with a disruption in the technique of surgery (very low incision without maintaining the lower part of the cervix uterus, unsystematic hemostasis - imposing massive or frequent stitches, "pulling" knots when comparing the edges of the wound, ligation of the uterine artery), and I the result of necrobiotic inflammation (anaerobic or putrefactive flora);
• visualization of the defect of the postoperative suture, which looks like a "niche" or "niche", i.e. Funnel-shaped "retraction" of varying size and depth; as a rule, the defect zone is always "covered", i.e. Is delimited from the free abdominal cavity by the posterior wall of the bladder and the vesicle-uterine fold, so when the hysteroscope is inserted into the "niche", the posterior wall of the bladder or the vesicle-uterine fold can be visualized;
• Sometimes the fistula is formed (with uterine-fistula fistula), in this case, when the methylene blue is introduced into the bladder, the latter is determined in the uterine cavity (and vice versa); the cystoscopy specifies the localization and size of the fistulous opening in the bladder (as a rule, the posterior wall is injured) and its relationship with the ureteral orifices.

[1], [2], [3], [4], [5], [6], [7], [8]