Postpartum purulent-septic diseases: treatment

The only radical method for treating delayed complications of cesarean delivery is surgical. The management of patients should be individual, the nature of the surgical component should be determined by the form of a purulent-septic infection, and especially the presence or absence of its generalization. Early recognition of the secondary inconsistency of sutures on the uterus and the use of active tactics make it possible to count on a favorable outcome for the patient.

In the absence of generalized infection, two options for surgical treatment are applicable:

• I variant - conservative-surgical treatment, in which the surgical component is hysteroscopy;
• II option - organ-saving surgical treatment - application of secondary sutures to the uterus.

The first two types of surgical treatment are undertaken in the absence of adverse clinical, echographic and hysteroscopic signs, indicative of the spread and generalization of infection (complete incompetence of the uterus, panmetritis, abscessing); the first option, i.e. Hysteroscopy, is used in all patients, including before applying secondary sutures to the uterus as an adequate preoperative preparation.

• III variant - radical surgical treatment is undertaken in patients in cases of late admission of patients with already generalized infection, as well as in the absence of the effect of conservative surgical treatment and the identification of adverse clinical, echographic and hysteroscopic signs indicative of the progression of the infection.

Conservative-surgical treatment includes hysteroscopy (a surgical component of treatment) and medical treatment.

Hysteroscopy must necessarily begin with the "leaching out" of the abnormal substrate (fibrin, pus) from the uterine cavity to clean water with the current of a cool antiseptic liquid, including the targeting removal of necrotic tissues, suture material, placental tissue residues and ending with the introduction into the uterus cavity of a double-lumen silicone tube for subsequent within 1-2 days of active aspiration of the uterine cavity with the help of OP-1 apparatus.

Methodology

In order to create the most favorable conditions for the healing of sutures on the uterus, a double-lumen tube of silicone rubber with a diameter of 11 mm is inserted into the uterine cavity by the perforated end and is brought to its bottom. APD is carried out with a negative pressure of 50-70 cm aq. Art. And introducing a solution of furacilin (1: 5000) through a narrow tube lumen at a rate of 20 cap / min. APD lasts 24-48 hours depending on the severity of the process. The only contraindication for this method is the presence of inconsistency of the sutures on the uterus after cesarean section with signs of diffuse peritonitis, when, of course, urgent surgical intervention is necessary. This method of local treatment is pathogenetic, providing in the primary focus:

• active leaching and mechanical removal of the infected and toxic contents of the uterine cavity (fibrin, necrotic tissues), which leads to a significant decrease in intoxication;
• Suspension of further growth of microbial invasion (hypothermic effect of chilled furacilin);
• increased motor activity of the uterus;
• removal of edema in the affected organ and surrounding tissues;
• prevention of the entry of toxins and microorganisms into the circulatory and lymphatic systems. Ensuring a reliable outflow of washing liquid and lochi excludes the possibility of increasing intrauterine pressure and penetration of the contents of the uterus into the abdominal cavity.

Thus, with the development of postoperative endometritis after cesarean section, therapeutic-diagnostic hysteroscopy should be performed on the 5th-7th day. Early diagnosis and active tactics (including hysteroscopy with the removal of the pathological substrate, ligatures, washing the uterine cavity with antiseptic solutions, active aspiration and drainage of the uterine cavity) increase the likelihood of recovery or reconstructive surgery with an inconsistent suture on the uterus after caesarean section and prevent generalization of the infection.

Simultaneously with hysteroscopy and subsequent aspiration-washing drainage of the uterine cavity, drug treatment is performed. Its components are:

1. Antibacterial therapy.

For the treatment of postpartum endometritis, the literature recommends the use of the following agents affecting the most likely pathogens of the inflammatory process.

The following drugs or their combinations that affect the main pathogens are used. They must necessarily be administered intraoperatively, i.e. During hysteroscopy (intravenous administration at the maximum single dose) and continue antibiotic therapy in the postoperative period for 5 days:

• combinations of penicillins with inhibitors / beta-lactamases, for example combinations of amoxicillin / clavulanic acid (augmentin). A single dose of augmentin - 1.2 g IV, daily - 4.8 g, course - 24 g, the dose used during hysteroscopy - 1.2 g of the drug intravenously;
• cephalosporins II generation in combination with nitroimidazoids and aminoglycosides, for example, cefuroxime + metrogyl + gentamicin:
  • cefuroxime in a single dose of 0.75 g, a daily dose of 2.25 g, a course dose of 11.25 g;
  • Metrogil in a single dose of 0.5 grams, a daily dose of 1.5 grams, a course dose of 4.5 grams;
  • gentamycin in a single dose of 0.08 g, a daily dose of 0.24 g, a course dose of 1.2 g;
  • Intra-operatively intravenously, 1.5 g of cefuroxime and 0.5 g of metrogyl are injected;
• cephalosporins I generation in combination with nitroimidazoles and aminoglycosides, for example, cefazolin + metrogyl + gentamicin:
  • cefazolinum in a single dose of 1 g, a daily dose of 3 g, a course dose of 15 g;
  • Metrogil in a single dose of 0.5 grams, a daily dose of 1.5 grams, a course dose of 4.5 grams;
  • gentamycin in a single dose of 0.08 g, a daily dose of 0.24 g, a course dose of 1.2 g;
  • Intra-operatively intravenously, 2.0 g of cefazolin and 0.5 g of metrogyl are injected.

At the end of antibiotic therapy, all patients should make correction of the biocenosis with therapeutic doses of probiotics: lactobacterin or acylactone (10 doses 3 times) in combination with stimulants of normal intestinal microflora growth (for example, hilak forte 40-60 drops 3 times a day) and enzymes festal, mezim forte for 1-2 tablets at each meal).

2. Infusion therapy: the volume of transfusions is reasonable 1000-1500 ml per day, the duration of therapy is individual (average 3-5 days). It includes:
   • crystalloids (5 and 10% solutions of glucose and substitutes) that contribute to the restoration of energy resources, as well as electrolyte exchange correctors (isotonic sodium chloride solution, Ringer-Locke solution, lactasol, yonostearil);
   • plasma-replacing colloids (reopolyglucin, hemodes, gelatin, 6 and 10% solutions of HAES sterile);
   • protein preparations (freshly frozen plasma, 5, 10 and 20% albumin solutions);
   • improvement of rheological properties of blood is facilitated by the use of disaggregants (trental, quarantil), which are added respectively 10 ml or 4 ml in infusion media.
3. It is mandatory to use funds that help reduce uterus, in combination with antispasmodics (oxytocin 1 ml and no-dose 2.0 v / m 2 times per day).
4. The use of antihistamines in combination with sedatives is justified.
5. It is advisable to use immunomodulators - thymalin or T-activatedin 10 mg daily for 10 days (for a course of 100 mg).
6. The use of non-steroidal anti-inflammatory drugs with an analgesic and antiaggregatory effect is pathogenetically substantiated. The drugs are prescribed after the abolition of antibiotics. It is recommended to use diclofenac (voltaren) 3 ml IM every day or every other day (for a course of 5 injections).
7. It is expedient to prescribe drugs accelerating the reparative processes - Actovegin 5-10 ml IV or solkoseril 4-6 ml IV drip, then 4 ml IM daily.

The results of treatment are assessed by the nature of the changes in the temperature response, blood counts, the timing of involution of the uterus, the character of the loli, the ultrasound and the control hysteroscopy.

With the effectiveness of conservative-surgical treatment within 7-10 days, clinical and laboratory parameters (temperature, number of leukocytes, total protein, level of medium molecules) are normalized, involution of the uterus occurs, positive dynamics is revealed with ultrasound.

According to our data, in most puerperas, when using complex conservative surgical tactics (hysteroscopy and adequate drug therapy), the scar on the uterus was healed by secondary tension. In control hysteroscopy after 3 months, in 21.4% of patients in the area of the isthmus behind the inner throat, tissue of pale yellow color (granulation) was detected throughout the scar, which was removed with biopsy forceps. In the remaining patients, the endometrium corresponded to the phase of secretion, the scar area was not visualized. Menstrual function in patients resumed in 3-5 months.

In control studies (ultrasound with doplerometry), conducted at 6, 12 and 24 months, no pathological changes were detected.

In a number of patients, as a rule, with an unfavorable obstetric anamnesis (loss or traumatization of children in childbirth), when the process was differentiated and positive dynamics were present in the process of conservative surgical treatment, nevertheless, in a control study (ultrasound and hysteroscopy data), a significant defect in the uterine wall remained, that even in the case of prolonged healing by secondary tension and lack of activation of the process (menstruation, etc.) and its generalization, there was a risk of rupture of the uterus during subsequent pregnancy. In this contingent of puerperas, we applied the technique of applying secondary sutures to the uterus.

Indication for the use of the procedure: relief of acute inflammatory process and the presence of a local necrosis zone in the region of the lower segment in the absence of generalization of infection, as evidenced by the following:

• after carrying out conservative-surgical treatment, along with the positive dynamics of clinical and laboratory indicators (lowering the temperature to normal or low-grade figures, improving blood counts), there is a persistent subinvolution of the uterus, whose size exceeds by 4-6 cm the value corresponding to the period of normal involution;
• with ultrasound the uterine cavity remains enlarged, signs of local panmetritis are revealed;
• with control hysteroscopy, signs of a clasped endometritis or its residual effects are detected, while a scar on the uterus is retained.

Surgery Technique

The abdominal cavity is opened by a repeated incision in the old scar. Acute pathways split in the abdominal cavity and pelvic cavity, the separation of the posterior wall of the bladder and the vesicle-uterine fold from the anterior wall of the uterus. In order to create maximum accessibility of the isthmus, the separation of the bladder is made widely. Intraoperatively, the picture usually looks as follows: the uterus body is enlarged within the terms of 7-12 weeks of pregnancy, in some cases it is welded to the anterior abdominal wall, the color is normal, the pink cover is pink, the uterus is soft. Typically, the post-operative suture on the uterus is closed by the back wall of the bladder or the vesicle-uterine fold.

After excision of the acute pathway of the bladder, a seam with a defect is found, the dimensions of which are very variable - from 1 to 3 cm. The edges of the defect are infiltrated, calluses, with many catgut or synthetic ligatures and detritus. The myometrium along the seam line is necrotic. Changes in the myometrium and serous cover in the region of the uterus and posterior wall are not noted.

The peculiarities of the technique of applying secondary sutures to the uterus are:

• Careful mobilization of the anterior wall of the uterus and the posterior wall of the bladder.
• Excision of all necrotic and destructive tissues of the lower segment (up to unchanged areas of myometrium) by an acute route, complete removal of the remains of the old suture material.
• The application of secondary sutures to the uterus in a single row, that is, only the nodal musculocutaneous sutures are applied. Closure of the wound in this way is more reliable - the tissues are compared without displacement; In the case of rupture of one thread, the rest continue to hold the juxtaposed edges of the wound. The amount of suture material with this method is minimal. The spread of microorganisms along the line of nodal seams is also less likely than along a continuous seam.
• To keep the compared tissues should be used mainly vertical seams. On both sides of the wound, the same areas are caught: the needle is pushed back 1-1.5 cm from the edge of the wound, the optimal distance between the seams is 1-1.5 cm.
• Subsequent closure of the area of secondary seams is carried out by the back wall of the bladder or vesicle-uterine fold, which is fixed to the serous cover of the uterus above the seam line on the uterus by separate sutures.
• As a suture material only absorbable synthetic threads (vikril, monocryl, polysorb) are used.
• For the prevention of bacterial-toxic shock and subsequent complications during surgery, all patients are shown one-step administration of the following antibiotics:
  • ticarcillin / clavulanic acid (timentin) 3.1 g,

Or

• • Cefotaxime (claforan) 2 g or ceftazidime (fortum) 2 g in combination with metronidazole (metrogil) in a dose of 0.5 g

Or

• • Meropenem (meronem) in a dose of 1 g.
• The operation is completed by sanation of the pelvis cavity with solutions of antiseptics (dioxidin, chlorhexidine) and drainage of the uterine cavity (a double-lumen silicone tube is injected into it to actively aspirate the contents and create conditions for healing the "dry" wound).

In the postoperative period, active drainage of the uterine cavity lasts up to two days. Within 10-14 days, complex anti-inflammatory treatment is carried out aimed at preventing the progression of endometritis and improving reparative processes.

Antibiotic therapy includes the following drugs.

• combinations of beta-lactam antibiotics with beta-lactamase inhibitors - ticarcillin / clavulonic acid (timentin) in a single dose of 3.1, daily - 12.4 g and course - 62 g;
• combinations of lincosamines and aminoglycosides, for example, lincomycin + gentamycin or clindamycin + gentamicin:
  • lincomycin in a single dose of 0.6 g, a daily dose of 2.4 grams, a course dose of 12 g;
  • clindamycin in a single dose of 0.15 g, a daily dose of 0.6 g, a course dose of 3 g;
  • gentamycin in a single dose of 0.08 g, a daily dose of 0.24 g, a course dose of 1.2 g;
• cephalosporins III generation or combinations thereof with nitroimidazoles, for example, cefotaxime (claforan) + metronidazole or ceftazidime (fortum) + metronidazole: cefotaxime (claphoran) in a single dose of 1 g, daily dose of 3 g, course dose of 15 g;
  • ceftazidime (fortum) in a single dose of 1 g, daily dose of 3 g, a course dose of 15 g;
  • metronidazole (metrogil) in a single dose of 0.5 g, daily dose of 1.5 g, a course dose of 4.5 g;
• monotherapy with meropenems, for example;
  • a meronem in a single dose of 1 g, a daily dose of 3 g, a course dose of 15 g.

The use of clindamycin in combination with aminoglycosides (gentamicin or tobramycin) is considered to be classic for the treatment of endomyometritis after cesarean delivery. Such treatment is directed against both aerobes and anaerobes. It is believed that antianaerobic cephalosporins (cefoxitin, cefotetan), as well as semisynthetic penicillins (ticarcillin, piperacillin, mezlocillin), can be used in the form of monotherapy of postpartum infection.

To correct metabolic disorders and improve repair conditions, infusion therapy is performed in the volume of 1200-1500 ml. It is shown the introduction of protein preparations, mostly fresh-frozen plasma, 250-300 ml daily or every other day, colloids (400 ml) and crystalloids in a volume of 600-800 ml. As part of the infusion therapy, the use of ethylated starch HAES-6 or HAES-10 is recommended. To normalize the microcirculation in the infusion medium, it is advisable to add disaggregants (trental, quarantil) and preparations accelerating the reparative processes - actovegin 5-10 ml IV or solcoseryl 4-6 ml IV drip, then 4 ml IM daily .

Stimulation of the intestines is performed by "soft", physiological methods due to the application of epidural blockade, correction of hypokalemia and use of metoclopramide preparations (cerucal, raglan). In the absence of sufficient effect, the use of proserine, calimin, ubretide is shown.

Heparin, which helps to potentiate the action of antibiotics, improve the aggregation properties of blood and reparative processes, is administered in an average daily dose of 10,000 units. (2.5 thousand units under the skin of the abdomen in the peripodal region).

It is advisable to use uterotonic drugs in combination with antispasmodics (oxytocin, 1 ml in combination with no-shpu 2.0 v / m 2 times a day).

It is advisable to use immunomodulators (thymalin or T-activin 10 mg daily for 10 days, for a course of 100 mg).

After the abolition of antibiotics and heparin, it is advisable to use non-steroidal anti-inflammatory drugs. It is recommended to use diclofenac (voltaren) 3 ml IM every day or every other day (for a course of 5 injections). All patients at the same time are being corrected for the biocenosis, intramuscular injection of actovegin (solcoseryl) is continuing, immunomodulators are being treated.

If the operation was performed according to strict indications and the technique of superimposing secondary seams on the uterus was exactly observed, there were no complications (even wound infection) after a second operation in any case. Patients were discharged home on the 14th-16th day. At further observation, at 6.12 and 24 months, menstrual dysfunction was not observed.

Morphological examination of excised tissues of the postoperative suture revealed signs of local inflammation in combination with limited necrosis. Inflammation was characterized by the presence of severe lymphoid infiltration with an admixture of polymorphonuclear leukocytes and plasma cells, granulation tissue sites and necrosis foci. The leukocytes were located in the stroma diffusely and in the form of clusters of different sizes perivascular and periglundular. Changes in the vascular wall were particularly pronounced in capillaries. The epithelial cells of the crypts swelled, became larger, as if rounded, when they were painted, they looked lighter. The glands of the stroma due to edema and infiltration were squashed. There were pronounced dystrophic changes in both the integumentary and glandular epithelium. In the muscle layer, inflammatory infiltration along the vessels and their thrombosis were detected.

Patients were discharged on the 14th-16th day after a second operation. No complications were observed in any case.

Repeated examinations with ultrasound and hysteroscopic control were performed at 3.6, 12 months. And after 2 years. After 3 and 6 months. With ultrasound, the scar was clearly visualized without signs of deformity, changes in the uterine cavity and myometrium were also not noted.

With hysteroscopic control after 6 and 12 months. The scar was represented in the form of a cylindrical thickening (up to 0.2-0.3 cm) in the region of the isthmus with smooth contours. After 2 years, the scar did not visualize either with ultrasound or with hysteroscopy. Violations of menstrual function was not detected.

Subsequent pregnancy in such women is undesirable, but in our practice there was a case when a patient with a defect of contraception 3 months after the operation became pregnant. It proceeded without complications, clinical and echographic signs of the inconsistency of the scar. At the usual time, the delivery was performed by cesarean section. The postpartum period was uneventful, discharged on the 9th day.

Surgical treatment of patients with generalized forms of purulent postpartum diseases is carried out according to the principles of radical removal of the purulent focus and its adequate drainage. Operation is expedient to spend in conditions of remission of a purulent inflammation.

Preoperative preparation in such cases should be aimed at correcting the disturbances of protein and water-electrolyte metabolism, immune status, suppression of exudative and infiltrative manifestations of inflammation, improvement of microcirculation and prevention of bacterial shock. Carrying out antibacterial therapy during this period is inadvisable, since the character of purulent process in such cases is already chronic, the focus of purulent inflammation is delimited (delimited), so antibiotic therapy does not reach the goal, besides, patients receive by this time, according to our data, 2-3 courses of antibiotics. The duration of preoperative preparation is 3-5 days, if there is no indication for an emergency operation (diffuse purulent peritonitis, septic shock, threat of perforation of pelvic abscesses in the bladder). According to the research, as a result of such training, 71.4% of patients normalized their temperature, 28.6% became subfebrile, 60.7% had white blood cells and a medium molecule level. More stable indicators, reflecting the presence and severity of the destructive process, were a shift in the leukocyte formula and the level of hemoglobin. Thus, 53.6% of patients retained a shift of the leukocyte formula to the left; 82.1% of patients had moderate and severe anemia.

A number of authors describe the possibility of performing supravaginal amputation of the uterus with an inconsistent suture on the uterus with the development of peritonitis after cesarean section. It seems to us inadequate to perform supravaginal amputation of the uterus in conditions of a widespread purulent process, because purulent necrotic changes in the isthmus of the uterus, ischemia of the tissues and the remaining septic thrombosis of vessels in the cervix below the level of amputation continue to be the main source of activation of the purulent process and high risk of stump abscess and small cavity pelvis, peritonitis and sepsis. This was confirmed in the course of studies, when no cases of relaparotomy after the extirpation of the uterus were detected.

Features of the surgical manual in this subgroup of patients are associated with a pronounced adhesive process in the abdominal cavity and cavity of the small pelvis, the presence of multiple abscesses, pronounced destructive changes in the uterus and adjacent organs, pelvic, parametric, zabudyzyrnaya fiber, wall of the bladder and gut.

The morphological picture of the study in patients who underwent extirpation of the uterus was characterized by the presence of extensive necrosis of the suture in combination with foci of suppuration. Necrotic foci were located both in the endometrium and in the myometrium. Endometrium was in the stage of reverse development, regenerating, in a number of cases, parts of decidual tissue with necrosis, fibrin overlays, diffuse mixed inflammatory infiltration were determined. The latter in the intermuscular and perivascular connective tissue tissues extended almost to the whole thickness of the myometrium, decreasing towards the serous membrane. When painting on Mallory in the seam area, hemorrhagic impregnation was found, which did not diminish in the necrosis zone of the vein, small foci of fibrosis and numerous thrombosed arterioles and autologous clots in the venules.

On the border of the seam there was a zone of necrosis. Scarring occurred more slowly than the development of the necrotic zone. Necrotic masses were planted in the foci, which prevented the resorption of necrotic masses and scarring. Necrotized areas of myometrium were surrounded by hyperemic, thrombosed vessels in different places.

Radical operations were performed in 85.8% of patients, organosaving - in 14.2% of cases (in equal shares with vesicoureteral and uterine-fistula fistula). Features of operational technology are described in the chapter on genital fistula. All patients underwent antibiotics intraoperatively.

In the postoperative period in all cases, aspiration-washing drainage of the pelvic cavity and the destruction zones is performed using the transvaginal method of introducing drains through the open dome of the vagina during the extirpation of the uterus or the colpotomy wound while maintaining it. The transvaginal method allows long-term drainage without fear of fistula formation, development of abscesses and phlegmon of the anterior abdominal wall.

In the case of the arrangement of abscesses in the subhepatic and sub-diaphragmatic spaces, drainages are additionally introduced through the counter-lines in the meso- and epigastric regions.

In the postoperative period, intensive therapy is performed according to the scheme described above (with the exception of uterotonic drugs).

The effectiveness of the developed surgical technique is confirmed by the results of treatment of many patients. So, in no case the postoperative period was complicated by the generalization of a purulent infection (peritonitis, sepsis), there were no suppurative processes in the abdominal cavity and postoperative wound, thromboembolic complications, lethal outcomes.

It should be noted that in patients with delayed complications of cesarean section who underwent repeated surgery, there was a high risk of developing urinary system diseases as a result of urinary tract outflow due to compression of the ureteral by infiltrates of parametric and paravezic fiber, necrosis of the papillary tissue and destruction of the bladder wall.

Prevention

The main methods of prevention of purulent complications after cesarean section are:

• identification of risk groups;
• use of rational surgical technique and adequate suture material;
• perioperative antibiotic prophylaxis (one to three times the administration of drugs) depending on the degree of risk.

At a low degree of infectious risk, prevention is performed by a single intraoperative (after clamping the umbilical cord) by administration of cefazolin (2.0 g) or cefuroxime (1.5 g).

At an average risk level, intraoperative (after clamping the umbilical cord) use of augenthin in a dose of 1.2 g, and if necessary (a combination of many risk factors) the drug at the same dose (1.2 g) is additionally administered and in the postoperative period - after 6 and 12 h after its first use. Possible variants: cefuroxime 1.5 g + metrogyl 0.5 g intraoperatively (after clamping the umbilical cord), and if necessary cefuroxime 0.75 g + metrogil 0.5 g at 8 and 16 h after the first injection.

With a high real risk of complications - preventive antibacterial therapy (5 days) in combination with the APD of the uterine cavity (the tube is injected intraoperatively); creation of optimal conditions for repair of the postoperative zone; early adequate and effective treatment of endometritis after cesarean section.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]