Postpartum purulent-septic diseases - Treatment

The only radical method of treating delayed complications of cesarean section is surgical. The tactics of patient management should be individual, the nature of the surgical component should be determined by the form of purulent-septic infection, and above all by the presence or absence of its generalization. Early recognition of secondary failure of the sutures on the uterus and the use of active tactics allow us to count on a favorable outcome for the patient.

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

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

The first two types of surgical treatment are undertaken in the absence of unfavorable clinical, echographic and hysteroscopic signs indicating the spread and generalization of infection (complete failure of the sutures on the uterus, panmetritis, abscess formation); in this case, the first option, i.e. hysteroscopy, is used in all patients, including before the application of secondary sutures on the uterus as adequate preoperative preparation.

• Option III - radical surgical treatment is undertaken in patients in cases of late admission with already generalized infection, as well as in the absence of effect from conservative surgical treatment and the detection of unfavorable clinical, echographic and hysteroscopic signs indicating the progression of infection.

Conservative surgical treatment includes hysteroscopy (surgical component of treatment) and drug treatment.

Hysteroscopy must necessarily begin with the “washing out” of the pathological substrate (fibrin, pus) from the uterine cavity until the waters are clear with a stream of cool antiseptic liquid, include targeted removal of necrotic tissue, suture material, remnants of placental tissue, and end with the insertion of a double-lumen silicone tube into the uterine cavity for subsequent active aspiration of the uterine cavity over the course of 1-2 days using the OP-1 apparatus.

Methodology

In order to create the most favorable conditions for healing of the sutures on the uterus, a double-lumen silicone rubber tube with a diameter of 11 mm with a perforated end is inserted into the uterine cavity and brought to its bottom. APD is carried out with a negative pressure of 50-70 cm H2O and the introduction of a furacilin solution (1:5000) through the narrow lumen of the tube at a rate of 20 drops / min. APD continues for 24-48 hours depending on the severity of the process. The only contraindication for this method is the presence of suture failure on the uterus after a cesarean section with signs of diffuse peritonitis, when, naturally, emergency surgery is necessary. This method of local treatment is pathogenetic, providing in the primary focus:

• active washing out and mechanical removal of infected and toxic contents of the uterine cavity (fibrin, necrotic tissue), which leads to a significant reduction in intoxication;
• stopping the further growth of microbial invasion (hypothermic effect of cooled furacilin);
• increased uterine motility;
• reduction of swelling in the affected organ and surrounding tissues;
• preventing the entry of toxins and microorganisms into the blood and lymphatic systems. Ensuring reliable drainage of lavage fluid and lochia eliminates the possibility of increased intrauterine pressure and penetration of uterine contents into the abdominal cavity.

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

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

1. Antibacterial therapy.

For the treatment of postpartum endometritis, the literature recommends the use of the following drugs that act on the most likely causative agents of the inflammatory process.

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

• combinations of penicillins with beta-lactamase inhibitors, such as amoxicillin/clavulanic acid (Augmentin). A single dose of Augmentin is 1.2 g intravenously, daily dose is 4.8 g, course dose is 24 g, the dose used during hysteroscopy is 1.2 g of the drug intravenously;
• second generation cephalosporins in combination with nitroimidazodes and aminoglycosides, for example, cefuroxime + metronidazole + gentamicin:
  • cefuroxime in a single dose of 0.75 g, daily dose of 2.25 g, course dose of 11.25 g;
  • metrogyl in a single dose of 0.5 g, daily dose of 1.5 g, course dose of 4.5 g;
  • gentamicin in a single dose of 0.08 g, daily dose of 0.24 g, course dose of 1.2 g;
  • 1.5 g of cefuroxime and 0.5 g of metrogyl are administered intravenously during surgery;
• first generation cephalosporins in combination with nitroimidazoles and aminoglycosides, for example, cefazolin + metrogyl + gentamicin:
  • cefazolin in a single dose of 1 g, daily dose of 3 g, course dose of 15 g;
  • metrogyl in a single dose of 0.5 g, daily dose of 1.5 g, course dose of 4.5 g;
  • gentamicin in a single dose of 0.08 g, daily dose of 0.24 g, course dose of 1.2 g;
  • 2.0 g of cefazolin and 0.5 g of metrogyl are administered intravenously intraoperatively.

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

2. Infusion therapy: the appropriate transfusion volume is 1000-1500 ml per day, the duration of therapy is individual (on average 3-5 days). It includes:
   • crystalloids (5 and 10% glucose solutions and substitutes), which help restore energy resources, as well as electrolyte balance correctors (isotonic sodium chloride solution, Ringer-Locke solution, lactasol, ionosteril);
   • plasma-substituting colloids (rheopolyglucin, hemodez, gelatinol, 6 and 10% HAES-steril solutions);
   • protein preparations (fresh frozen plasma; 5, 10 and 20% albumin solutions);
   • The use of disaggregants (trental, curantil), which are added to infusion media at 10 or 4 ml, respectively, helps improve the rheological properties of blood.
3. It is necessary to use agents that promote uterine contraction in combination with antispasmodics (oxytocin 1 ml and no-shpa 2.0 intramuscularly 2 times a day).
4. The use of antihistamines in combination with sedatives is justified.
5. It is advisable to use immunomodulators - thymalin or T-activin, 10 mg daily for 10 days (100 mg per course).
6. The use of nonsteroidal anti-inflammatory drugs, which also have an analgesic and antiaggregatory effect, is pathogenetically justified. The drugs are prescribed after antibiotics are discontinued. It is recommended to use diclofenac (Voltaren) 3 ml intramuscularly daily or every other day (a course of 5 injections).
7. It is advisable to prescribe drugs that accelerate reparative processes - actovegin 5-10 ml intravenously or solcoseryl 4-6 ml intravenously by drip, then 4 ml intramuscularly daily.

The results of treatment are assessed based on the nature of changes in temperature reaction, blood parameters, timing of uterine involution, nature of lochia, ultrasound data and control hysteroscopy.

If conservative surgical treatment is effective, clinical and laboratory parameters (temperature, number of leukocytes, total protein, level of medium molecules) are normalized within 7-10 days, uterine involution occurs, and positive dynamics are revealed by ultrasound.

According to our data, in most women in labor, when using a comprehensive conservative-surgical tactic (hysteroscopy and adequate drug therapy), the uterine scar healed by secondary intention. During control hysteroscopy after 3 months, pale yellow tissue (granulation tissue) was detected in the area of the isthmus behind the internal os along the entire scar in 21.4% of patients, which was removed with biopsy forceps. In the remaining patients, the endometrium corresponded to the secretory phase, the scar area was not visualized. Menstrual function in patients resumed after 3-5 months.

During control studies (ultrasound with Doppler) conducted after 6, 12 and 24 months, no pathological changes were detected.

In a number of patients, usually with an unfavorable obstetric history (loss or trauma of children during childbirth), with the process isolated and positive dynamics in the process of conservative surgical treatment, nevertheless, during control studies (ultrasound and hysteroscopy data), a significant defect of the uterine wall remained, which, even in the case of prolonged healing by secondary intention and the absence of activation of the process (menstruation, etc.) and its generalization, threatened a rupture of the uterus during a subsequent pregnancy. In this contingent of women in labor, we used the method of applying secondary sutures to the uterus.

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

• after conservative surgical treatment, along with positive dynamics of clinical and laboratory parameters (decrease in temperature to normal or subfebrile values, improvement of blood parameters), persistent subinvolution of the uterus occurs, the size of which exceeds by 4-6 cm the value corresponding to the period of normal involution;
• during ultrasound, the uterine cavity remains dilated, signs of local panmetritis are revealed;
• During control hysteroscopy, signs of stopped endometritis or its residual phenomena are revealed, while the defect of the scar on the uterus remains.

Technique of surgical intervention

The abdominal cavity is opened by a repeated incision along the old scar. Adhesions in the abdominal cavity and the pelvic cavity are separated sharply, the posterior wall of the urinary bladder and the vesicouterine fold are separated from the anterior wall of the uterus. In order to create maximum accessibility of the isthmus, the urinary bladder is separated widely. The intraoperative picture usually looks like this: the body of the uterus is enlarged within the period of 7-12 weeks of pregnancy, in some cases fused with the anterior abdominal wall, normal color, serous cover is pink, the consistency of the uterus is soft. As a rule, the postoperative suture on the uterus is covered by the posterior wall of the urinary bladder or the vesicouterine fold.

After acute separation of the urinary bladder, a suture with a defect is found, the size of which is quite variable - from 1 to 3 cm. The edges of the defect are infiltrated, callous, with many catgut or synthetic ligatures and detritus. The myometrium along the suture line is necrotic. Changes in the myometrium and serous cover in the area of the fundus of the uterus and the posterior wall are not noted.

The features of the technique for applying secondary sutures to the uterus are:

• Careful mobilization of the anterior wall of the uterus and the posterior wall of the bladder.
• Sharp excision of all necrotic and destructive tissues of the lower segment (down to unchanged areas of the myometrium), complete removal of the remains of the old suture material.
• The application of secondary sutures to the uterus in one row, i.e. only interrupted myomuscular sutures are applied. Closing the wound in this way is more reliable - the tissues are matched without displacement; if one thread breaks, the others continue to hold the matched edges of the wound. The amount of suture material in this method is minimal. The spread of microorganisms along the line of interrupted sutures is also less likely than along a continuous suture.
• To hold the matched tissues, vertical sutures should be used mainly. The same areas are captured on both sides of the wound: the needle is inserted, retreating 1-1.5 cm from the edge of the wound, the optimal distance between sutures is 1-1.5 cm.
• Subsequent closure of the area of secondary sutures is carried out using the posterior wall of the urinary bladder or the vesicouterine fold, which are fixed to the serous layer of the uterus above the suture line on the uterus with separate sutures.
• Only absorbable synthetic threads (vicryl, monocryl, polysorb) are used as suture material.
• To prevent bacterial toxic shock and subsequent complications during surgery, all patients are prescribed the following antibiotics at the same time:
  • ticarcillin/clavulanic acid (timentin) 3.1 g,

Or

• • Cefotaxime (Claforan) 2 g or ceftazidime (Fortum) 2 g in combination with metronidazole (Metrogyl) at a dose of 0.5 g

Or

• • meropenem (meronem) at a dose of 1 g.
• The operation ends with sanitization of the pelvic cavity with antiseptic solutions (dioxidine, chlorhexidine) and drainage of the uterine cavity (a double-lumen silicone tube is inserted into it for the purpose of active aspiration of the contents and creating conditions for healing of the “dry” wound).

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

Antibacterial therapy includes the following drugs.

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

The classic treatment for endomyometritis after cesarean section is the use of clindamycin in combination with aminoglycosides (gentamicin or tobramycin). This 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 as monotherapy for postpartum infection.

Infusion therapy in a volume of 1200-1500 ml is performed to correct metabolic disorders and improve reparative conditions. It is recommended to administer protein preparations, mainly fresh frozen plasma, at 250-300 ml daily or every other day, colloids (400 ml) and crystalloids in a volume of 600-800 ml. It is recommended to use ethylated starch HAES-6 or HAES-10 as part of infusion therapy. To normalize microcirculation, it is advisable to add disaggregants (trental, curantil) and drugs that accelerate reparative processes to the infusion media - actovegin at 5-10 ml intravenously or solcoseryl at 4-6 ml intravenously by drip, then 4 ml intramuscularly daily.

Intestinal stimulation is performed by "soft", physiological methods through the use of epidural blockade, correction of hypokalemia and the use of metoclopramide preparations (cerucal, reglan). In the absence of sufficient effect, the use of proserin, kalimin, ubretide is indicated.

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

It is advisable to use uterotonic agents in combination with antispasmodics (oxytocin 1 ml in combination with no-shpa 2.0 intramuscularly 2 times a day).

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

After discontinuing antibiotics and heparin, it is advisable to use nonsteroidal anti-inflammatory drugs. It is recommended to use diclofenac (voltaren) 3 ml intramuscularly daily or every other day (for a course of 5 injections). At the same time, all patients undergo biocenosis correction, continue intramuscular administration of actovegin (solcoseryl), and complete the course of treatment with immunomodulators.

If the operation was performed according to strict indications and the technique of applying secondary sutures to the uterus was strictly observed, there were no complications (even wound infection) after the repeated operation in any case. Patients were discharged home on the 14th-16th day. During further observation after 6, 12 and 24 months, no menstrual dysfunction was noted.

Morphological examination of excised tissues of the postoperative suture revealed signs of local inflammation combined with limited necrosis. The inflammation was characterized by the presence of pronounced lymphoid infiltration with an admixture of polymorphonuclear leukocytes and plasma cells, areas of granulation tissue and foci of necrosis. Leukocytes were located in the stroma diffusely and in the form of clusters of various sizes perivascularly and periglandularly. Changes in the vascular wall were especially pronounced in the capillaries. The epithelial cells of the crypts swelled, became larger, as if rounded, and looked lighter when stained. The stromal glands were compressed due to edema and infiltration. Pronounced dystrophic changes were noted in both the integumentary and glandular epithelium. In the muscular layer, inflammatory infiltration along the vessels and their thrombosis were detected.

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

Repeated examinations with ultrasound and hysteroscopic control were carried out after 3.6, 12 months and after 2 years. After 3 and 6 months, ultrasound examination clearly visualized the scar without signs of its deformation, and no changes in the uterine cavity or myometrium were noted.

During hysteroscopic control after 6 and 12 months, the scar appeared as a ridge-shaped thickening (up to 0.2-0.3 cm) in the isthmus area with smooth contours. After 2 years, the scar was not visualized either by ultrasound or hysteroscopy. No menstrual dysfunction was detected.

Subsequent pregnancy in such women is undesirable, however, in our practice there was a case when one of the patients with a contraceptive defect became pregnant 3 months after the operation. It proceeded without complications, clinical and echographic signs of scar failure. The delivery was performed at the usual time by cesarean section. The postpartum period proceeded without complications, the woman was 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. It is advisable to perform the operation in conditions of remission of purulent inflammation.

Preoperative preparation in such cases should be aimed at correcting protein and water-electrolyte metabolism disorders, immune status, stopping exudative and infiltrative manifestations of inflammation, improving microcirculation and preventing bacterial shock. Antibacterial therapy during this period is inappropriate, since the nature of the purulent process in such cases is already chronic, the focus of purulent inflammation is encapsulated (limited), therefore antibacterial therapy does not achieve the goal, in addition, 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 are no indications for emergency surgery (diffuse purulent peritonitis, septic shock, risk of perforation of pelvic abscesses into the bladder). According to research data, as a result of such preparation, 71.4% of patients had normalized temperature, 28.6% had subfebrile temperature, 60.7% of patients had decreased leukocyte count and medium molecule level. More stable indicators reflecting the presence and severity of the destructive process were shift in leukocyte formula and hemoglobin level. Thus, 53.6% of patients had left shift in leukocyte formula; 82.1% of patients had moderate and severe anemia.

A number of authors describe the possibility of performing supravaginal amputation of the uterus in case of an incompetent suture on the uterus with the development of peritonitis after cesarean section. We believe that performing supravaginal amputation of the uterus in conditions of a widespread purulent process is inadequate, since purulent-necrotic changes in the isthmus of the uterus, tissue ischemia and persistent septic thrombosis of the vessels in the cervix below the level of amputation continue to be the main source of activation of the purulent process and a high risk of developing abscesses of the stump and pelvic cavity, peritonitis and sepsis. This was confirmed in the course of studies, when not a single case of relaparotomy after extirpation of the uterus was identified.

The peculiarities of surgical intervention in this subgroup of patients are associated with a pronounced adhesive process in the abdominal cavity and pelvic cavity, the presence of multiple abscesses, pronounced destructive changes in the uterus and adjacent organs, pelvic, parametrium, retrovesical tissue, the wall of the bladder and intestine.

The morphological picture of the study in patients who underwent hysterectomy was characterized by the presence of extensive suture necrosis combined with foci of suppuration. Necrotic foci were located both in the endometrium and myometrium. The endometrium was in the stage of reverse development, regenerating, in some cases areas of decidual tissue with necrosis, fibrin deposits, diffuse mixed inflammatory infiltration were determined. The latter, along the intermuscular and perivascular connective tissue layers, spread to almost the entire thickness of the myometrium, decreasing towards the serous membrane. When stained according to Mallory, hemorrhagic impregnation was found in the suture area, veins that did not contract in the necrosis zone, small foci of fibrosis and numerous thrombosed arterioles and thrombi in venules that underwent autolysis.

There was a necrotic zone at the suture border. Scarring of the suture occurred more slowly than the development of the necrotic zone. Necrotic masses were positioned in foci, which prevented the resorption of necrotic masses and scarring. Necrotic areas of the myometrium were surrounded by hyperemic vessels, thrombosed in various places.

Radical operations were performed in 85.8% of patients, organ-preserving ones - in 14.2% of cases (in equal shares for vesicouterine and abdominal wall-uterine fistulas). The features of the surgical technique are described in the chapter devoted to genital fistulas. All patients were given antibiotics intraoperatively.

In the postoperative period, in all cases, aspiration-washing drainage of the pelvic cavity and destruction zones is used using the transvaginal method of introducing drainage through the open vaginal dome during extirpation of the uterus or the colpotomy wound when it is preserved. The transvaginal method allows for long-term drainage without fear of fistula formation, abscess development and phlegmon of the anterior abdominal wall.

In case of abscesses located in the subhepatic and subdiaphragmatic spaces, additional drainage is introduced through counter-openings in the meso- and epigastric regions.

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

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

It should be noted that patients with delayed complications of cesarean section who underwent reoperation had a high risk of developing urinary system diseases as a result of impaired urine outflow due to compression of the ureteral orifices by infiltrates of the parametrium and paravesical tissue, necrosis of the retrovesical tissue and destruction of the bladder wall.