Postpartum purulent-septic diseases

Postpartum purulent-septic diseases represent a serious problem and are one of the main causes of maternal morbidity and mortality.

The frequency of purulent-septic diseases after cesarean section varies, according to different authors, from 2 to 54.3%. In women with a high risk of infection, the incidence of inflammatory complications reaches 80.4%.

Read also:

• Treatment of postpartum purulent-septic diseases
• Prevention of inflammatory postoperative complications in gynecology

The most common complication of cesarean section surgery is endometritis. It is the main cause of generalization of infection and formation of an inferior cicatrix on the uterus. The frequency of endometritis, according to individual authors, reaches 55%. In most cases, with adequate treatment, endometritis is cured.

If purulent endomyometritis takes a prolonged, torpid current, microabsessing occurs in the joint zone, which leads to a divergence of the edges of the wound and the formation of an incomplete scar on the uterus (delayed complications - secondary inconsistency of the scar on the uterus).

The process can be further spread with the formation of panmetritis, purulent tubo-ovarian formations, purulent-infiltrative parametritis, genital fistulas, pelvic abscesses, delimited peritonitis and sepsis.

Postpartum infectious diseases, directly related to pregnancy and childbirth, develop after 2-3 days. After birth until the end of the 6th week (42 days) and are caused by infection (mainly bacterial).

Hospital-acquired infection (hospital, nosocamial) is any clinically pronounced infectious disease that a patient has experienced during her stay in an obstetric hospital or for 7 days after discharge from it, as well as with medical personnel because of his work in an obstetric hospital.

Most bacterial nosocomial infections occur 48 hours after hospitalization (childbirth). Nevertheless, each case of infection should be assessed individually, depending on the incubation period and the nosological form of the infection.

Infection is not considered nosocomial if:

• The patient has an infection in the incubation period before admission to the hospital;
• complication or continuation of the infection that occurred in the patient at the time of hospitalization.

The infection is considered hospital-acquired, provided:

• acquiring it in a hospital facility;
• intranatal infection.

Profiles of antibiotic resistance is a compound of the determinants of resistance of each isolated strain of a microorganism. Profiles of antibiotic resistance characterize the biological features of the microbial ecosystem, which was formed in the hospital. Hospital strains of microorganisms have multiple resistance to at least 5 antibiotics.

[1], [2], [3]

Causes of the postpartum purulent-septic diseases

Causes of postpartum purulent-septic diseases

The main pathogens of obstetric septic complications are associations of gram-positive and gram-negative anaerobic and aerobic microbes, with the predominance of opportunistic microflora. In the last decade, a new role in these associations has also been played by new-generation infections that are transmitted sexually: chlamydia, mycoplasmas, viruses, etc.

The state of normal microflora of female genital organs plays an important role in the development of purulent-septic pathology. A high correlation between bacterial vaginosis (vaginal dysbacteriosis) in pregnant women and infection with amniotic fluid, complications of pregnancy (chorioamnionitis, premature birth, premature rupture of membranes, postpartum endometritis, fetal inflammatory complications) is established.

With hospital infection, which occurs 10 times more often, the exogenous arrival of bacterial pathogens plays a leading role. The main pathogens of nosocomial infections in obstetric-gynecological practice are gram-negative bacteria, among which enterobacteria (intestinal pannochia) are most often found.

Despite a wide variety of pathogens, in most cases, postpartum infection reveals Gram-positive microorganisms (25%). Staphylococcus aureus - 35%, Enterococcus spp. - 20%, Coagulase-negative staphylococcus - 15%, Streptococcus pneumonie - 10%, other gram-positive - 20%;

Gram-negative microorganisms (25%). Escherichia coli - 25%, Klebsiella / Citrobacter - 20%, Pseudomonas aeruginosa - 15%, Enterobacter spp. - 10%, Proteus spp. - 5%, others - 25%; fungi of the genus Candida - 3%; anaerobic microflora - with the help of special research methods (20%); Unidentified microflora - in 25% of cases.

[4], [5],

Pathogenesis

Pathogenesis of postpartum purulent-septic diseases

Inflammation is the normal response of the body to infection; can be defined as a localized protective response to tissue damage, the main task of which is to destroy the microorganism-pathogen and damaged tissues. But in some cases, the body responds to the infection by a massive excessive inflammatory reaction.

A systemic inflammatory response is a systemic activation of the inflammatory response, secondary to the functional impossibility of mechanisms to limit the spread of microorganisms, the products of their vital functions from the local damage zone,

Currently, it is proposed to use such a term as "Systemic Inflammatory Response Syndrom (SIRS) syndrome, and consider it as a universal response of the body's immune system to the effect of strong stimuli, including infection. When infected with such irritants are toxins (exo and endotoxins) and enzymes (hyaluronidase, fibrinolysin, collagenase, proteinase), which are produced by pathogenic microorganisms. One of the most powerful triggers of the CASV reaction cascade is lipopolysaccharide (LPS) membranes of gram-negative bacteria.

The basis of SIRS is the formation of an excessively large amount of biologically active substances - cytokines (interleukins (IL-1, IL-6), tumor necrosis factor (TMFa), leukotrienes, y-interferon, endothelin, platelet activating factor, nitric oxide, kinins, histamine , thromboxane A2, etc.), which have a pathogenic effect on the endothelium (disrupt coagulation, microcirculation), increase vascular permeability, leading to tissue ischemia.

There are three stages in the development of SIRS (R, S. Bone, 1996):

• Stage I - local production of cytokines; in response to the effect of infection, anti-inflammatory mediators perform a protective role, destroy microbes and take part in the healing process of the wound;
• II stage - release of a small amount of cytokines into the systemic circulation; is controlled by anti-inflammatory mediator systems, antibodies, creating prerequisites for the destruction of microorganisms, wound healing and preservation of homeostasis;
• III stage - generalized inflammatory reaction; the number of mediators of the inflammatory cascade in the blood increases as much as possible, their destructive elements begin to dominate, which leads to a disruption of the functions of the endothelium with all the consequences.

A generalized inflammatory response (SIRV) to a reliably detected infection is defined as sepsis.

Possible sources of postpartum infection, which may exist before pregnancy, are:

• infection of the upper respiratory tract, especially when using general anesthesia;
• infection of epidural membranes;
• thrombophlebitis; lower extremities, pelvis, places of catheterization of veins;
• infection of the urinary organs (asymptomatic bacteriuria, cystitis, pyelonephritis);
• septic endocarditis;
• appendicitis and other surgical infections.

The favorable factors for the development of postpartum infectious complications include:

• cesarean section. The presence of suture material and the formation of a focus of ischemic necrosis of infected tissues along with a cut on the uterus create ideal conditions for septic complications;
• prolonged labor and premature rupture of amniotic membranes that lead to chorioamnionitis;
• traumatization of tissues during vaginal delivery: application of forceps, perineal incision, repeated vaginal examination during labor, intrauterine manipulation (manual removal of the placenta, manual examination of the uterine cavity, internal rotation of the fetus, internal monitoring of the fetus and uterine contractions, etc.);
• infection of reproductive fact;
• low social level in combination with poor nutrition and unsatisfactory hygiene.

The causes of infection generalizations can be:

• incorrect surgical tactics and inadequate volume of surgical intervention;
• incorrect choice of the volume and components of antibacterial, detoxification and symptomatic therapy;
• decreased or altered immunoreactivity of the macroorganism;
• presence of severe concomitant pathology;
• presence of antibiotic-resistant strains of microorganisms;
• absence of any treatment.

Symptoms of the postpartum purulent-septic diseases

Symptoms of postpartum infectious diseases

Postpartum infection is predominantly wound infection. In most cases, the primary focus is located in the uterus, where the placental site after placenta separation is a large wound surface. It is possible to infect the ruptures of the perineum, vagina, cervix. After cesarean section, the infection can develop in the operative wound of the anterior abdominal wall. Toxins and enzymes, which are produced by microorganisms and which caused wound infection, can enter the vascular bed at any localization of the primary focus.

Thus, any conditionally limited, postpartum infection localized by a protective response can become a source of sepsis development.

Characteristic of the general clinical manifestations of the inflammatory reaction;

• local inflammatory reaction: pain, hyperemia, edema, local fever, violation of the function of the affected organ;
• general reaction of the body: hyperthermia, fever. Signs of intoxication (general weakness, tachycardia, lowering blood pressure, tachypnea) indicate the development of SIRS.

Forms

Classification

For many years the classification of S.V. Sazonov-AB Bartels, according to which different forms of postpartum infection are considered as separate stages of a dynamic infectious (septic) process and are divided into limited and common. This classification does not meet the modern concept of the pathogenesis of sepsis. Significantly changed the interpretation of the term "sepsis" in connection with the introduction of a new concept - "syndrome of a systemic inflammatory response."

The modern classification of postpartum purulent-inflammatory diseases presupposes their distribution to conditionally limited and generalized forms. To conditionally limited include suppuration of the post-natal wound, endometritis, mastitis. Generalized forms are represented by peritonitis, sepsis, septic shock. The presence of a systemic inflammatory response in a parturient woman with a conditionally restricted form of the disease requires intensive observation and treatment, both in sepsis.

Postpartum infection is most likely to occur with an increase in body temperature above 38 ° C and pain in the uterus 48-72 h after delivery. In the first 24 hours after childbirth, a normal increase in body temperature is often observed. About 80% of women with an increase in body temperature in the first 24 hours after delivery through the natural birth canal signs of an infection process are absent.

The International Classification of Diseases ICD-10 (1995) also identifies the following postpartum infectious diseases under the heading "Postpartum sepsis":

085 Postpartum sepsis

Postpartum (s):

• endometritis;
• fever;
• peritonitis;
• septicemia.

086.0 Infection of a surgical obstetrical wound

Affected:

• Caesarean section after birth;
• seam of the perineum.

086.1 Other genital tract infections after childbirth

• cervicitis after childbirth
• vaginitis

087.0 Surface thrombophlebitis in the postpartum period

087.1 Deep phlebotrombosis in the postpartum period

• Deep vein thrombosis in the postpartum period
• Pelvic thrombophlebitis in the postpartum period

[6], [7], [8]

Diagnostics of the postpartum purulent-septic diseases

Diagnosis of postpartum infectious diseases

Diagnostics takes into account the following data:

• clinical: examination of the damaged surface, evaluation of clinical signs. Complaints, anamnesis;
• laboratory: general blood test (leukogram), general urine analysis, bacteriological examination of exudate, immunogram;
• instrumental: ultrasound.

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