Postpartum purulent-septic diseases

Postpartum purulent-septic diseases are 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 various authors, from 2 to 54.3%. In women with a high risk of infection, the frequency of inflammatory complications reaches 80.4%.

Read also:

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

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

If purulent endomyometritis takes a protracted, sluggish course, microabscessing occurs in the suture area, which leads to divergence of the edges of the wound and the formation of an inadequate scar on the uterus (delayed complications - secondary failure of the uterine scar).

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

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

Hospital-acquired infection (hospital, nosocomial) is any clinically expressed infectious disease that occurs in a patient during her stay in an obstetric hospital or within 7 days after discharge from it, as well as in medical personnel as a result of their work in an obstetric hospital.

Most bacterial hospital-acquired infections occur within 48 hours after hospitalization (birth of the child). However, each case of infection should be assessed individually depending on the incubation period and the nosological form of the infection.

An infection is not considered to be hospital-acquired if:

• the presence of an infection in the patient during the incubation period before admission to hospital;
• complications or continuation of an infection that the patient had at the time of hospitalization.

An infection is considered to be hospital-acquired if:

• purchasing it from a hospital;
• intrapartum infection.

Antibiotic resistance profiles are a combination of resistance determinants of each isolated microorganism strain. Antibiotic resistance profiles characterize the biological features of the microbial ecosystem that has formed in the hospital. Hospital strains of microorganisms have multiple resistance to at least 5 antibiotics.

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Causes postpartum purulent-septic diseases

The main pathogens of obstetric septic complications are associations of gram-positive and gram-negative anaerobic and aerobic microbes, with opportunistic microflora predominating. In the last decade, new generation infections that are sexually transmitted have also begun to play a certain role in these associations: chlamydia, mycoplasma, 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 has been established between bacterial vaginosis (vaginal dysbacteriosis) in pregnant women and infection of amniotic fluid, pregnancy complications (chorioamnionitis, premature birth, premature rupture of membranes, postpartum endometritis, fetal inflammatory complications).

In hospital infections, which occur 10 times more often, the exogenous entry of bacterial pathogens is of primary importance. The main pathogens of nosocomial infections in obstetric and gynecological practice are gram-negative bacteria, among which enterobacteria (intestinal pannochka) are most common.

Despite the wide variety of pathogens, in most cases of postpartum infection, gram-positive microorganisms are detected (25%). Staphylococcus aureus - 35%, Enterococcus spp. - 20%, Coagulase-negative staphylococcus - 15%, Streptococcus pneumoniae - 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%; Candida fungi - 3%; anaerobic microflora - using special research techniques (20%); unidentified microflora - in 25% of cases.

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Pathogenesis

Inflammation is the body's normal response to infection; it can be defined as a localized protective response to tissue injury, the main purpose of which is to destroy the causative microorganism and the damaged tissue. But in some cases, the body responds to infection with a massive, excessive inflammatory response.

A systemic inflammatory reaction is a systemic activation of the inflammatory response, secondary to the functional impossibility of the mechanisms of limiting the spread of microorganisms and their waste products from the local area of damage,

Currently, it is proposed to use such a concept as "systemic inflammatory response syndrome" (SIRS) and consider it as a universal response of the body's immune system to the impact of strong irritants, including infection. In case of infection, 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 SIRS reaction cascade is lipopolysaccharide (LPS) of gram-negative bacteria membranes.

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

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

• Stage I - local production of cytokines; in response to infection, anti-inflammatory mediators play a protective role, destroy microbes and participate in the wound healing process;
• Stage II - release of a small amount of cytokines into the systemic bloodstream; controlled by anti-inflammatory mediator systems, antibodies, creating the preconditions for the destruction of microorganisms, wound healing and maintaining homeostasis;
• Stage III - generalized inflammatory reaction; the amount of inflammatory cascade mediators in the blood increases to the maximum, their destructive elements begin to dominate, which leads to disruption of endothelial function with all the consequences.

A generalized inflammatory response (SIRS) to a clearly identified infection is defined as sepsis.

Possible sources of postpartum infection that may exist before pregnancy include:

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

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 an incision on the uterus, create ideal conditions for septic complications;
• prolonged labor and premature rupture of membranes, which lead to chorioamnionitis;
• tissue trauma during vaginal delivery: application of forceps, perineal incision, repeated vaginal examinations during labor, intrauterine manipulations (manual removal of the placenta, manual examination of the uterine cavity, internal rotation of the fetus, internal monitoring of the fetus's condition and uterine contractions, etc.);
• reproductive infections;
• low social level combined with poor nutrition and unsatisfactory hygiene.

The causes of generalization of infection may be:

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

Symptoms postpartum purulent-septic diseases

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

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

General clinical manifestations of an inflammatory reaction are characteristic;

• local inflammatory reaction: pain, hyperemia, swelling, local increase in temperature, dysfunction of the affected organ;
• General reaction of the body: hyperthermia, fever. Signs of intoxication (general weakness, tachycardia, decreased blood pressure, tachypnea) indicate the development of SIRS.

Forms

In the CIS countries, the classification of S.V. Sazonov-AB Bartels has been used for many years, 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 widespread. This classification does not correspond to the modern understanding of the pathogenesis of sepsis. The interpretation of the term "sepsis" has changed significantly due to the introduction of a new concept - "systemic inflammatory response syndrome".

The modern classification of postpartum purulent-inflammatory diseases assumes their division into conditionally limited and generalized forms. Conditionally limited include suppuration of the postpartum wound, endometritis, mastitis. Generalized forms are represented by peritonitis, sepsis, septic shock. The presence of a systemic inflammatory response in a woman in labor with a conditionally limited form of the disease requires intensive monitoring and treatment as in sepsis.

Postpartum infection is most likely to occur when the body temperature rises above 38 °C and there is pain in the uterus 48-72 hours after delivery. In the first 24 hours after delivery, an increase in body temperature is normally often observed. Approximately 80% of women with an increase in body temperature in the first 24 hours after vaginal delivery have no signs of an infectious process.

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

085 Postpartum sepsis

Postpartum:

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

086.0 Infection of surgical obstetric wound

Infected:

• cesarean section wound after childbirth;
• perineal suture.

086.1 Other genital tract infections after childbirth

• cervicitis after childbirth
• vaginitis

087.0 Superficial thrombophlebitis in the postpartum period

087.1 Deep phlebothrombosis in the postpartum period

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

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Diagnostics postpartum purulent-septic diseases

The following data are taken into account during diagnostics:

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

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Prevention

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

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

In case of low infectious risk, prophylaxis is carried out by a single intraoperative (after clamping the umbilical cord) administration of cefazolin (2.0 g) or cefuroxime (1.5 g).

In case of moderate risk, intraoperative (after clamping the umbilical cord) use of Augaentin at a dose of 1.2 g is advisable, and if necessary (combination of many risk factors), the drug at the same dose (1.2 g) is additionally administered in the postoperative period - 6 and 12 hours after its first use. Possible options: cefuroxime 1.5 g + metrogyl 0.5 g intraoperatively (after clamping the umbilical cord), and if necessary, cefuroxime 0.75 g + metrogyl 0.5 g 8 and 16 hours after the first administration.

In case of high real risk of complications - prophylactic antibacterial therapy (5 days) in combination with APD of the uterine cavity (the tube is inserted intraoperatively); creation of optimal conditions for reparation of the postoperative zone; early adequate and effective treatment of endometritis after cesarean section.

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