Sepsis after childbirth

Postpartum sepsis cannot be considered the result of a direct action of a microorganism on a macroorganism; it is a consequence of important disturbances in the immune system, which undergo stages in their development from a state of excessive activation ("hyperinflammation phase") to a state of immunodeficiency ("immunoparalysis phase"). The body's immune system is an active participant in the autodestructive process. Very often, septicemia (the presence of microbes in the blood) is absent. In 1992, the American Association of Anesthesiologists proposed the following classification of septic conditions, which is recognized by most scientists.

Systemic inflammatory response syndrome is manifested by two or more signs:

1. body temperature above 38 °C or below 36 C;
2. Heart rate over 90 beats per minute;
3. respiratory rate more than 20 per 1 min, PaCO2 _below 32 mm Hg;
4. the number of leukocytes is more than 12x10 ⁹ /l or less than 4x10 ⁹ /l, immature forms are more than 10%.

Postpartum sepsis is a systemic response to a reliably identified infection in the absence of other possible causes for such changes characteristic of SIRS. It manifests itself with the same clinical signs as SIRS.

Severe sepsis is sepsis after childbirth, which is characterized by organ dysfunction, tissue hypoperfusion, and arterial hypotension. Acidosis, oliguria, and impaired consciousness are possible. With the development of severe sepsis, the following symptoms are added:

• thrombocytopenia less than 100 thousand liters, which cannot be explained by other reasons;
• increase in procalcitonin levels over 6 ng/ml (A);
• positive blood culture for circulating microorganisms (A);
• positive endotoxin test (B).

Septic shock is defined as severe sepsis with arterial hypotension that develops despite adequate infusion therapy. The diagnosis is established if the above clinical and laboratory indicators are accompanied by:

• arterial hypotension (systolic pressure less than 90 mm Hg or a decrease of more than 40 mm Hg from the initial level); -
• disturbance of consciousness;
• oliguria (diuresis less than 30 ml/h);
• hypoxemia (PaO2 _less than 75 mm Hg when breathing atmospheric air);
• SaO2 less _than 90%;
• increase in lactate level over 1.6 mmol/l;
• petechial rash, necrosis of a skin area.

Multiple organ failure syndrome is the presence of acute dysfunction of organs and systems.

Diagnosis of sepsis after childbirth

To diagnose clinical forms of sepsis, it is necessary to carry out the following measures in women in labor with any form of postpartum infection:

• monitoring: blood pressure, heart rate, central venous pressure, leukocytes and blood count;
• counting the respiratory rate, assessing the level of blood gases, SaO ₂;
• hourly monitoring of diuresis,
• measuring rectal body temperature at least 4 times a day to compare with body temperature in the axillary areas;
• urine, blood, and cervical secretion cultures;
• determination of the acid-base balance of the blood and tissue oxygen saturation;
• platelet count and determination of fibrinogen and fibrin monomer levels;
• ECG, ultrasound of the abdominal organs and X-ray examination of the chest organs.

[ 1 ], [ 2 ], [ 3 ]

Treatment of sepsis after childbirth

Basic principles of treatment measures:

1. Hospitalization in the intensive care unit.
2. Correction of hemodynamic disturbances by inotropic therapy and adequate infusion support.

By assessing arterial pressure, pulse arterial pressure, central venous pressure, heart rate, and diuresis, the volume of infusion therapy is determined. Determining central venous pressure in dynamics makes it possible to control the infusion of colloidal and crystalloid solutions with an assessment of the volumes of introduced and lost fluid and blood products.

Hydroxyethyl starch derivatives (refortan, voluven, stabizol) and crystalloids (isotonic sodium chloride solution, Ringer's solution) are used in the infusion in a ratio of 1:2. In order to correct hypoproteinemia, only 20-25% albumin solution is prescribed. The use of 5% albumin in critical conditions increases the risk of death (A).

Fresh frozen plasma (600-1000 ml) should be included in infusion therapy due to the presence of antithrombin (B) in it.

The use of glucose is inappropriate (B), since its administration to patients with critical conditions increases the production of lactate and CO ₂, increases ischemic damage to the brain and other tissues. Glucose infusion is used only in cases of hypoglycemia and hypernatremia,

3. Inotropic support is used if CVP remains low. Dopamine is administered at a dose of 5-10 mcg/(kg-min) (maximum up to 20 mcg/(kg-min)) or dobutamine 5-20 mcg/(kg-min). In the absence of a persistent increase in blood pressure, norepinephrine hydrotartrate is administered 0.1-0.5 mg/(kg-min), simultaneously reducing the dopamine dose to 2-4 mcg/(kg-min) (A). Simultaneous administration of naloxone up to 2 mg is justified, which causes an increase in blood pressure (A). In case of ineffective complex hemodynamic therapy, glucocorticosteroids (hydrocortisone 2000 mg/day) (C) together with H2-blockers (ranitidine, famotidine) (B) can be _used.
4. Maintaining adequate ventilation and gas exchange. Indications for mechanical ventilation are: PaO2 _less than 60 mm Hg, PaCO2 _more than 50 mm Hg or less than 25 mm Hg, PaO2 _less than 85%, respiratory rate more than 40 per 1 min.
5. Normalization of bowel function and early enteral nutrition.
6. Timely correction of metabolism under constant laboratory monitoring.

Antibacterial treatment of postpartum sepsis

The decisive factor is the rational choice of antimicrobial agents, in particular antibiotics. Unfortunately, targeted antibacterial therapy is possible, in the best case, not earlier than 48 hours later. While waiting for identification, empirical antibiotic therapy is used, taking into account the nature of the primary source of infection, the functional state of the liver, kidneys, and the immune system of the patient.

Current trends in antibacterial therapy for purulent-septic infections include the use of bactericidal antibiotics rather than bacteriostatic ones, the use of less toxic analogues (for example, new generations of aminoglycosides or their replacement with fluoroquinolones), the replacement of combination antibiotic therapy with equally effective monoantibiotic therapy, the replacement of immunosuppressive antibiotics with immunostimulating ones, and the use of adequate doses and administration regimens.

Based on the need to suppress the growth of the entire predicted spectrum of pathogens of obstetric infection (gram-negative and gram-positive aerobes and anaerobes), empirical antimicrobial therapy uses combination triple antimicrobial therapy regimens (e.g. semi-synthetic penicillins, cephalosporins + aminoglycosides + imidazoline), dual antibiotic therapy (e.g. clindamycin + aminoglycosides), monoantibiotic therapy (third-generation cephalosporins, carbapenems, ureidopenicillins, aminopenicillins, etc.).

Triple antimicrobial therapy, although active against a range of pathogens, places an additional burden on organs and systems due to the use of a large number of drugs, and the side effects of antibiotic therapy increase with an increase in the number of drugs used. Such therapy involves frequent administration of antibiotics of the group of low-lusynthetic penicillins (ampicillin, oxacillin) or cephalosporins of the first and second generations (cefazolin, cephalexin, cefuroxime), which are most effective against gram-positive aerobic pathogens (staphylococci), less effective against gram-negative aerobic pathogens, and do not act on pseudomonads (Pseudomonas aeruginosa) and anaerobes. The effectiveness of such a complex is increased by prescribing aminoglycosides (gentamicin, tobramycin, amikacin, netromycin), which are highly effective against gram-negative aerobic bacteria (enterobacteria, Pseudomonas aeruginosa). Imidazole group drugs (metronidazole, ornidazole, tinidazole) are highly effective against anaerobes, including bacteroides. In connection with the above, the popular triple antibiotic regimen for severe purulent-septic diseases cannot be considered rational.

Dual antibiotic therapy most often involves the use of drugs from the lincosamide group (clindamycin), which have a broad spectrum of activity against anaerobic bacteria and gram-positive aerobes, and aminoglycosides are additionally prescribed to affect gram-negative microflora. Combinations of third-generation cephalosporins with imidazoles, beta-lactam antibiotics with aminoglycosides have also been proposed.

Monoantibiotic therapy can be carried out with drugs whose spectrum of action covers gram-negative and gram-positive aerobes and anaerobes: third-generation cephalosporins (it is necessary to remember the large release of endotoxins), carbapenems. In severe cases of sepsis, the most acceptable drugs are the carbapenem group (imipenem + sodium cilastin, meropsnem).

Taking into account the latest scientific achievements in the field of studying the pathogenesis of sepsis and SIRS, it is especially necessary to dwell on the clinical significance of the release of endotoxin (LPS), which is induced by antibiotics. The formation of endotoxin induced by antibiotics increases in the following order: carbapenems - the least; aminoglycosides, fluoroquinolones, cephalosporins - the most.

Anti-candidal drugs are mandatory in antimicrobial therapy.

7. Evaluation of pathophysiological and pathobiochemical deregulations, which can be distinguished into the following syndromes: renal, hepatic, various types of cardiovascular and respiratory failure, DIC syndrome, microcirculatory disorders, gastrointestinal dysfunction with bacterial flora translocation into the lymphatic system, and then into the systemic bloodstream with the development of multiple organ failure syndrome. Pathobiochemical deregulations are manifested by disturbances in water-electrolyte balance and acid-base balance, etc. Each syndrome requires its own approach, individual application of certain methods and means that cover all sections of intensive care.
8. Improving microcirculation (use of pentoxifylline or dipyridamole). The use of pentoxifylline (trental) improves microcirculation and rheological properties of blood, has a vasodilatory effect and improves tissue oxygen supply, which is important in the prevention of DIC and multiple organ failure.
9. Antimediator therapy. Given the decisive role of massive release of inflammation mediators (cytokines) into the vascular bed in the development of SIRS, the use of antimediator therapy is rational. These methods are at the stage of thymic development, although some are recommended for clinical use: antioxidants (vitamin E, N-acetylcysteine, glutathione), corticosteroids (dexamethasone), lysophilin, phosphodiesterase inhibitors (amrinone, milrinone, pentoxifylline) and adenosine deaminase (dipyridamole), adenosine and alpha-blockers. In recent years, the drug "Drotrecogin-alfa" (Drotrecogin alfa) - recombinant human activated protein C - has acquired particular importance.

This is a new drug intended only for the treatment of severe sepsis and multiple organ failure. Activated protein C is an endogenous protein that supports fibrinolysis, inhibits thrombosis, and has anti-inflammatory properties. The standard of care used in the UK since 2004 is drotrecotine alfa 24 mcg/kg for 96 hours.

[ 4 ], [ 5 ], [ 6 ], [ 7 ]

Surgical treatment of sepsis after childbirth with removal of the source of infection

Indications for laparotomy and extirpation of the uterus with fallopian tubes are:

1. lack of effect from intensive therapy (24 hours);
2. endometritis that does not respond to conservative treatment (24-48 hours);
3. uterine bleeding that does not respond to treatment by other methods and threatens the patient's life;
4. purulent formations in the uterine appendages with the development of SIRS;
5. development of SIRS caused by the presence of placental remnants in the uterus (confirmed by ultrasound).

Extracorporeal blood purification (detoxification) is a promising direction in the correction of homeostasis disorders in severe cases. For this purpose, the following are used: hemodialysis, ultrafiltration, hemofiltration, hemodiafiltration, plasmapheresis.