Sepsis after childbirth

Sepsis after childbirth can not be considered the result of direct action of the microorganism on the macroorganism, it is a consequence of important disorders in the immune system, which go through the stages of development from the state of excessive activation (the "phase of hyperinflammation") to the state of immunodeficiency ("immunological phase"). The immune system of the body is an active participant in the autodestructive process. Very often, there is no septicemia (the presence of microbes in the blood). The American Association of Anaesthesiologists in 1992 proposed the following classification of septic conditions, which is recognized by most scientists.

The syndrome of the systemic inflammatory response manifests with two or more symptoms:

1. body temperature over 38 ° C or below 36 ° C;
2. Heart rate more than 90 in 1 min;
3. the respiratory rate is more than 20 per 1 min, Raco _{2 is} below 32 mm Hg. P.
4. the number of leukocytes is more than 12х10 ⁹ / l or less 4х10 ⁹ / l, immature forms more than 10%.

Sepsis after childbirth is a systemic response to a reliably detected infection in the absence of other possible causes for similar changes characteristic of SIRS. It shows the same clinical signs as the SIRS.

Severe sepsis - this is sepsis after childbirth, which is characterized by impaired function of the organs, tissue hypoperfusion, arterial hypotension. Possible acidosis, oliguria, impaired consciousness. With the development of severe sepsis, the following symptoms are added:

• Thrombocytopenia is less than 100 thousand liters, which can not be explained by other causes;
• increase in the level of procalcitonin more than 6 ng / ml (A);
• positive blood culture for the detection of circulating microorganisms (A);
• positive endotoxin test (B).

Septic shock is defined as severe sepsis with arterial hypotension, which develops despite adequate infusion therapy. The diagnosis is established if the following clinical and laboratory indicators are attached to:

• arterial hypotension (systolic pressure less than 90 mm Hg or decrease more than 40 mm Hg from the baseline); -
• impaired consciousness;
• oliguria (diuresis less than 30 ml / h);
• hypoxemia (PaO ₂ less than 75 mm Hg when breathing atmospheric air);
• SaO _{2 is} less than 90%;
• increase of lactate level more than 1.6 mmol / l;
• petechial rash, necrosis of the skin area.

Syndrome of multiple organ failure - the presence of acute impairment of organs and systems.

Diagnosis of sepsis after childbirth

To diagnose clinical forms of sepsis, the following measures should be taken in puerperas with any form of postpartum infection:

• monitoring: blood pressure, heart rate, central venous pressure, leukocytes and blood formula;
• counting of respiratory rate, estimation of blood gases level, SaO ₂;
• hourly control of diuresis,
• measurement of rectal body temperature at least 4 times a day for comparison with body temperature in axillary sites;
• sowings of urine, blood, excretions from the cervical canal;
• the determination of the acid-base state of the blood and the saturation of the tissues with oxygen;
• counting the number of platelets and determining the level of fibrinogen and fibrin monomers;
• ECG, ultrasound of the abdominal cavity organs and X-ray examination of the thoracic cavity organs.

[1], [2], [3],

Treatment of sepsis after childbirth

Basic principles of treatment:

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

Assessing blood pressure, pulse blood pressure, CVP, heart rate, diuresis, determine the amount of infusion therapy. Determination of CVP in dynamics makes it possible to control the infusion of colloidal and crystalloid solutions with an estimate of the volumes of injected and lost fluid and blood preparations.

For the infusion, hydroxyethyl starch derivatives (refortan, voluven, stabilazole) and crystalloids (isotonic sodium chloride solution, Ringer's solution) are used in the ratio 1: 2. For the purpose of correcting hypoproteinemia, only 20-25% albumin solution is prescribed. The use of 5% albumin in critical conditions increases the risk of death (A).

In infusion therapy it is necessary to include fresh frozen plasma 600-1000 ml due to the presence of antithrombin (B).

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

3. Inotropic support is used if the CVP remains low. Dopamine is administered at a dose of 5-10 μg / (kg-min) (maximum to 20 μg / (kg-min)) or dobutamine 5-20 μg / (kg-min). In the absence of a persistent increase in blood pressure, noradrenaline hydrotartrate 0.1-0.5 mg / kg-min is administered, while reducing the dose of dopamine to 2-4 μg / (kg-min) (A). Simultaneously, simultaneous administration of naloxone to 2 mg, which causes an increase in blood pressure (A). In case of ineffective complex hemodynamic therapy, it is possible to use glucocorticosteroids (hydrocortisone 2000 mg / day) (C) together with H ₂ -blockers (ranitidine, famotidine) (B).
4. Support adequate ventilation and gas exchange. Indications for mechanical ventilation are: PaO ₂, less than 60 mm. Gt; st, Razo ₂ more than 50 mm. Gt; Art. Or less than 25 mm. Gt; paO _{2 is} less than 85%, respiratory rate is more than 40 per 1 min.
5. Normalization of bowel function and early enteral nutrition.
6. Timely correction of metabolism under constant laboratory control.

Antibacterial treatment of postpartum sepsis

The decisive factor is the rational choice of antimicrobial agents, in particular antibiotics. Unfortunately, targeted antibiotic therapy is possible, at best, not earlier than 48 hours. Expecting identification, empirical antibiotic therapy is used, taking into account the nature of the primary focus of infection, the functional state of the liver, kidneys, immune system of the patient.

The current trends in antibiotic therapy for purulent-septic infection are the use of bactericidal antibiotics, not bacteriostatic, the use of less toxic analogues (for example, new generations of aminoglycosides or their replacement with fluoroquinolones), the replacement of combined antibiotic therapy with equally effective monoantibiotics, the replacement of immunosuppressive antibiotics with immunostimulants, the use of adequate doses and modes of administration.

Based on the need to suppress the growth of the entire foreseeable spectrum of pathogens of obstetric infection (gram-negative and gram-positive aerobes and anaerobes), schemes of combined triple antimicrobial therapy (for example, semisynthetic penicillins, cephalosiorins + aminoglycosides + imidazoline), double antibiotics (eg, clindamycin + aminoglycosides), monoantibiotics (third generation cephalosporins, carbapenems, ureidopenicillins, aminopenicillins, etc.).

Triple antimicrobial therapy, although active against the spectrum of pathogens, but the use of a large number of drugs gives an additional burden to organs and systems, and with the increase in the number of drugs used, the side effects of antibiotic therapy are increasing. Such therapy provides for the frequent administration of antibiotics of the group of losynthetic penicillins (ampicillin, oxacillin) or cephalosporins of the I-II generation (cefazolin, cephalexin, cefuroxime), which are most effective against gram-positive aerobic pathogens (staphylococci), are less effective in gram-negative aerobic pathogens, do not act on pseudomonads (Pseudomonas aeruginosa) and anaerobes. The effectiveness of such a complex is enhanced by the appointment of aminoglycosides (gentamicin, tobramycin, amikacin, netromycin), highly effective against gram-negative aerobic bacteria (enterobacteria, Pseudomonas aeruginosa). High efficacy against anaerobes, including bacteroides, is characterized by imidazole group preparations (metronidazole, ornidazole, tinidazole). In connection with the foregoing, the popular triple regime of antibiotic treatment in the severe form of purulent-septic diseases can not be considered rational.

Double antibiotic therapy most often involves the administration of drugs of the group of lincosamides (clindamycin), which have a wide spectrum for anaerobic bacteria and Gram-positive aerobes, and aminoglycosides are additionally prescribed to influence the gram-negative microflora. Combinations of third-generation cephalosporins with imidazoles, beta-lactam antibiotics with aminoglycosides are also proposed.

Monoantibiotikoterapiya can be carried out with drugs, the spectrum of which covers gram-negative and Gram-positive aerobes and anaerobes: third-generation cephalosporins (remember the large release of endotoxins), carbapenems. In severe sepsis, the most suitable drugs are carbapenems (imipenem + sodium cilastin. Meropsenem).

Considering the latest scientific achievements in the field of studying the pathogenesis of sepsis and SIRS. Especially the clinical significance of the release of endotoxin (LPS), which is induced by antibiotics, should be considered. The formation of endotoxin, induced by antibiotics, increases in the following order: carbapenems are the least; aminoglycosides, fluoroquinolones, cephalosporins - most of all.

Antimicrobial drugs are mandatory in antimicrobial therapy.

7. Evaluation of pathophysiological and pathobiochemical deregulation, which can be isolated into the following syndromes: renal, hepatic, various variants of cardiovascular and respiratory failure, DIC syndrome, microcirculation disorders, dysfunction of the digestive tract with translocation of the bacterial flora into the lymphatic system, and then in systemic blood flow with the development of multiple organ dysfunction syndrome. Pathobiochemical deregulation is manifested by disturbances in the water-electrolyte balance and acid-base state, etc. Each of the syndromes requires its own approach, individual application of certain methods and means that cover all sections of intensive care.
8. Improvement of microcirculation (use of pentoxifylline or dipyridamole). The use of pentoxifylline (trental) improves microcirculation and rheological properties of blood, has a vasodilating effect and improves oxygen supply to tissues, which is important in the prevention of internal combustion engine and multi-organ failure.
9. Antimediator therapy. Considering the crucial role in the development of SSRS of a massive release of inflammatory mediators (cytokines) into the vascular bed, the use of antimediative 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 a-adrenoblockers. In recent years, the drug "Drotrekogin-alfa" (Drotrecogin alfa) - recombinant human activated protein C.

It is a new drug intended only for the treatment of severe forms of sepsis and multiple organ failure. Activated protein C is an endogenous protein that supports fibrinolysis, inhibits loudness, and also has anti-inflammatory properties. The standard of treatment that has been used in the UK since 2004 is drotrekotin-alpha 24 μg / kg for 96 hours.

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

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

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

1. absence of effect from intensive care (24 h);
2. endometriometritis, which is not amenable to conservative treatment (24-48 hours);
3. uterine bleeding that can not be treated by other methods and threatens the patient's life;
4. purulent formations in the appendages of the uterus in the development of SIRS;
5. development of SIRS caused by the presence of placental residues in the uterus (confirmed by ultrasound).

Extracorporeal cleansing of blood (detoxification) is a promising direction in the correction of homeostatic disorders in severe cases. To this end, they apply: hemodialysis, ultrafiltration, hemofiltration, hemodiafiltration, plasmapheresis.