Septic shock in gynecology

One of the most serious complications of purulent-septic processes of any localization is septic (or bacterial-toxic) shock. Septic shock is a special reaction of the body, manifested in the development of severe systemic disorders associated with a violation of adequate tissue perfusion, which comes in response to the introduction of microorganisms or their toxins.

For the first time, describe this pathological process in 1956 Studdiford and Douglas. According to the frequency of occurrence, bacterial-toxic shock is on the third place after hemorrhagic and cardiac shock, and on lethality - on the first. With septic shock, 20 to 80% of patients die.

Septic (bacterial, endotoxic, infectious-toxic) shock can develop at any stage of a purulent disease, but more often it develops during a regular exacerbation of the purulent process or at the time of surgery, as well as at any time in patients with sepsis.

The incidence of shock in patients with sepsis is 19%.

It should be noted that in gynecological patients with purulent pelvic organs, septic shock now occurs much less frequently (less than 1%, whereas in the 1980s, this complication was observed in 6.7% of patients).

Shock dramatically increases the course of the disease, and it is often the immediate cause of death of patients. Mortality of patients with septic shock reaches 62.1%.

In gynecological practice, septic shock complicates infected out-of-hospital abortions, limited and diffuse peritonitis, wound infection. As is known, in recent decades the frequency of purulent-septic diseases of pregnant and gynecological patients is constantly increasing. This trend can be explained by many causal factors:

• change in the nature of microflora, the appearance of antibacterial-resistant and even antibiotic-dependent forms of microorganisms;
• a change in the cellular and humoral immunity of many women due to the widespread use of antibiotics, corticosteroids and cytostatics;
• increased allergization of patients;
• wide introduction in gynecologic practice of methods of diagnosis and therapy associated with entry into the uterine cavity.

With an increase in the growth of purulent-septic diseases, the practical doctor increasingly faces septic shock, this formidable pathology, which poses a mortal threat to the life of the patient.

Septic shock in obstetrics is currently encountered much less often. However, it still occupies a leading place in the maternal mortality structure in developing countries, which is due to various causes, primarily with the frequency of septic abortion and postpartum endometritis. Maternal mortality from complicated abortion in Africa is 110 per 100,000 live births. In developed countries, the incidence of septic complications is significantly less, and for individual nosologies can differ by hundreds of times. For example, in the US, maternal mortality from a complicated abortion is 0.6 per 100,000 live births. The frequency of endometritis after spontaneous delivery is on average 2-5%, after caesarean section - 10-30%. The course of sepsis and septic shock in obstetrics accompanies a lower mortality rate than in other categories of patients (in obstetrics - 0-28%, non-pregnant - 20-50%). This is due to the fact that patients with obstetric shock are usually younger than with other types of shock. They have a less burdened premorbid background, the primary focus of infection is located in the pelvic cavity - a zone accessible for diagnostic and surgical interventions, the microflora is sensitive to broad-spectrum antibacterial drugs.

In recent years, domestic and foreign researchers have clearly formulated the basic principles of diagnosis and intensive therapy of sepsis and septic shock.

ICD-10 code

• O08.0 Infection of the genital tract and pelvic organs caused by abortion, extra-mammary and molar pregnancy
• A08.3 Shock caused by abortion, ectopic and molar pregnancy
• O41.1 Infection of the amniotic cavity and membranes
• O75.1 Mother shock during delivery or after childbirth and delivery
• A.85 Postpartum sepsis
• O.86 Other postpartum infections
• 086.0 Infection of a surgical obstetrical wound
  • O86.1 Other genital tract infections after childbirth
  • O86.2 Urinary tract infection after childbirth
  • O86.3 Other infections of the urogenital tract after childbirth
  • O86.4 Hyperthermia of unknown origin that has arisen after delivery
  • O86.8 Other specified postpartum infections
  • O88.3 Obstetrical pyemic and septic embolism

What causes septic shock?

The main foci of infection with septic shock in obstetrics - the uterus with complicated abortion and postnatal endometritis, mammary glands with mastitis, a postoperative wound with its suppuration. The most significant risk factors for the development of septic shock include many factors:

• Low socio-economic status.
• Immunodeficiency status.
• Chronic foci of infection (urogenital tract).
• Diabetes.
• Operative interventions (caesarean section).
• Community-acquired infection with an abortion.
• Premature birth.
• Blood loss, hemorrhagic shock (placenta previa, placental abruption).
• Intrauterine manipulation.
• Anemia.
• Preeclampsia and eclampsia.

The main causative agents of sepsis and septic shock in obstetrics include Escherichia coli, Bacteroides spp, Clostridium spp, Klebsiella spp, Pseudomonas aeruginosa, Streptococcus pyogenes, Staphylococcus aureus, Streptococcus agalactiae, Peptostreptococcus spp, Peptococcus spp, Enterococcus spp, Listeria monocytogenes, Enterobacter spp, Proteus spp, various kinds of fungi.

Septic abortion

Infection most often occurs in the ascending way during the abortion or postabortion period. Less often observed primary infection of membranes (amnionitis, chorionitis) with the subsequent termination of pregnancy. The etiological spectrum of pathogens of infectious complications of abortions is almost similar to that of inflammatory diseases of pelvic organs. Polymicrobial etiology with the predominance of aerobic-anaerobic associations of microorganisms of the vaginal microflora is characteristic.

The main causative agents of enterobacteria (more often E. Coli), Gram-positive cocci (Streptococcus pyogenes, Enterococcus spp, S. Aureus, etc.) and nonspore-forming anaerobes (Bacteroid.es spp, Peptucoccus spp, Peptostreptococcus spp). In some cases (especially with criminal abortions), the causative agent may be Clostridium peijhngens.

Postpartum endometritis is characterized by an upward path of infection from the vagina and cervix, the polymicrobial etiology of postpartum endometritis. In the overwhelming majority of observations (80-90%), these are associations of aerobic and anaerobic conditionally pathogenic microorganisms that enter the normal microflora of the genital tract in women. Most often, pathogens are enterobacteria and enterococci, and obligate anaerobes are bacteroides.

• Facultative anaerobes: Enterobacteriaceae E coli (17-37%), less often Proteus spp, Klebsiella spp, Enterobacter spp, Enterococcus faecalis (37-52%)
• Obligatory anaerobes: Bacteroides fragilis (40-96%), less often Fusobacterium spp, Peptococcus spp, Peptostreptococcus spp
• Streptococcus pyogenes, Staphylococcus spp (S. Aureus 3-7%) and others are more rarely detected.

How does septic shock develop?

The pathogenesis of septic shock in obstetrics is fundamentally indistinguishable from the main stages of septic shock of any other etiology. However, a number of factors can accelerate the formation of PNS in the development of sepsis and septic shock in obstetrics. Already in itself, the development of pregnancy is accompanied by an inflammatory response to trophoblast invasion. During pregnancy, the number of leukocytes, the level of proinflammatory cytokines, the concentration of clotting factors (fibrinogen, factor VIII), the level of D-dimer, the C-reactive protein are increased, the fibrinolytic system is activated, the level of protein C and S, hemoglobin and the number of erythrocytes . The endothelial function of the vessels changes in the direction of increasing permeability.

With a complicated course of pregnancy, for example, with gestosis, these changes progress and develop the so-called maternal inflammatory response as a variant of SSRM. Leukocytosis, a stab shift, an increase in the content of septic shock mediators, a change in coagulation, a violation of the function of the organs in severe gestosis and eclampsia can significantly complicate the timely diagnosis of sepsis. Most often it is encountered in those situations when the patient is being given prolonged ventilation. Therefore, for the prevention of sepsis with prolonged ventilation for severe gestosis and eclampsia, antibiotic therapy is used.

For normal development of pregnancy, a certain immunosuppression is also necessary. Of great importance is the initial infection of the urogenital tract. These changes contribute to the development and progression of the infectious process and significantly impede the timely diagnosis of sepsis, especially in the postpartum period.

Symptoms of septic shock

To diagnose septic shock, it is necessary to take into account the clinical picture:

• increased body temperature,
• shortness of breath,
• tachycardia,
• increase and soreness of the uterus,
• purulent discharge from the vagina,
• purulent discharge from the uterus,
• bleeding.

Diagnosis of septic shock

• The number of leukocytes and the leukocyte formula (leukocytosis, stab-shift).
• C-reactive protein (increased).
• Procalcitonin test (increased)

In order to assess the NON, it is necessary to determine:

• hemoglobin, erythrocytes (decrease),
• number of platelets, APTT, INR, fibrinogen, D-dimer level (signs of ICE),
• bilirubin, ACT, AJIT, AP (increase),
• urea, plasma creatinine (increase),
• electrolytes (electrolyte disturbances),
• the concentration of glucose in the blood (hypo- or hyperglycemia),
• blood gases (p02, pCO2),
• CBS (metabolic acidosis)

[1], [2], [3], [4], [5], [6]

Instrumental research

The ultrasound of the pelvic organs allows to establish the presence of formations in the small pelvis, to estimate the size of the uterus and the presence of foreign inclusions in its cavity.

CT or MRI can detect septic thrombophlebitis of pelvic veins, abscesses of the small pelvis, thrombosis of the ovarian vein.

Radiography of the lungs can reveal signs of ARDS. Bacteriological studies are used for the purpose of etiotropic treatment of sowing from the separable uterus, operating wound, blood and urine. For an adequate choice of treatment tactics, it is extremely important to notice signs of sepsis, PON and septic shock in accordance with generally accepted criteria in a timely manner.

The attending physician should be alarmed by not always explainable violations of the function of individual organs and systems, especially in the postpartum or postoperative period. The clinical severity of the inflammatory reaction may be influenced by carrying out preventive antibiotic therapy, infusion therapy and analgesia of labor or cesarean section. Therefore, often the only symptom of the generalization of the septic process and the development of PNS may be a violation of consciousness or a progressive impairment of the function of the liver, kidneys, lungs,

Treatment of septic shock

Intensive therapy of sepsis and septic shock in obstetrics practically does not differ from the generally accepted principles of treatment of this pathology. In this regard, extremely few RCTs and practical guidelines for high-level evidence for the treatment of septic shock in obstetrics. The focus is on prevention and adequate evaluation of its effectiveness in abortion and postpartum endometritis.

Septic abortion

Manipulation:

• Curettage of the uterine cavity to remove the infected remains of the fetal egg, rinsing the uterus with an antiseptic solution.

Antibiotic therapy:

At present, preventive use of antibacterial drugs during abortion is mandatory.

When a septic abortion is detected, the following schemes are used:

• amoxicillin + clavulanic acid 1.2 g intravenously 3-4 times a day,
• ticarcillin + clavulanic acid by 3.2 g intravenously 4 times a day,
• carbapenems (for example, imipenem + cilastatin or meropenem) by 0.5 g intravenously 4 times a day.

Alternative schemes:

• cefalosporins II-III generation (cefuroxime 1.5 g intravenously 3 times a day, ceftriaxone 2.0 g intravenously once a day) and metronidazole 500 mg intravenously 3 times a day,
• clindamycin 900 mg intravenously 3 times a day and gentamicin 5-6 mg / kg intravenously or intramuscularly for one administration,
• ofloxacin 400 mg intravenously twice a day and metronidazole 500 mg intravenously 3 times a day.

When C is detected, it is prescribed penicillin preparations in large doses - 10-20 million units per day.

Postpartum and postoperative endometritis

During Caesarean section for the purpose of prophylaxis, a single intraoperative (after umbilical cord clamping) administration of one therapeutic dose of a wide-spectrum antibiotic is shown:

• cephalosporin I-II generation (cefazolin, cefuroxime),
• aminopenicillins and beta-lactamase inhibitors (ampicillin + sulbactam, amoxicillin + clavulanic acid).

Preventative administration reduces the risk of postpartum infectious complications by 60-70%.

With postpartum and postoperative endometritis, after removing the uterine contents and washing the uterus with an antiseptic solution, the following antibiotic therapy regimens are used:

• amoxicillin + clavulanic acid 1.2 g intravenously 3-4 times a day,
• cefalosporins II-III generation (cefuroxime 1.5 g intravenously 3 times a day, ceftriaxone 2.0 g intravenously once a day) and metronidazole 500 mg intravenously 3 times a day,
• clindamycin 900 mg intravenously 3 times a day and gentamicin 5-6 mg / kg intravenously or intramuscularly for one administration.

If ineffective emptying of the uterus from detritus, washing with disinfectant solutions and prescribing antibiotics raise the issue of removal of the uterus along with the tubes, which is of decisive importance for the outcome.

If the source of sepsis is suppurative mastitis, suppuration of the postoperative wound, then a wide opening of the abscess, its emptying and drainage is shown.

In other respects, after removal of the main focus of infection, with intensive therapy of septic shock in obstetrics adhere to the principles developed by domestic and foreign researchers for treatment and sepsis, and septic shock in general.