Septic shock in gynecology

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

This pathological process was first described in 1956 by Studdiford and Douglas. In terms of frequency of occurrence, bacterial toxic shock is third after hemorrhagic and cardiac shock, and in terms of mortality, it is first. From 20 to 80% of patients die from septic shock.

Septic (bacterial, endotoxic, infectious-toxic) shock can develop at any stage of a purulent disease, but more often it develops during another exacerbation of the purulent process or at the time of surgical intervention, 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 diseases of the pelvic organs, septic shock currently occurs much less frequently (less than 1%, whereas in the 80s this complication was observed in 6.7% of patients).

Shock dramatically aggravates the course of the disease, and it is often the direct cause of death of patients. The mortality rate of patients with septic shock reaches 62.1%.

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

• changes in the nature of microflora, the emergence of antibiotic-resistant and even antibiotic-dependent forms of microorganisms;
• changes in cellular and humoral immunity of many women due to the widespread use of antibiotics, corticosteroids and cytostatics;
• increased allergy of patients;
• the widespread introduction into gynecological practice of diagnostic and therapeutic methods associated with entry into the uterine cavity.

With the increasing incidence of purulent-septic diseases, the practicing physician increasingly has to deal with septic shock, this formidable pathology that poses a mortal threat to the life of the patient.

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

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

ICD-10 code

• O08.0 Infection of the genital tract and pelvic organs following abortion, ectopic and molar pregnancy
• O08.3 Shock due to abortion, ectopic and molar pregnancy
• O41.1 Infection of amniotic cavity and membranes
• O75.1 Maternal shock during or after labour and delivery
• O.85 Postpartum sepsis
• O.86 Other postpartum infections
• 086.0 Infection of surgical obstetric wound
  • O86.1 Other genital tract infections after childbirth
  • O86.2 Postpartum urinary tract infection
  • O86.3 Other genitourinary tract infections after childbirth
  • O86.4 Hyperthermia of unknown origin following delivery
  • O86.8 Other specified puerperal infections
  • O88.3 Obstetric pyemic and septic embolism

What causes septic shock?

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

• Low socio-economic status.
• Immunodeficiency state.
• Chronic foci of infection (urogenital tract).
• Diabetes mellitus.
• Surgical interventions (caesarean section).
• Infected abortion outside the hospital.
• Premature birth.
• Blood loss, hemorrhagic shock (placenta previa, placental abruption).
• Intrauterine manipulations.
• Anemia.
• Preeclampsia and eclampsia.

The main pathogens 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, and various types of fungi.

Septic abortion

Infection most often occurs ascendingly during an abortion or post-abortion period. Less common is primary infection of the fetal membranes (amnionitis, chorionitis) followed by termination of pregnancy. The etiologic spectrum of pathogens causing infectious complications of abortions is almost identical to that of inflammatory diseases of the pelvic organs. Polymicrobial etiology with a predominance of aerobic-anaerobic associations of vaginal microflora microorganisms is typical.

The main pathogens are enterobacteria (most often E. coli), gram-positive cocci (Streptococcus pyogenes, Enterococcus spp, S. aureus, etc.) and non-spore-forming anaerobes (Bacteroid.es spp, Peptucoccus spp, Peptostreptococcus spp). In some cases (especially in cases of illegal abortions), the pathogen may be Clostridium peijhngens.

Postpartum endometritis is characterized by an ascending route of infection from the vagina and cervix, polymicrobial etiology of postpartum endometritis. In the overwhelming majority of observations (80-90%), these are associations of aerobic and anaerobic opportunistic microorganisms that are part of the normal microflora of the female genital tract. Most often, the causative agents of postpartum endometritis are enterobacteria and enterococci, and from obligate anaerobes - bacteroids.

• Facultative anaerobes: Enterobacteriaceae E coli (17-37%), less often Proteus spp, Klebsiella spp, Enterobacter spp, Enterococcus faecalis (37-52%)
• Obligate anaerobes: Bacteroides fragilis (40-96%), less often Fusobacterium spp, Peptococcus spp, Peptostreptococcus spp
• Less frequently, Streptococcus pyogenes, Staphylococcus spp (S. aureus 3-7%), etc. are 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 MOF during the development of sepsis and septic shock in obstetrics. The development of pregnancy itself is accompanied by an inflammatory response to trophoblast invasion. During pregnancy, the number of leukocytes, the level of proinflammatory cytokines, the concentration of coagulation factors (fibrinogen, factor VIII), the level of D-dimer, C-reactive protein increase, the complement system is activated, the activity of the fibrinolytic system, the level of protein C and S, hemoglobin and the number of erythrocytes are reduced. The function of the vascular endothelium changes towards increased permeability.

In complicated pregnancy, such as gestosis, these changes progress and the so-called maternal inflammatory response develops as a variant of SIRS. Leukocytosis, band shift, increased levels of septic shock mediators, coagulation changes, and organ dysfunction in severe gestosis and eclampsia can significantly complicate the timely diagnosis of sepsis. This is most often encountered in situations where the patient undergoes prolonged mechanical ventilation. Therefore, antibacterial therapy is used to prevent sepsis during prolonged mechanical ventilation in severe gestosis and eclampsia.

A certain immunosuppression is also necessary for the normal development of pregnancy. The initial infection of the urogenital tract is of great importance. These changes contribute to the development and progression of the infectious process and significantly complicate 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:

• increase in body temperature,
• shortness of breath,
• tachycardia,
• enlargement and soreness of the uterus,
• purulent vaginal discharge,
• purulent discharge from the uterus,
• bleeding.

Diagnosis of septic shock

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

To assess the PON, it is necessary to determine:

• hemoglobin, red blood cells (decrease),
• platelet count, APTT, INR, fibrinogen, D-dimer level (signs of DIC),
• bilirubin, AST, AJIT, ALP (increase),
• urea, plasma creatinine (increase),
• electrolytes (electrolyte disturbances),
• blood glucose concentration (hypo- or hyperglycemia),
• blood gases (p02, pCO2),
• AAC (metabolic acidosis)

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Instrumental research

Ultrasound of the pelvic organs allows us to determine the presence of formations in the pelvis, assess the size of the uterus and the presence of foreign inclusions in its cavity.

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

Chest X-ray reveals signs of ARDS. Bacteriological studies are used to prescribe etiotropic treatment: cultures from uterine discharge, surgical wound, blood and urine. For an adequate choice of treatment tactics, it is extremely important to promptly notice signs of sepsis, multiple organ failure and septic shock in accordance with generally accepted criteria.

The attending physician should be alerted by dysfunctions of individual organs and systems that are not always explainable, especially in the postpartum or postoperative period. The clinical severity of the inflammatory reaction may be affected by preventive antibacterial therapy, infusion therapy, and pain relief during labor or cesarean section. Therefore, often the only symptom of generalization of the septic process and the development of PON may be impaired consciousness or progressive dysfunction of the liver, kidneys, lungs, etc.

Treatment of septic shock

Intensive care of sepsis and septic shock in obstetrics has virtually no differences from the currently generally accepted principles of treating this pathology. In this regard, there are extremely few RCTs and practical guidelines with a high level of evidence on the treatment of septic shock in obstetrics. The main attention is paid to issues of prevention and adequate assessment of its effectiveness in abortion and postpartum endometritis.

Septic abortion

Manipulations:

• Curettage of the uterine cavity to remove infected remnants of the fertilized egg, washing the uterus with an antiseptic solution.

Antibacterial therapy:

Currently, prophylactic use of antibacterial drugs is mandatory when performing an abortion.

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 3.2 g intravenously 4 times a day,
• carbapenems (eg, imipenem + cilastatin or meropenem) 0.5 g intravenously 4 times a day.

Alternative schemes:

• cephalosporins of the second and third generations (cefuroxime 1.5 g intravenously 3 times a day, ceftriaxone 2.0 g intravenously 1 time per 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 in one administration,
• ofloxacin 400 mg intravenously 2 times a day and metronidazole 500 mg intravenously 3 times a day.

If C re$pshet is detected, penicillin preparations are prescribed in large doses - 10-20 million IU per day.

Postpartum and postoperative endometritis

During a cesarean section, for prophylactic purposes, a single intraoperative (after clamping the umbilical cord) administration of one therapeutic dose of a broad-spectrum antibiotic is indicated:

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

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

In case of postpartum and postoperative endometritis, after removal of uterine contents and washing of the uterus with an antiseptic solution, the following antibacterial therapy regimens are used:

• amoxicillin + clavulanic acid 1.2 g intravenously 3-4 times a day,
• cephalosporins of the second and third generations (cefuroxime 1.5 g intravenously 3 times a day, ceftriaxone 2.0 g intravenously 1 time per 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 in one administration.

If emptying the uterus of detritus, rinsing with disinfectant solutions and prescribing antibiotics are ineffective, the question of removing the uterus together with the tubes is raised, which is of decisive importance for the outcome.

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

Otherwise, after removal of the main source of infection, intensive care for septic shock in obstetrics adheres to the principles developed by domestic and foreign researchers for the treatment of both sepsis and septic shock in general.