Endometritis

Endometritis - inflammation of the uterine mucosa of polymicrobial etiology. Endometritis during labor (chorioamnionitis) is a polymicrobial infection of membranes and amniotic fluid.

Acute endometritis and endomyometritis do not belong to the frequently occurring diseases requiring the doctor to provide emergency care.

[1], [2], [3], [4], [5], [6], [7], [8]

Epidemiology

The incidence of endometritis after spontaneous physiological birth is 1-5%, after pathologically occurring - 4-6%, after cesarean section - more than 12%. Chorioamnionitis develops in 0.78-1% of women. At each 5-th child, the chorioamnionitis passes into postpartum endometritis.

According to observations, acute endometritis and endometriometritis are diagnosed in 2.1% of cases of all diseases or in 9.7% of acute inflammatory processes of the upper parts of the reproductive apparatus. Inflammation of the uterus in the structure of inflammatory diseases of the internal genital organs is even less common (0.9%). Endometritis is often combined with damage to the uterine appendages, while vivid clinical manifestations of adnexitis can mask signs of an inflammatory process in the uterus, which certainly affects the statistical data.

[9], [10], [11], [12], [13], [14], [15], [16]

Causes of the endometritis

Polymicrobial disease, which can be caused by staphylococci, streptococci, gram-negative rods of the Enterobacteriaceae family and non-spore forming anaerobes; rarely mycoplasma, chlamydia, viruses. The most frequent pathogens are conditionally pathogenic aerobic and anaerobic bacteria.

The primary inflammatory process, limited to the outside of the uterus, usually develops as a result of the ascent of infection through the cervical canal. An intact endocervical barrier can overcome such highly virulent microorganisms as the gonococcus. Usually the penetration of bacteria into endometrium and myometrium tissue occurs when the integrity of the cervical barrier is violated in spontaneous and artificial abortions, diagnostic curettage of the mucous membrane of the cervix and the uterine body, the introduction of IUD and other intrauterine interventions. Hematogenous, lymphogenic and contact spread of infection on the tissue of the uterus wall is much less common. Endomiometrit in such cases necessarily combined with inflammatory processes of internal genital organs of other localization.

[17], [18], [19], [20], [21]

Symptoms of the endometritis

Symptoms of acute endometritis are largely due to the nature of the causative agent of the disease, the age and state of women's health, the features of previous manipulations on the uterus.

Gonorrheal endometritis as an isolated disease is observed infrequently: in 7.1 % of cases of ascending gonorrhea. Young women, who lead an active, often erratic sex life, usually fall ill. The onset of an inflammatory process in the uterus can be triggered by childbirth, abortion, and any intra-uterine manipulation. However, as mentioned above, the development of gonorrheal endometritis is possible with an intact cervical barrier. In such cases, the initial manifestations of the disease, as a rule, occur in the first 14 days of the menstrual cycle and in some patients are quite pronounced: pain in the lower abdomen, malaise, headache, fever. Significantly more often acute gonorrheal endometritis manifests itself only by bleeding in the form of prolonged menstruation or in the form of blood discharge that appeared a few days after the end of menstruation. Allocations often take a sac or gnostic character.

The general condition of patients is usually assessed as satisfactory. Pulse corresponds to body temperature. The abdomen remains soft, painless on palpation, sometimes there is a moderate soreness over the bosom. There are no swelling of the intestines, symptoms of irritation of the peritoneum are absent. When examining the external genitalia, vagina and exocervix, you can identify signs of gonorrheal involvement of the lower parts of the genitourinary apparatus: urethritis, endocervicitis, inflammation of the excretory ducts of the large glands of the vaginal vestibule. Bimanual examination makes it possible to determine the usual condition of the cervix, some soreness of the uterus body, no changes in appendages and parameters. At the first examination of the patient before the beginning of treatment, it is necessary to take a material from the urethra, cervical canal and rectum for bacterioscopic and bacteriological examination.

A practical doctor working in the department of urgent gynecology often has to deal with patients suffering from acute endometritis after spontaneous or induced abortion.

In domestic obstetrics, spontaneous abortion is considered to be the termination of pregnancy until the 28-week period. Miscarriage, which occurred in the first 16 weeks, i.e. Before the formation of the placenta, is called early; after this period - late. Endometritis can complicate spontaneous miscarriage of any term.

Artificial termination of pregnancy is currently produced by different methods:

1. the so-called mini-abortion, carried out with the help of vacuum aspiration with a delay of 7 to 20 days;
2. traditional abortion, produced before the 12-week period by expanding the cervix and removing the fetal egg with a curette or vacuum suction;
3. late abortion, performed on medical grounds by intra-amniatic administration of hypertensive solutions, intravenous infusion of prostaglandins or oxytocin, small caesarean section.

All these types of abortions can be complicated by acute endometritis, the frequency of which depends on the term and method of abortion, the degree of blood loss, and the adequacy of anesthesia. Predisposing factors include general diseases (pathology of the cardiovascular, respiratory, urinary, endocrine and other systems and organs), inflammatory processes of the genital organs in the past.

Many times more often, endometritis and endometriometritis are complications of artificial criminal abortions performed outside the hospital.

Violation of the integrity of the cervical barrier, significant defects in the endometrium allows infection pathogens to penetrate easily into the tissues of the uterine wall. Their growth is supported by fibrin, blood clots, foci of necrosis and the possible presence of elements of the fetal egg. As causative agents of acute postabortion endometritis, at the present time there are aerobes (enterococci, Escherichia coli, group B streptococci, staphylococci) and anaerobes (bacteroides, fusobacteria, peptococci, peptostreptococci). Enterococci and E. Coli, bacteroides and fusobacteria are most often sown from the uterine cavity. The severity of the disease largely depends on the nature of the microflora and the degree of bacterial obesomenennosti of the uterine cavity. Acute endometritis with severe clinical course is usually caused by the introduction of aerobic-anaerobic associations: Escherichia coli, group B streptococcus, fusobacteria, peptococcus and peptostreptococcus in various combinations. Bacterial contamination exceeds 10 ⁴ cfu / ml. The importance of Chlamydia infection in the development of acute endometritis after artificial, abortion is still not exactly determined. Most researchers believe that the clinic of the inflammatory process, caused by chlamydia, is characterized by a more protracted course and less pronounced symptomatology. Mycoplasma can be the etiologic factor of endometritis after any vitro-matic interventions, including after an artificial abortion, even more often after a spontaneous abortion, which is not so rarely provoked by them.

Symptoms of acute endometritis or endomyometritis after an abortion have a fairly typical picture. The disease begins on the 2nd-5th day after the intervention, and the early manifestation of symptoms indicates a more severe course of it. The general condition of a woman worsens, chills are not uncommon. The body temperature rises from low-grade figures to severe hyperthermia. There are pains in the lower abdomen, radiating to the sacrum or groin areas. The patient complains of purulent or bloody-purulent discharge from the genital tract, with abundant purulent, mucopurulent, purulent-sacred detachable indicating a possible chlamydial infection; the putrid nature of liquid, purulent, sometimes foamy, secretions indicates the probability of anaerobic flora. In the presence of the remains of the fetal egg, there may be quite a significant bleeding.

Appearance of patients depends on the degree of intoxication and blood loss. However, in most cases they have the usual color of the skin; Wet tongue; tachycardia corresponding to body temperature. Pallor, severe tachycardia, hypotension are the result of severe bleeding. Gray color of the skin speaks of intoxication. The abdomen remains soft, painful on palpation of the lower parts.

Gynecological examination allows us to determine the usual form of the painful uterus, which is in a state of subinvolution. If there are small fetal egg residues in the uterine cavity, the outer cervix is left ajar, with a late miscarriage, the cervical canal freely passes the finger, and the inner yaw can palpate the tissues of the fetal egg and blood clots. The body of the uterus has a spherical shape, its involution is significantly delayed. Pathological changes in appendages and parameters are absent. During the first examination before the appointment of antibacterial therapy, it is necessary to take a material to identify pathogens. A clinical blood test is characterized by moderate leukocytosis and an increase in ESR.

As a rule, endometritis, which was a complication of spontaneous or artificial abortion, produced in hospital conditions, with timely and adequate therapy is proceeding favorably. Liquidated within a week. However, one should not overlook the possibility of spreading the infection and developing such a grave complication, such as septic (or bacterial-toxic) shock.

Endometritis after the criminal interventions is more difficult, which is explained by the massive intake of microflora in the uterus, the possible mechanical and chemical damage to the walls of the uterus, the toxic effect of substances used for the abortion of the woman on the woman's body, as well as late seeking medical help for such a contingent of patients. These factors can contribute to the spread of the infection, up to its generalization, and therefore require the doctor to take clear action and mobilize all the necessary tools and therapies.

In connection with the proliferation of intrauterine contraceptives, practitioners often have to deal with patients whose inflammatory process of genital organs develops with IUD. The presence of IUD facilitates the transcervical passage of bacteria, and the tissue reaction around the contraceptive contributes to the acute course of the inflammatory process with rapid abscessing.

In his daily practice, a doctor may come across a secondary purulent uterine lesion - a pyometra, which arises from the narrowing of the isthmus or cervical canal by a tumor, myoma, polyp, endometriosis. In women who are in menopause, senile atrophy can lead to narrowing of the cervical canal. Often the retention of purulent exudate in the uterine cavity proceeds secretly, without giving a clinical picture. However, very often women enter the hospital with complaints of high fever with chills and severe pain in the lower abdomen; purulent discharge from the genital tract may be absent or be scarce because of difficulty in outflowing them from the uterine cavity. When gynecological examination, the atrophic or usual cervix of the uterus is detected and the uterine body is enlarged, round, soft or of a tauto-elastic consistency. Overcoming of the obstruction by the uterine probe in the cervical canal or isthmus promotes the outflow of pus and confirms the diagnosis of pyometers. However, bearing in mind the possible malignant nature of the narrowing of the cervix or uterine neck, it is necessary to take the material for histological examination with the help of the curette. It is also necessary to take a purulent discharge for bacteriological research and determine the sensitivity of microflora to antibiotics.

[22], [23], [24], [25], [26], [27], [28]

Forms

There are 3 clinical forms of endometritis:

• light;
• of moderate severity;
• heavy.

The mild form of endometritis - the disease begins on the 5th-12th day of the postpartum period. There are no signs of intoxication. The general condition of patients within 24 hours does not deteriorate significantly. Sleep and appetite are good. Headaches are not present. Uterus slightly enlarged, sensitive to palpation. Lochias remain blood for a long time. Under the influence of treatment, the body temperature decreases within 2-3 days, the soreness of the uterus disappears after 1-2 days after the palpation, the character of the loli is normalized on 2-3 days.

Moderately severe form of endometritis - the disease develops on the 2-7th day of the postpartum period. Clinical manifestations are more pronounced. There is a moderate intoxication. Uterus enlarged, painful on palpation. The lochia is turbid, bloody-purulent, sometimes with a fetid odor. Against the background of treatment, the symptoms of the disease gradually disappear within 8-10 days. High temperature persists for 5-7 days and passes to the end of the disease in the subfebrile.

Severe form of endometritis - the disease begins on the 2-3rd day of the postpartum period, mainly in women after cesarean section. The general intoxication is expressed. The condition of patients within 24 hours does not improve, negative dynamics is possible. The clinical picture is characterized by headache, weakness, tachycardia with a heart rate of more than 110 per minute, fever with chills, sleep, appetite, dry mouth, intestinal paresis, decreased diuresis, lower abdominal pain. Uterus enlarged, markedly painful on palpation. Lochias are purulent, with a chicken smell.

Currently, against the background of preventive administration of antibiotics and ITT, often erased forms of endometritis occur. With these forms, the clinical picture does not reflect the severity of the condition of the puerpera. The first symptoms of the disease appear within 1-7 days. The clinical data and the results of laboratory tests correspond to the mild form of the flow of the endometritis. In a bimanual study, the uterus is painless and not enlarged in size, which is related to the uterine bend in the area of the postoperative suture. The edema of the area of the postoperative suture and the inflection of the uterus help delay the blood clots in its cavity and create conditions for the permanent resorption of bacterial and tissue toxins. After the weakening of therapy with this variant of the disease general infection begins quickly.

Chorioamnionitis develops in the anhydrous interval for more than 24 hours or when there is bacterial vaginosis in the parturient. Characteristic: worsening of the general condition of the parturient, increased body temperature, chills, tachycardia, soreness of the uterus during palpation, and puffy discharge from the genital tract. The disease can be asymptomatic, but lead to intrauterine infection of the fetus (manifested tachycardia in the fetus).

[29], [30], [31], [32], [33], [34]

Diagnostics of the endometritis

Researches 1, 2, 3, 5 are performed by all patients, 4, 6 - if there are technical possibilities and when doubting the diagnosis.

1. Thermometry. With a mild form of body temperature increase to 38-38.5 ° C, with a severe form, the temperature is above 39 ° C.
2. Clinical blood test. With a mild form, the number of leukocytes is 9-12 × 10 ⁹ / L, a slight neutrophil shift of the white blood formula is determined to the left; ESR 30-55 mm / h. In severe form, the number of leukocytes reaches 10-30 × 10 ⁹ / l, a neutrophil shift to the left, a toxic granularity of leukocytes; ESR - 55-65 mm / h.
3. Ultrasound of the uterus. All puerperas are performed after spontaneous delivery or by cesarean section on the 3-5th day. The volume of the uterus and its anteroposterior size are increased. Define a dense fibrinous plaque on the walls of the uterus, the presence of gas in its cavity and in the ligature region.
4. Hysteroscopy. There are 3 variants of the course of endometritis in terms of the degree of intoxication of the organism and local manifestations:
   • endometritis (whitish coating on the walls of the uterus due to fibrinous inflammation);
   • Endometritis with necrosis of decidual tissue (endometrial structures of black color, tight, somewhat bulging over the wall of the uterus);
   • endometritis with delayed placental tissue, is more common after childbirth (a tuberous structure with a bluish outflow sharply contours and stands out against the background of the walls of the uterus).

A number of patients are diagnosed with a tissue defect in the form of a niche or a course - a sign of a partial divergence of the sutures on the uterus.

5. Bacteriological study of aspirates from the uterine cavity with the definition of sensitivity to antibiotics. Prevalent are not spore forming anaerobes (82.7%) and their associations with aerobic microorganisms. Anaerobic flora is highly sensitive to metronidazole, clindamycin, lincomycin, aerobic - to ampicillin, carbenicillin, gentamicin, cephalosporins.
6. Determination of the acid-base state of lochia. Endometritis is characterized by pH <7.0, pCO2> 50 mmHg. St, pO2 <30 mm Hg. Art. The change in these indicators precedes the clinical manifestations of the disease.

Screening

In order to identify puerperas with subinvolution of the uterus, which constitute a risk group for postpartum endometritis, ultrasound is performed on the 3-5th day after delivery.

[35], [36], [37], [38], [39], [40]

Differential diagnosis

Differential diagnosis is performed with postpartum parametritis, pelvic peritonitis, metrotrombophlebitis, thrombophlebitis of pelvic veins.

• Postnatal parametritis - inflammation of retroperitoneal fibro-fatty tissue of the small pelvis. The disease begins on the 10th -12th day of the postpartum period with chills and a fever of 39-40 ° C. The parlor complains of dull pain in the lower abdomen. 2-3 days after the onset of the disease, the infiltrate is palpated between the lateral surface of the uterus and the pelvic wall with a dough or a dense consistency, moderately painful, immobile. Lateral arch is flattened. With a one-sided parametrization, the uterus is displaced in the opposite direction from the localization of the process, with a bilateral one - upwards and forwards. When the infiltrate spreads anteriorly, it is palpated above the inguinal ligament, percussion of the superior anterior palsi of the iliac bones is determined by muffling the percussion sound. Transition of inflammation to peribubuse fiber leads to its spreading on the posterior surface of the anterior abdominal wall to the navel. From the upper part of the parameter, the infiltrate can spread to the kidneys.
• Postnatal pelvioperitonitis is an inflammation of the peritoneum, limited by the pelvic cavity. Local symptoms of the disease predominate. The onset of the disease resembles a clinic of diffuse peritonitis: it is acute, accompanied by fever, chills, sharp pains in the abdomen, nausea, vomiting, swelling and abdominal tension. After 1-2 days, the condition of the puerpera is improved, bloating is limited to the lower half. On the anterior abdominal wall, a transverse furrow is defined on the border between the inflamed and healthy parts of the abdominal cavity. When vaginal examination in the first days of the disease, only the densification and soreness of the posterior arch is noted; then behind the uterus appears effusion, protruding posterior arch in the form of a dome and having first a doughy, then densely elastic consistency. The effusion displaces the uterus anteriorly and upwards. The disease lasts 1-2 months.
• Metrotromboflebit - a lesion of veins of the uterus. There are tachycardia up to 100 or more per minute, subinvolution of the uterus, soreness in the region of the uterine ribs during palpation; when vaginal examination, painful tendons on the uterus are determined. Bloody discharge from the genital tract is long, abundant.
• Thrombophlebitis of the pelvic veins - develops at the end of the second week of the postpartum period. Subinvolution of the uterus is noted. With vaginal examination, the affected veins are palpated at the base of the broad ligament and on the side wall of the pelvis in the form of painful, dense and tortuous cords.

Treatment of the endometritis

The goal of endometritis treatment is removal of the pathogen, relief of the symptoms of the disease, normalization of laboratory indicators and functional disorders, prevention of complications of the disease.

Indications for hospitalization

Occurrence of clinical and laboratory signs of endometritis.

Non-pharmacological treatment of endometritis

• Bed rest.
• Cold on the bottom of the abdomen.
• Influence on the foci of infection
• Physiotherapy in remission:
  • drug electrophoresis;
  • magnetotherapy;
  • phonophoresis of ointments;
  • ultraviolet irradiation;
  • diadynamic currents;
  • local darsonvalization.

Medication for endometritis

The main component is antibacterial therapy. Early prescription of broad-spectrum antibiotics is necessary.

With mild and moderate forms of endometritis, antibacterial monotherapy is performed. Cephalosporins are used: cefoxytin 2 g every 6 hours IV, ceftazidime 1 g every 8 hours IV.

If suspected of enterococcal infection, preference is given to antibiotics of penicillin series: ampicillin 3 g at 6 h / m.

When the form of endometritis is severe, it is advisable to use a combination of antibiotics:

• clindamycin 600-900 mg every 8 hours + gentamicin 1.5 mg / kg every 8 hours IV;
• metronidazole 500 mg every 6-8 h iv + gentamycin at 1.5 mg / kg every 8 hours iv.

Effective third generation cephalosporins:

• ceftazidime 1 g every 8 hours or 2 g after 12 hours IV or / m;
• cefoperazone 1-2 g IM every 12 h, iv slowly in the form of a solution of 100 mg / ml, the maximum single dose of 2 g.

Treatment of chorioamnionitis

It is necessary to combine the use of drugs that affect the aerobic and anaerobic microflora:

• Ampicillin 2 g IV every 6 hours in combination with gentamycin (1.5 mg / kg IM every 8 hours) and metronidazole (500 mg IV every 6 hours);
• combination of cephalosporins I and II generations (cephalexin 250-500 mg every 6-12 hours IV, cefazolin 1 g iv twice a day, cefoxitin 1-2 g every 8 hours IV, IM) with clindamycin (600 mg to 900 mg IV every 8 hours).

Effective use of cephalosporins of the third generation.

For the prevention of candidiasis and dysbiosis use:

• Nystatin 500,000 units 4 times a day inside;
• levorin 250,000 units 4 times a day inside.

To prevent allergic reactions against the background of antibacterial therapy, antihistamines are indicated:

• Chloropyramine 0.025 g 2 times a day or 2% solution of 1 ml 1-2 times per day IM;
• Diphenhydramine 0,05 g 2 times a day inwards or 1% solution of 1 ml 1-2 times per day IM;
• Promethazine to 0.025 g 2 times a day or 2.5% solution of 1 ml 1-2 times per day IM.

It is necessary to carry out infusion therapy. The ratio between colloidal and crystalloid solutions should be 1: 1 (400 ml of solution of ethoxylated starch, 200 ml of blood plasma, 400 ml of 10% glucose solution, 250 ml of Ringer's solution.The total infusion volume is 1250 ml / day).

Treatment of acute endometritis should be carried out in a hospital. No considerations of the economic order should be taken into account, as this pathology, as a rule, occurs in young women, and the doctor faces a responsible task to restore the patient's health, preserving her reproductive function.

The effectiveness of treatment depends on the timeliness and adequacy of their conduct. To begin therapy it is necessary not baggy, at once at receipt of the patient in a hospital. The amount of treatment should be sufficient for each specific case of the disease, but not excessive. The truncated course does not prevent further spread of the infection or contributes to the chronization of the process. Excessive prescriptions of medicines, in addition to high monetary costs, can lead to an increase in undesirable side effects and allergization of patients.

Principles of treatment of patients with acute endometritis and endomyometritis are common, they are characterized by their complexity, etiological and pathogenetic validity, individual approach.

The patient needs to provide bed rest for the entire period of high body temperature. The diet should be rich in vitamins, easily digestible, not leading to bowel dysfunction. Periodic application of cold on the lower abdomen has anti-inflammatory, analgesic and haemostatic effect. Local hypothermia contributes to a reduction in hyperemia and hyperhydration of tissues in the inflammatory focus, a local decrease in metabolic processes and oxygen consumption, a weakening of allergic reactions, an increase in the activity of antibiotics.

The tendency to rapid spread of infection from the uterus to the appendages, parametric fiber and peritoneum of the pelvis dictates the need for early initiation of antibacterial therapy. The doctor has no right to waste time identifying the pathogen and receiving an antibiotic. The results of such studies will help to make the necessary correction in the treatment, and it should be started immediately after taking the material for bacterioscopic and bacteriological research, stopping its choice on the preparations to which the sensitivity of the flora, which is most prevalent in modern conditions, shows sensitivity. Various associations of gram-negative and gram-positive aerobes and anaerobes, chlamydia and gonococcus represent that spectrum of agents of acute endometritis, which must be blocked by prescribing antibiotics. This requirement is met by tetracyclines, cephalosporins, and levomycetin. The following drugs have the necessary antimicrobial effect: benzylpenicillin sodium salt or carbenicilline disodium salt with gentamicin sulfate, carbenicillin disodium salt with lincomycin hydrochloride or clindamycin phosphate, benzylpenicillin sodium salt with tetracycline hydrochloride (metacycline hydrochloride, doxycycline hydrochloride). To enhance the antibacterial action directed against anaerobic nonclostridial flora, include preparations of metronidazole. All of these drugs for acute endometritis used in average therapeutic dosages.

For the treatment of gonorrheal endometritis, antibiotics of the penicillin series are currently being used. However, due to the fact that ascending gonorrhea (especially provoked by intrauterine manipulation) often occurs as a mixed infection, it is advisable to combine these antibiotics with sulfonamides, nitrofurans, metronidazole or apply broad-spectrum antibiotics.

Not all patients need infusion therapy. In case of severe intoxication, colloidal and crystalloid blood substitutes are prescribed: hemodez, polydease, rheopolyglucin, gelatinol, isotonic solutions of sodium chloride and glucose.

An indispensable, pathogenetically substantiated component of the complex of measures in acute endometritis (as with inflammation of the sexual organs of other localization) is desensitizing therapy. To this end, you can use any medications available to the doctor: diphenhydramine, fenkarol, diprazine, diazolin, suprastin, tavegil. Depending on the degree of severity of the disease, they are administered orally or parenterally. As antiallergic agents can be used 10% calcium chloride or gluconate, which are administered intravenously, 5-10 ml. Calcium preparations are widely used for the treatment of acute endometriometritis also because they have the ability to reduce vascular permeability, have hemostatic effects, contribute to uterine contraction.

The inclusion of uterotonic agents into the complex of medical measures is motivated by the fact that they improve the outflow of lochia, reduce the wound surface of the endometrium, reduce the resorption of products of microbial and tissue decay. You can imagine that such a mechanism of therapeutic effect of drugs that reduce the uterus is effective in endometritis. With myometrites, the contractility of the uterus is difficult to correct, and in the case of involvement in the inflammatory process of uterine veins, the appointment of strongly fast, but short-acting uterotonic agents can promote the spread of thrombi. Therefore, we give preference to medications that cause moderate strength, prolonged contraction of the uterine musculature: quinine hydrochloride powder 0.15 g 3-4 times per day per os; tablets of deaminooxytocin 50 ED also 3-4 times a day buccal. A good effect can be achieved by acupuncture and other types of reflexology. With success use different types of physiotherapy, for example zinc electrophoresis with diadynamic currents, which possesses not only contractile but also anti-inflammatory properties.

To improve the outflow of losally, the use of uterine contracting agents should be combined with the appointment of antispasmodics, for example, 2% solution of no-shpa 1-2 ml 2 -3 times a day. In the complex treatment of acute endometritis should include vitamins C and B group.

In addition to the above general principles of care for patients with acute endometritis, each individual case requires an individual approach. Thus, the treatment of patients whose endometritis occurred against the background of IUD should start with the removal of the contraceptive, and one should not forget about taking from the surface of the IUD for seeding, bacterioscopic and cytological examination.

The presence of infected remains of the fetal egg after artificial abortion aggravates the severity of the course of the endometritis. Antibiotic therapy in such cases is ineffective, since necrotic remnants of the fetal egg are not available for antibiotics. It is not necessary to hope for the formation of the so-called granulating shaft because many modern pathogens have high enzymatic activity, leading to necrobiosis of uterine tissues. Therefore, under the present conditions, there is no doubt about the need for early instrumental emptying of the uterine cavity.

Evacuation of infected fetal egg residues should be performed carefully with abortion and curette, fixing the cervix with bullet forceps, but if possible, not displacing the uterus. Vacuum-aspiration of delayed parts of the fetal egg in the overwhelming number of cases is ineffective due to a rather intimate attachment to the uterine wall. This method can be preferred only in the first 3-4 days after the abortion. Emptying the uterine cavity should be done immediately when the patient enters the hospital against the background of antibiotics. In severe cases, accompanied by multiple chills, hyperthermia and intoxication, the removal of the remains of the fetal egg should be carried out simultaneously with the infusion therapy. Such a tactic should be followed with an incomplete, uncomplicated, uncomplicated abortion.

If the endometritis is a complication of an abortion of a late period (including that produced by a small cesarean section), it is advisable to complement the therapy package with intra-uterine lavage. In these cases, the cervical canal freely passes the drainage tube, which is inserted into the uterine cavity under visual control after exposing the vaginal part of the cervix with the help of mirrors.

Lavage can be carried out by aspiration-washing method, using double-lumen silicone or chlorovinyl tubes. Through a narrow channel connected to the system for blood transfusion, the liquid enters the cavity; through a wide channel equipped with additional openings, evacuation of liquefied infectious-toxic exudate, pus, fibrin, blood clots with the help of various types of electro-aspirators, which make it possible to maintain a vacuum of 30-60 cm of water. Art.

Lavage is carried out with the help of various antiseptic solutions. Widely used furatsilin in a 1: 5000 dilution, which has antimicrobial activity against Gram-positive and Gram-negative bacteria. Dioxydin has a wide spectrum of antibacterial action. Proteus, Pseudomonas aeruginosa, staphylococci, streptococci, anaerobes are sensitive to it. For lavage, 5 ampoules (50 ml) of 1% dioxygen solution are diluted in 450 ml of isotonic sodium chloride solution to give 0.1% concentration. A good effect can be achieved with a 2.07% hydrolysis solution, obtained by fermenting certain strains of saccharomycetes, is characterized by antibacterial activity against staphylococci, to a lesser extent - a proteus and Pseudomonas aeruginosa; Baliz-2 promotes the rejection of necrotic tissues and stimulates reparative processes in the wound.

After identifying the flora and determining its sensitivity to antibacterial drugs, lavage can be performed using solutions of antibiotics, sulfonamides or nitrofurans purposefully. High efficiency in anaerobic infection is metronidazole, 100-200 ml of which can be used as a 0.5% solution produced by the pharmaceutical industry, and in dilution with an equal amount of isotonic sodium chloride solution.

Lavance sessions are held daily for 3-5 days. The duration of the procedure is 1-2 hours, the flow rate is 500-1000 ml. Before the procedure, the solutions are cooled to 4-5 ° C.

The inclusion of lavage in the complex of endometritis therapy that appeared after late-term abortions promotes acceleration of suppression of the infectious principle and prevention of contamination, helps unimpeded removal of necrotic masses and wound exudate, promotes involution of the uterus. According to our observations, the duration of inpatient treatment is reduced by 1-2 days.

Surgery

To influence the focus of infection, vacuum aspiration of the postpartum uterus and washing with antiseptic solutions are used. These measures should be carried out against the background of antibacterial, infusion, detoxification therapy.

Indications for consultation of other specialists

Before conducting surgical treatment, an anesthesiologist should be consulted.

Student training

The baby girl should be informed that if the general state of health worsens, sleep, appetite, temperature increases, and odor discharge occurs, the doctor should be consulted immediately.

Further management of the patient

Observation in the female consultation within 3 months after clinical recovery and removal from the register.

Prevention

It is necessary to allocate a group of risk of development of endometritis. It includes pregnant women with exacerbation or chronic infectious diseases; of women in childbirth who have been operated on in an emergency with a labor duration of more than 15 hours and / or an anhydrous interval of more than 6 hours.

Preventive use of antibiotics in cesarean section (intravenous antibiotic after clamping of the umbilical cord and use of a short course at 6 and 12 or 12 and 24 hours), after a manual examination of the postpartum uterus, with an anhydrous interval of 12 hours or more.

For the prevention of penicillins use a wide range of action and cephalosporins. It is advisable to combine them with metronidazole, lincomycin, clindamycin (effect on non-spore forming anaerobes).

[41], [42], [43], [44], [45], [46], [47]

Forecast

Chorioamnionitis in every 4-year-old woman in labor passes into postpartum endometritis. Endometritis often proceeds in mild form and ends with recovery, but it can cause insufficiency of the sutures on the uterus with subsequent peritonitis or sepsis.

[48], [49], [50], [51]