Obstetrics and Gynecology - A.M. Hromova 2000

Postpartum septic conditions
First stage

Postpartum ulcer

The new mother complains of discomfort and pain in the genital area, often accompanied by a body Temperature rise up to 38°C. The febrile stage lasts for 4–5 days. The wound surface is covered with a dirty-gray or grayish-yellow coating that is tightly adhered to the underlying tissue. The wound bleeds easily. Tissue edema and inflammatory hyperemia frequently develop around it.

Treatment

Patients with a postpartum ulcer serve as a source of infection for healthy postpartum women and therefore must be isolated in a separate obstetric unit.

Local therapy is administered in all cases of postpartum ulcers. General treatment is prescribed when pronounced intoxication is present. If an inflammatory infiltrate forms in the area of the sutures and Perineum, the wound should be opened to ensure proper drainage of the purulent exudate. In cases of suppuration, the wound must be drained and thoroughly rinsed with antiseptics. To promote better granulation tissue formation, we recommend The Use of Proteolytic Enzymes (Trypsin, Chymotrypsin). They are applied as a solution (10–20 mg of the drug diluted in 25–50 ml of a 0.25% novocain solution) used to moisten a gauze swab inserted into the wound. This helps reduce the healing time of the postpartum ulcer by one-third. For extensive ulcers with tissue necrosis, ultrasonic treatment is performed; for this, the wound is filled with a furatsilin solution (1:5000) and exposed to the cannula of an ultrasonic device for 5–10 minutes. Once the wound is cleansed, ointment dressings, UHF therapy, and quartz therapy are applied. We discuss the principles of comprehensive therapy, which is carried out in the event of a deterioration in the patient's general condition, in detail in the chapter on the treatment of Postpartum Endometritis.

Postpartum endometritis

Causes: breach of asepsis and antisepsis rules, prolonged labor, extended dry period, maternal birth trauma, operative delivery, and Manual Exploration of the uterine cavity. Placental previa sometimes leads to bleeding and creates favorable conditions for the onset and development of infection during labor and the postpartum period. Endometritis begins on the 2nd to 3rd day postpartum.

Clinical presentation

Depending on the clinical course, mild, moderate, and severe forms of endometritis are distinguished, alongside latent (smoldering) and abortive forms.

Clinical signs of the mild form of endometritis appear on the 5th–12th day of the postpartum period. Symptoms include body temperature elevation to 38–38.5°C, tachycardia, and no significant Changes in the general condition; the Uterus is slightly enlarged and tender along the lateral margins (where major Lymphatic vessels run). Lochial discharge remains bloody for a prolonged time. Lochiometra—the retention of lochia within the uterine cavity—may develop. A complete Blood count reveals leukocytosis within the range of 9–12×10⁹/_L, a minor neutrophilic left shift of the leukocyte formula, and a moderate increase in the ESR (30–55 mm/h).

The severe form of endometritis is characterized by purulent-resorptive fever and a realistic threat of infection spreading (hyperplasia of infection). It is marked by the early onset of clinical symptoms—on the 2nd to 3rd day after delivery—and an altered general condition, manifesting as weakness, headache, Sleep disturbance, loss of appetite, and lower abdominal pain. The uterus is acutely tender, lochia become purulent with an ichorous odor, and lochiometra progresses to pyometra. Laboratory examination reveals leukocytosis of 14–30×10⁹/_L and an ESR exceeding 55 mm/h. Anemia develops in one out of every three patients.

In the abortive form, regression of the pathological process occurs either As a result of adequate treatment or due to the body's natural defense mechanisms.

The latent (smoldering) form of infection deserves special attention. It develops against the Background of reduced immune reactivity and lowered resistance in postpartum women. Because its clinical presentation mimics the mild or abortive form, it is rarely diagnosed in a timely manner, leading to inadequate treatment. Consequently, a generalized infection develops rapidly.

Latent forms are characterized by a discrepancy between the general condition and the pulse rate (tachycardia disproportionate to fever), between temperature and pulse (an accelerated pulse that does not match the level of hyperthermia), between the clinical picture and laboratory findings (leukocytosis, ESR), and between clinical and morphological manifestations (the latter are more pronounced than one might infer from the clinical picture alone).

Regardless of the form of endometritis, therapy must be comprehensive. The primary focus of intervention must be directed at the source of the infection—the uterus.

If lochia retention occurs in the uterine cavity, vacuum aspiration or curettage should be performed. When discharge is minimal, one may limit intervention to dilating the cervical canal to ensure better outflow of pus; to reduce the absorption of breakdown products and toxins, the uterine cavity is lavaged with chilled antiseptic and antibiotic solutions.

The use of uterotonic (uterine-contracting) agents in postpartum endometritis is controversial and not always advisable.

Antibacterial therapy. This involves the simultaneous administration of a combination of at least two Antibiotics at maximum dosages, taking into account the antibiogram. The antibiotic combinations include: oxacillin, amoxicillin at 6.0 g per day; ceporin, kefzol, cefamizin at 6.0 g per day; kanamycin at 0.5 g four times a day; and gentamicin at 80 mg twice a day.

In the presence of anaerobic infection, third-generation Cephalosporins (such as cefotaxime), combinations of gentamicin with clindamycin, or semi-synthetic Penicillins with metronidazole are prescribed.

Alongside antibiotics, sulfa drugs (10% sodium etazole solution, 10 ml IV twice a day) and nitrofurans (furadonin, furazolidone at 0.4 g twice a day) are administered.

To prevent candidiasis and dysbiosis, the treatment regimen includes nystatin (500,000 IU four times a day) and levorin (250,000 IU four times a day).

Immunosuppressive and restorative (stimulatory) therapy is carried out using:

- Hyperimmune antimicrobial plasma, 250 ml, 4–5 times per treatment course;

- Antistaphylococcal gamma-globulin or immunoglobulin, 5 ml intramuscularly or intravenously, 4–5 times;

- Healthy donor leukocyte suspension, 300–400 ml daily for 2–3 days;

- immunomodulators: Decaris 150 mg every 2 days for 10 days, Tactivin, Splenin, Thymolin, Thymogen i.m. or s.c. daily for 10 days.

Anti-inflammatory therapy includes the use of steroidal agents (glucocorticoids and their analogues) which possess universal anti-inflammatory and immunosuppressive effects, as well as nonsteroidal anti-inflammatory drugs (indomethacin, diclofenac sodium, ibuprofen, etc.) acting as inhibitors of inflammatory prostaglandin mediators.

To eliminate hypovolemia, ensure detoxification, and correct the colloid-osmotic status, multi-component therapy is administered taking into account specific blood test results of the patient.

In hyperoncotic states, infusion therapy is carried out using colloids and crystalloids in a 1:2 or 1:3 ratio. Crystalloids include Ringer's solution, 5% or 10% glucose solution, and a glucose-novocaine mixture.

In normooncotic states, The ratio of colloids to crystalloids is 1:1. The infusion therapy program includes: 400 ml of rheopolyglucin, 200 ml of Blood Plasma, 400 ml of 10% glucose solution, and 250 ml of Ringer's solution. The total infusion volume is 1250 ml.

In hypooncotic states, hyperoncotic solutions are used: plasma, 6% polyglucin, 10% rheopolyglucin, 5% and 10% albumin.

Purulent-Inflammatory Diseases lead to an increased content of free histamine and histamine-like substances in the body. Consequently, the administration of antihistamines is justified: suprastin 0.025 g twice daily, or 2% solution 1 ml 1–2 times i.m.; diphenhydramine 0.05 g twice daily, or 1% solution 1 ml 1–2 times i.m.

The efficacy of the aforementioned complex therapy should be evaluated no later than the 7th day of treatment. A reduction in uterine volume, stabilization of clinical and laboratory parameters, and improvement in the patient's well-being indicate that the therapy is properly directed and should be continued until complete recovery. If complex therapy proves ineffective, the issue of hysteroscopy must be addressed.

Postpartum Gonorrhea

Typically, gonococcal infection in the postpartum period manifests as mild endometritis characterized by a delayed rise in body temperature on the 6th–8th day postpartum. The primary sign is the early appearance of purulent discharge (on the 2nd–3rd postpartum day), which subsequently becomes viscous with mucous admixtures (gonococcal Endocervicitis).

In more severe cases, the infection spreads to the fallopian tubes and Ovaries. As a result, during the second week of the postpartum period, high body temperature, intense lower abdominal pain, and peritoneal irritation signs appear. Palpation reveals tenderness in the adnexal region and tubal induration, and a hydrosalpinx (or pyosalpinx) may form. Diagnosis is confirmed by isolating gonococci from the lochia. Treatment involves antibiotic therapy (predominantly penicillins). Local therapy for urethral and rectal lesions is performed immediately after delivery, whereas Treatment of the cervix is initiated 6–8 weeks postpartum (once it has fully involuted).

Vaccine therapy is not administered during Lactation.