Obstetrics and Gynecology - A.M. Gromova 2000

Postpartum Septic Infections
Second Stage

Postpartum metritis

Postpartum metritis is a deeper uterine infection that extends beyond the endometrium into the myometrium via lymphatic clefts and vessels.

Metritis typically begins simultaneously with endometritis or, if it stems from the latter, no earlier than the 7th postpartum day. The patient's general condition worsens significantly, body Temperature rises to 40°C, and chills develop. Uterine involution is impaired. On pelvic examination, the cervix remains unformed even 9 days after delivery. Palpation reveals uterine tenderness, particularly along the lateral margins. Vaginal discharge is scant, dark red with purulent admixture, and malodorous. The disease duration is 3–4 weeks.

Metritis is managed following the same principles as severe endometritis.

Postpartum parametritis

Pathomorphology: inflammation of the parametrial cellular tissue due to lymphogenic spread of infection.

Clinical presentation

The condition usually manifests on the 10th–12th postpartum day. Characteristic features include fever, with body temperature rising to 39°C and occasionally up to 40°C, accompanied by Complaints of moderate, dragging lower abdominal pain. Severe pain occurs when the Peritoneum becomes irritated. Early in the course, internal examination reveals tissue pastiness in the affected area. Within 2–3 days, a well-defined infiltrate of doughy and subsequently firm consistency forms; it is moderately tender, fixed, and localized between the lateral surface of the Uterus and the pelvic wall.

Treatment

Management follows General Principles for septic conditions. In acute parametritis, targeted antibiotic therapy (based on antibiogram results), infusion therapy, local cold application to the lower abdomen, and Vitamins are prescribed. Severe cases require combination therapy with two Antibiotics, while anaerobic Etiology calls for The addition of metronidazole or lincomycin. Immunological response stimulators, analgesics, and sedatives are also indicated. If suppuration of the infiltrate occurs, surgical intervention is necessary: colpotomy is performed, and a T-shaped tube is inserted into the abscess cavity for aspiration-irrigation drainage. Once body temperature normalizes, resorption therapy and physical therapy are initiated.

Postpartum thrombophlebitis

Postpartum thrombophlebitis is classified into superficial and deep vein thrombophlebitis. Deep vein thrombophlebitis is further divided into metrothrombophlebitis, pelvic vein thrombophlebitis, and deep vein Thrombosis of the lower extremities.

The Development of thrombophlebitis is often preceded by warning signs: prolonged subfebrile temperature, pulse lability, step-like pulse, pain in the calf Muscles or along the venous trajectory, a positive cuff test, and elevated prothrombin index alongside other coagulation parameters.

Superficial vein thrombophlebitis in the postpartum period is uncommon and usually develops against the Background of varicose Veins. The affected vein appears tense and tender upon palpation, with overlying Skin hyperthermia and erythema; edema occurs relatively infrequently.

Metrothrombophlebitis is difficult to diagnose. Key diagnostic indicators include tachycardia, uterine subinvolution, and prolonged, heavy lochial bleeding. Bimanual examination may reveal tortuous cords (dilated veins) on the uterine surface.

Pelvic vein thrombophlebitis typically emerges by the end of the first postpartum week. It is characterized by delayed uterine involution, with affected veins palpable in the broad ligament area and lateral pelvic walls as tender, firm, tortuous cords.

Deep vein thrombophlebitis develops during the 2nd–3rd postpartum week. The onset is acute, marked by leg pain, fever, and chills. Edema appears a few days later. Objective Examination reveals smoothing of the inguinal region, tenderness upon palpation in the femoral triangle, and along the major Vessels of the thigh and leg. The duration of the disease is 6–8 weeks.

Treatment. Patients are maintained on bed rest with the legs elevated above trunk level, combined with elastic bandaging of the lower extremities. Pharmacotherapy includes broad-spectrum antibiotics, desensitizing agents, and antispasmodics.

Anticoagulant therapy should not be initiated earlier than the 3rd postpartum day due to the risk of uterine Hemorrhage. Direct anticoagulants (such as heparin, nadroparin) and indirect anticoagulants (such as dicumarol, phenindione) are prescribed (breastfeeding is strictly prohibited during this treatment course). Heparin administration requires monitoring of Blood clotting time (which should not exceed normal values by more than 3-fold), whereas indirect anticoagulants require monitoring of the prothrombin index (which should be maintained at 40–50%).

For lower extremity deep vein thrombosis, intravenous drip administration of fibrinolysin or streptokinase along with heparin is prescribed During the first 24 hours.

If conservative management fails to achieve the desired effect, surgical intervention is performed in a specialized department or vascular center.

During the convalescent phase, the patient is permitted to ambulate provided she has been afebrile for a week, the ERYTHROCYTE SEDIMENTATION RATE (ESR) does not exceed 30 mm/h, and paresthesias (tingling sensations) in the lower extremities are absent.

Salpingo-oophoritis

Inflammation of the uterine appendages is generally a complication of endometritis. The infection spreads via lymphatic pathways or through the fallopian tubes (intracanalicularly). The inflammatory process initially affects the fallopian tubes and subsequently extends to the Ovaries, forming a single conglomerate mass.

Clinical presentation

The disease develops on the 9th to 10th postpartum day and is accompanied by a deterioration in the patient's general condition, fever, chills, tachycardia, severe abdominal pain, nausea, flatulence, and peritoneal signs. Bimanual examination reveals that the uterine appendages are pasty and sharply tender. In hyperergic courses, suppuration (pyosalpinx, pyovarium) may occur, posing a risk of purulent Peritonitis.

Treatment

Bed rest, application of an ice pack to the lower abdomen, and a rational diet. Antibacterial therapy involving antibiotics, sulfonamides, nitrouran derivatives, and metronidazole. Nonsteroidal anti-inflammatory drugs, such as indomethacin and sodium diclofenac, along with a 30% sodium thiosulfate solution. Desensitizing therapy (diazolin, diphenhydramine, suprastin, pipolphen). Immunomodulators (levamisole, splenine, tactivin) and vitamin therapy.

Once the process begins to subside, resorbent therapy is prescribed—aloe, plasmol, lidase, FIBS—along with various physiotherapeutic Procedures.

Postpartum Pelvioperitonitis

This condition is more characteristic of gonorrheal infection than septic infection.

Clinical Presentation

Acute onset, high fever, sharp lower abdominal pain, abdominal distension and rigidity, and a positive Shchetkin-Blumberg sign in the lower abdomen. Auscultation of the Abdominal cavity reveals clear and frequent peristaltic sounds. The course of pelvioperitonitis can vary. In some cases, high fever slowly subsides, while in others, signs of progression to generalized peritonitis become apparent.

Pelvioperitonitis is generally treated using Conservative Methods. The patient requires rest and adequate Nutrition. Periodic Applications of an ice pack to the lower abdomen are recommended.

The primary role belongs to antibacterial therapy (see treatment of peritonitis). For detoxification, infusion-Transfusion Therapy is administered, including protein solutions, rheologically active plasma substitutes, saline solutions, glucose solution, and neogemodez. In cases of severe intoxication, 2 to 3 liters of fluid are administered daily, and Diuretics are used if diuresis is reduced.

The comprehensive treatment plan includes desensitizing agents, nonsteroidal anti-inflammatory drugs, analgesics, and vitamins. Ultraviolet irradiation of autologous blood is also advisable.

Surgical intervention is required for pelvioperitonitis developing against the background of pyosalpinx, pyovarium, or tubo-ovarian abscess, as well as when the condition progresses to generalized peritonitis.