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POST-NATURE PURULENT-SEPTIC DISEASES

Purulent-inflammatory diseases take 2-3 place among the causes of maternal mortality.



Factors contributing to the development of purulent-inflammatory diseases in pregnant women:



1. Immunological tolerance

- placental hormones:



a) placental lactogen

b) progesterone

c) chorionic gonadotropin

g) glucocorticoids



have an immunosuppressive effect:

- reduce T-cell immunity

(lead to a decrease in the level of T-helpers and increase the level of T-suppressors).

Immunosuppression lasts 2-3 weeks after childbirth.





Classification of purulent-inflammatory diseases in pregnant women

according to Sazonov - Bartels.



The first stage is an infection localized in the uterus or in the region of the external genital organs:

1) Endometritis

2) Chorionamnionitis



The second stage is an infection that extends beyond the uterus, but is limited within the pelvic region:

1) pelvioperitonitis

2) metrothrombophlebitis



The third stage is an infection close to generalized:

1) peritonitis

2) septic shock



The fourth stage is a generalized infection:

1) sepsis.



Anatomical classification.



1. Diseases of the lower genital tract:

• below an internal pharynx



2. ascending infection:

• in the uterus or pelvis



3. infection close to generalized:

• outside the pelvic





Chorionamnionitis.

- This is an inflammation of the chorion, amnion, and the underlying decidual membrane (this is endometritis in childbirth).



Causes.

Violation of barrier functions:



1. with rupture of the membranes against the background of an existing infection in the cervical canal



2. The duration of the anhydrous period is more than 6 hours

3. prolonged, prolonged labor



4. A large number of vaginal examinations performed - more than 5.



Etiology.

1) staphylococcus

2) E. coli

3) anaerobic bacteria

4) chlamydia



Clinic.

After the discharge of water in 6-8-12 hours, the first symptoms appear:



1. temperature increase

2. purulent discharge from the genital tract, sometimes with an unpleasant odor

3. tachycardia



In a general blood test:

- moderate leukocytosis, with a shift to the left - rarely

- anemia.



Medical tactics.



1) Antibacterial therapy

- appointed if the anhydrous period is more than 12 hours.



Preventively administered:

• semi-synthetic penicillins

• aminoglycosides

• less often - cephalosporins.



2) Infusion-transfusion therapy.



Its volume should be 800-1000 ml



Composition of media:

Colloids (detoxification drugs):

- polyglucin

- reopoliglyukin)



Crystalloids:

- glucose

- physical solution



3) Reducing the duration of labor.

- the introduction of uterotonics.



Caesarean section is performed only according to strict indications and in extraperitoneal variant.



In the postpartum period is carried out:



1) antibiotic therapy

2) infusion-transfusion therapy.





Endometritis.

is an inflammation of the endometrium.



It develops on 4-6 days after birth (or Caesarean section),

less often - for 10-12 days.



Clinic.



1) temperature increase to 38-38.5 C

2) weakness

3) malaise



4) nausea

5) decreased appetite



6) the appearance or intensification of purulent or purulent-bloody discharge from the genital tract



7) uterine lag in contraction - subinvolution

8) pain of the uterus during palpation and its displacement.



In a general blood test:

- moderate leukocytosis with a shift to the left

- lymphopenia

- very rarely - leukopenia



Additional research methods.



1) Ultrasound:

- an increase in the uterine cavity

- the presence in the uterine cavity of echo-positive and echo-negative inclusions (these are parietal clots, placental remnants, gas bubbles)



2) Hysteroscopy:

- endoscopic examination of the uterine cavity



3) Computed tomography

4) Nuclear magnetic resonance

- rarely used.



Endometritis treatment.



The principles of treatment:



1) Removal of the focus of infection

2) Antibacterial therapy



3) Infusion-transfusion therapy

4) Immunotherapy

5) Symptomatic therapy.



Removal of the focus of infection.



To this end, curettage of the walls of the uterine cavity is carried out by curettage or with hysteroscopy.



In 50% of cases, curettage determines placental tissue and fetal membranes.



In 30% of cases, during curettage, necrotic decidual tissue is determined.



In 20-25% of cases during curettage, blood clots, unchanged decidual tissue are determined.



Before curettage, it is necessary to begin carrying out antibacterial and infusion-transfusion therapy, since the barrier to the penetration of microorganisms is destroyed, and the risk of developing purulent-inflammatory complications is increased.



Antibiotic therapy.



Since, according to the etiology, endometritis is a mixed infection, the following are used:

broad-spectrum antibiotics (semisynthetic penicillins) simultaneously with antibiotics against anaerobic flora.

1) semisynthetic penicillins:

- ampicillin 4-6 g / day



2) antibiotics active against beta-lactase microorganisms not sensitive to penicillins

- surbactan



3) Aminoglycosides

- gentamicin - 240 mg / day for 5-7 days



4) Cephalosporins 3 and 4 generations:

- cloforan - 2-4 g / day



5) Fluoroquinolones:

- ciprolet - 0.5 g 2 times a day or 200 mg / day. intravenously

- ofloxacim - 400 mg / day. in / in



6) Carbopenems:

- Mironem - 1.5 g / day (3 times a day for 1 tablet)

acts on gram +, gram-microbes and on some anaerobes.



7) Metranidazole 100 mg 2 times a day or 0.5 gram 2 times a day - for 7 days

Affects anerobic flora.



Infusion-transfusion therapy.



Volume should be an average of 1.5 liters per day.

Colloids should be 50% and crystalloids should also be 50%.



Colloids:

1. reopoliglyukin

2. gelatin

3. haemodesis

4. protein preparations (albumin, protein, freshly frozen plasma).



Crystalloids:

1. glucose

2. Ringer-Locke solution

3. physical solution.

Immunotherapy.



At the initial stage, drugs containing ready-made antibodies are introduced, that is, creating passive immunity.



Preparations:



1) hyperimmune antistaphylococcal plasma



- receive with increasing titers of antibodies 1: 8-1: 16 from a donor immunized with staphylococcus



- inject 100-150 ml iv, every other day



2) antistaphylococcal immunoglobulin



is immunoglobulin G, obtained from a donor immunized with staphylococcus



- administered intramuscularly



3) human immunoglobulin



is immunoglobulin G

- 70-100 ml iv are administered, every other day



4) rheopheron



is alpha2-interferon

- protects the cell membrane from destruction

- is introduced in / in or in / m



5) viferon (instrumentation)



is a complex immune preparation containing alpha2-interferon.





Symptomatic Therapy



1) In heart failure

- cardiac glycosides





2) In case of respiratory failure

- oxygen therapy.

Obstetric peritonitis.

is inflammation of the peritoneum.



Causes:

1) 90% - occurs after Caesarean section

2) 10% - after childbirth through the natural birth canal.



There are three options for the development of peritonitis after Caesarean section.

1) Early peritonitis



2) Peritonitis due to inconsistency of sutures on the uterus



3) Paresis-peritonitis



Early peritonitis.



- occurs 1-2 days after Caesarean section



- as a result of the penetration of infected amniotic fluid into the abdominal cavity.





Peritonitis as a result of failure of sutures on the uterus.



- occurs 3-4 days after Caesarean section

- as a result of divergence of sutures on the uterus.



Paresis peritonitis.



- occurs 4-5 days after Caesarean section



- as a result of the penetration of microorganisms into the abdominal cavity through the wall of the intestine with persistent, noncupable paresis.







Classification of peritonitis.



1. The prevalence of the process:



1) Local

- limited to 1-2 anatomical areas

is pelvioperitonitis



2) Spilled

- spreads over 2-5 areas



3) General

- captures all anatomical areas.



2. By etiology:

1) aerobic

2) anaerobic.



3. By the nature of the exudate:

- serous

- purulent

- purulent fibrinous

- hemorrhagic

- dry (fibrinous).



Stage of peritonitis:

1) Reactive

2) Toxic

3) Terminal.



Reactive stage of peritonitis.



Local symptoms prevail over general ones.

- tongue is wet

- there is no effusion in the abdominal cavity.



Toxic stage of peritonitis.



A combination of local and general symptoms is characteristic.

- tongue dry

- there is an effusion in the abdominal cavity and fibrin deposits.



The terminal stage of peritonitis.



General symptoms of intoxication prevail over local ones.

- apathy

- retardation

- violation of consciousness.



Clinical signs of peritonitis.

1) weakness

2) malaise



3) Temperature increase

4) Chills



5) Nausea

6) Vomiting

7) Fluid chair



8) The recurrence of symptoms is characteristic:

- after the treatment, a temporary improvement is observed, and then all the symptoms appear again.



Features of obstetric peritonitis:



1. in 30-40% of cases, the symptom of Shchetkin-Blumberg is negative



2. Clinical inconsistency with morphological changes in the genitals is characteristic.





Treatment of peritonitis.



1. Infusion-transfusion therapy.

- the volume of infusion should be 1.5-2 liters.



2. Antibacterial therapy.



- cephalosporins

- aminoglycosides

- fluoroquinolones



3. Removal of the focus of infection.



1) median laparotomy



2) hysterectomy with fallopian tubes



3) abdominal lavage:



A) a special solution:

- 1 g of kanamycin per 1 liter of physical.
solution



B) furacilin



4) abdominal drainage



4 drainages are installed:



- 2 upper - in the subhepatic space and in the left hypochondrium (left lateral canal)



- 3 drainage - in the descending section of the lateral canal



- 4 drainage - into the pelvic cavity, through the vagina



5) intestinal intubation



- since with peritonitis, up to 5-6 liters of fluid rich in proteins and electrolytes accumulate in the intestinal lumen.

These proteins are a breeding ground for microorganisms. In addition, the formation of indoles and a large number of gases.



6) laparostomy

It is produced only in the terminal stage of peritonitis with the aim of producing programmed laparosanization.



4. Symptomatic therapy.

- oxygen therapy

- cardiac glycosides

- a complex of vitamins (group B, vitamin C)

- Improving liver function (essentials).



5. Immunotherapy.

- interleukin –1

- interleukin –2.

6. Efferent methods of treatment.

- apply 8-12 hours after surgery:



1) plasmapheresis

2) plasma sorption

3) hemosorption

4) UFO blood.





Septic shock.

- or the Sanorelli-Schwartzman phenomenon.



Mortality in septic shock is up to 40-50% in the first 2-3 days from the start.

The cause of death is the development of multiple organ failure.



Clinic.



There are 2 stages of septic shock:



1) hyperdynamic (warm)

2) hypodynamic (cold).



Clinic of the hyperdynamic stage of septic shock.

1. Leather

- warm

- hyperemic

- wet



2. Temperature

- increased (39-40.5 C)



3. Mental condition

- excitement

- disorientation



4. breath

- tachypnea (NPV more than 30 per minute)



5. Heart rate

- 110-120 per minute

6. HELL

- normal or elevated



7. Urination

- oliguria (20-30 ml per hour)



Clinic of the hypodynamic stage of septic shock.



1. Leather

- cold

- earthy

- marble

- dry

- acrocyanosis



2. Temperature

- moderately increased or decreased



3. Mental condition

- loss of consciousness

- coma



4. breath

- NPV less than 30 per minute



5. Heart rate

- 130-160 per minute



6. HELL

- reduced



7. Urination

- oligo- or anuria (less than 20 ml per hour)

- catheterization of the bladder is necessary.



The principles of treatment of septic shock.

- see peritonitis



Features:

1) the introduction of glucocorticoids is necessary:

- 1-2 g / day in terms of prednisone.

2) the introduction of diuretics:

- Lasix - 300-500-800 ml per day.
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