Puerperal infections

Description:

Puerperal diseases – puerperal bacterial infections. The problem of puerperal diseases is very serious, it is pathology which arises at women in a puerperal period (from the moment of allocation of an afterbirth and until the end of the 6th week), is directly connected with pregnancy and childbirth and caused by an infection (preferential bacterial).

All other diseases, including infectious (flu, dysentery, etc.), not connected revealed in a puerperal period, but directly with pregnancy and childbirth do not belong to puerperal diseases.

In obstetric hospitals where the considerable contingents of pregnant women, women in childbirth and newborns, owing to the physiological features very subject to infection concentrate, the hospital infection constitutes special danger. Frequency of puerperal diseases very varies due to the lack of the unified criteria and preferential fluctuates from 2 to 6%. More accurately it is reflected in separate clinical forms. Much more often puerperal diseases develop after operation of Cesarean section; so, the endometritis is noted at 10-15% of the operated women.

Due to the carried-out prevention, early detection and rational therapy of initial displays of a puerperal infection in particular, an endometritis, generalized septic processes at women in childbirth, and also deaths at them in modern conditions are observed less often.

Classification of postoperative diseases presents considerable difficulties in connection with variety of activators, polymorphism and dynamism of their clinical manifestations, and also lack of the unified criteria and terminology. Now in domestic literature classification of puerperal infectious diseases of Sazopov - Bartelsa is most accepted. According to this classification various forms of a puerperal infection of patrimonial ways are considered as separate stages of the uniform dynamically proceeding infectious (septic) process.

    * The first stage - is defined by the following local manifestations of infectious process in the field of a patrimonial wound (inflammatory process in the field of a patrimonial wound) a postnatal endomyometritis a puerperal ulcer pyoinflammatory process on a crotch, a vulva, a vagina, a neck of uterus)
    * The second stage - is defined by local manifestations of the infectious inflammatory process extending out of wound limits, but remaining localized: a metritis parametritissalpingo-oophoritisof pelviperitonitis metrothrombophlebitis thrombophlebitis of veins of a basin thrombophlebitis of femoral veins (the thrombophlebitises only limited, not breaking up belong to the second stage). At spread of an infection from a puerperal ulcer there are vulvita. colpitises, paracolpites, etc. (the same diseases can result also from the descending infection)
    * At the third stage the infection on weight close costs to generalized: diffuse peritonitis septic endotoxic shock a mephitic gas gangrene the progressing thrombophlebitis
    * The fourth stage - a generalized infection: sepsis without visible metastasises sepsis with metastasises

Authors suggest to consider the following options of a generalized infection characterizing and defining disease severity:

    * the endocardial, characterized existence of septic damage of heart (an endocarditis, a pancarditis)
    * peritoneal, polyserous, proceeding with a purulent inflammation of big serous cavities
    * tromboflebicheskiya which anatomic substrate is thrombophlebitis limfangichesky option at which generalization of an infection happens in the lymphogenous way

Unlike some other the infectious diseases caused by a certain activator the polietiologichnost is characteristic of puerperal diseases. various clinical forms of a puerperal infection can be caused  by various microorganisms. At the same time the puerperal disease is quite often connected with a polymicrobial infection. The course of any infectious disease is defined by interaction of the activator and an organism as a result of the interfaced evolution of a parasite and the owner. At the same time each species of microorganism having a specific set of biological properties, in a decisive way influences a clinical picture of puerperal diseases in essence, defining their character.

Symptoms of Puerperal infections:

The clinical picture of puerperal diseases is very variable that is connected with a polietiolognchnost of a puerperal infection, staging and various ways of its distribution, unequal response of an organism of the woman. At a considerable variety of a clinical current as localized, and generalized puerperal diseases there is a number of the symptoms characteristic of puerperal diseases.

General symptoms:

    * fervescence
    * tachycardia
    * fever
    * the strengthened sweating
    * sleep disorder
    * headache
    * euphoria
    * decrease or lack of appetite
    * dysuric and dispepsichesky phenomena
    * a lowering of arterial pressure (at septic shock, sepsis)

Local symptoms:

    * pain in the bottom of a stomach
    * delay of lokhiya
    * plentiful putreform lokhiya with an unpleasant smell
    * uterus subinvolution
    * suppuration of wounds of a crotch, vagina, a front abdominal wall after Cesarean section
    * crotch hypostasis

The erased, subclinical forms of puerperal diseases of which are characteristic discrepancy between health of the patient, clinical displays of a disease and its weight meet. Thus, prevention and adequate therapy of puerperal diseases allows to lower their effects.

Reasons of Puerperal infections:

The etiology of puerperal diseases underwent the essential changes caused generally by use of antibacterial drugs (especially antibiotics) in medical practice. In the 50-60th years golden staphylococcus was the main causative agent of puerperal diseases. Now in an etiology of puerperal diseases an escalating role is played by gram-negative opportunistic pathogenic bacteriums (escherichias, proteas, klebsiyella); they also complicate the course of puerperal diseases of other etiology. Puerperal diseases can develop when entering microorganisms from the environment (generally hospital strains) or owing to activation of own opportunistic microflora of a microorganism. Infection of ruptures of a crotch, vagina, neck of uterus is possible. Due to broader use in the last decade in obstetric practice of operation of Cesarean section the infection can develop as in a uterus (in the place of its section, and in an operational wound of a front abdominal wall). The main ways of spread of an infection from primary center - lymphatic and blood vessels (their combination is frequent).

A number of factors promotes development of puerperal diseases during pregnancy. Treat them:

    * colpitis
    * extra genital bacterial infection
    * late toxicoses
    * anemia
    * bleedings from generative organs
    *
    * invasive methods of a research of a functional condition of a fruit
    * surgical correction of istmiko-cervical insufficiency, etc.

At the time of delivery:

    * untimely izlity amniotic waters (premature, early) or not a reasonable amniotomy with a long anhydrous interval
    * the long (prolonged) childbirth
    * unreasonable repeated vaginal examonations
    * patrimonial traumatism
    * obstetric operations
    * bleedings from generative organs (at the time of delivery and in an early puerperal period)
    * invasive methods of a research of a functional condition of a fruit and sokratitelny activity of a uterus
    * horioamnionit, etc.

In a puerperal period:

    * uterus subinvolution
    * delay of parts of a placenta
    * the postponed earlier inflammatory diseases of generative organs
    * existence of the extra genital centers of a bacterial infection
    * anemia
    * endocrine diseases, etc.

In the presence of the specified factors of the woman have to be carried in group of high risk of development of puerperal diseases with holding the relevant preventive and medical activities.

Treatment of Puerperal infections:

Body resistance strengthening, mobilization of all its protective forces on fight against an infection has to be the first and main objective treatment of a septic infection.
From this point of view rest, healthy nutrition, a due care and the general drug treatment are important. All these actions belong to the general pespetsifichesky therapy of a septic infection. Rest, along with favorable conditions for sick body, is prevention of further spread of an infection. The guarding mode positively influences also the central nervous system.
The bed rest is necessary also at superficial forms of a puerperal infection. At all local processes in a pelvic cavity - adnexites, parametrites, pelvic peritonitises - treatment in the beginning identical: the general rest, a bed rest, ice on a stomach, anesthetics.
Especially strictly the bed rest at the general peritonitises and thrombophlebitises in view of danger of an embolism has to be observed, especially in initial stages of process, when there is no its otgranicheniye.
At some diseases special position of a body is necessary. So, at thrombophlebitises the sore leg should be raised, having slightly bent in a knee joint and to put freely in the tire or on a pillow; foot at the same time has to be slightly turned knaruzh. At an inflammation of a pelvic peritoneum for the best otgranicheniye of process it is necessary to lower the foot end of a bed. On purpose a sozdapiya of rest it is necessary to eliminate or limit manipulations which can promote spread of an infection. So, the vaginal research if there are no special indications, is recommended to be done not earlier than for the 9-10th day of a puerperal period.
Respect for purity of a body protects from various complications. Clarification of an oral cavity disinfecting solution, language and teeth glycerin or 3% solution of boric acid is prevention of developing of parotitises.
For the prevention of decubituses it is necessary to wipe area of a sacrum, shovels with camphoric alcohol, fragrant vinegar. At oznoba it is necessary to appoint cardiacs, to give oxygen, warm drink. It is necessary to make a toilet (cleaning) of external genitals at least 2 times a day.
Osobeppo is of great importance a balanced diet of patients. At a septic infection all types of exchange are broken, there is a strengthened combustion of carbohydrates and fats to accumulation in an organism of nedookislenny products; protein metabolism increases, acidosis develops, the vitamin deficiency is observed.
Food has to be various, easily acquired and to contain at the small volume ео not less than 2000 kcal in депь. Such patients should give broths, мпспыо extracts, sugar to 200 g a day, butter, cream, yolks, varepy fish, steam meat cutlets, cottage cheese with sour cream, lemons (for arousing appetite it is possible to use a sprat, caviar, a salmon). Plentiful drink in the form of tea, alkaline waters, a fruit drink, fruit juice is useful. It is necessary to remember that the patient should be fed, without expecting until she asks.
Extremely important section of treatment is the bacterial therapy directed to fight against contagiums. For this purpose appoint antibiotics. The doctor has to recognize that to their most part pathogenic staphylococcus and some other activators are not enough or are not sensitive at all. In the course of treatment sensitivity of the activator to antibiotics therefore the same drug cannot be used can change it is long (no more than 3-5 days in the absence of effect). It is necessary to appoint antibiotics in the maximum doses, for the purpose of creation in blood and fabrics of their uniform concentration at regular intervals. At a heavy septic infection, in the presence of an injury of fabrics of patrimonial ways or an apemiya use not less than two various, but compatible antibiotics or a combination of one of нрх with sulfanamide drugs is shown. Before definition of sensitivity of the activator to them it is necessary to choose drugs of a broad spectrum of activity to which sensitivity of a large number of pathogenic microbes is kept from a large number of antibiotics. Treat them: олететрип (Tetraolenum), Olemorphocyclinum, Monomycinum, Kanamycinum, Ristomycinum and others. Considering a possibility of a sensitization, it is necessary to establish absence of an allergy to an antibiotic by an intracutaneous test. Doses of antibiotics have to be massive. For elimination of the dysbacteriosis which is often arising at prolonged use of antibiotics appoint пистатин or levorinum. Recently widely apply semi-synthetic antibiotics to treatment of sepsis.
In a complex of antiseptic therapy control of hemodynamic indicators and rational transfusion therapy is of particular importance. First of all it is necessary to make compensation of liquid for the purpose of improvement of microcirculation and desintoxication of an organism. For this purpose recommend intravenous transfusions of Haemodesum, neokompepsan, reopoliglyukin, solutions of plasma, an albumpp, protein, blood, normal saline solutions of table salt, 5-10% of solution of glucose. Transfuziopny therapy has to be strictly regulated on time within a day and be carried out under control of determination of the central venous pressure which should not exceed 18 cm w.g.
When carrying out a transfusion of large amounts of liquid it is necessary to control continuously a condition of secretory function of kidneys (amount of urine, allocating and "1 h). If necessary appoint Mannitolum, eufilliya, furosemide, lasixum and other drugs.
Neutralization of acid products of exchange has to be carried out only under control of acid-base equilibrium spray. For the recovery broken acid-base balance vputrivenny introduction of 4-7% of solutions of soda, sodium lactate is shown.
In a complex of medical actions correction of electrolytes which is also carried out under control of electrolytic composition of blood is required.
For treatment of septic complications use of Trasylolum or Contrykal on 50 000-100 000 units intramusculary is reasonable.
From the means improving function of heart use of strophanthin, cocarboxylase, ascorbic acid, glucose with insulin is shown.
At a loss of consciousness for the purpose of ensuring passability of bronchial tubes the intubation and supply with oxygen are shown (1 - 3 l in 1 min.).
Considering that inflammatory process is followed by the sensitization phenomena, and quite often pathological sensitization arises in the course of treatment, surely appoint the desensibilizing drugs (Calcii chloridum, Dimedrol, Pipolphenum).
At the phenomena of an intravascular blood coagulation at endotoxic shock and other states recommend heparin use. At the same time it is necessary to remember possibility of bleeding in this connection regularly investigate a condition of coagulant system of blood and urine.
Corticosteroid drugs (cortisone, hydrocortisone) at treatment of sepsis render positive effect, especially in combination with antimicrobic therapy. Their use is shown at endotoxic shock. At the same time the dose of a hydrocortisone is increased to 1000-2000 mg a day. In addition to the general medical actions directed to fight against a septic infection at its any clinical form also special topical treatment depending on the nature of process is necessary.
At puerperal ulcers after a removal of sutures apply locally hypertonic salt solution of table salt, Furacilin, хлорофиллипт or other disinfectants, and also radiation by a quartz lamp.
At a lohia serosa usually it is possible by a metrorthosis and appointment spasmolytic (Nospanum, atropine) and the means reducing a uterus (oxytocin, Pituitrinum, methylergometrine, etc.) to cause outflow of the late allocations. At development of such complications as a parametritis, a pelviperitonitis, medicamentous conservative therapy, and from operational methods of treatment - a puncture of the back arch is shown (for evacuation of pus, administration of medicinal substances).
At piosalpinksa and pyoovariums it is not necessary to do a colpotomy; the abscess puncture through the back arch with suction of pus and introduction to a cavity of an abscess of antibiotics is necessary. Early operational treatment is shown at development of diffuse peritonitises. Operative measure volume at each patient is solved individually. When carrying out a laparotomy broad drainage of an abdominal cavity, creation of conditions for carrying out peritoneal dialysis is obligatory. It is necessary to remember that surgical removal of a suppurative focus not always leads to elimination of septic process. Owing to this fact Maun's hysterectomy "ет to be only one of the moments of a complex of therapeutic actions.
At all local acute processes in a small basin apply cold on a stomach and anesthetics. Along with the above therapeutic actions recommend to enter into a cavity of the uterus iodic tincture (5% solution on 2-3 ml within 5-7 days).
At more long inflammatory processes, and also at thrombophlebitises of pelvic bodies appoint anticoagulants to the affected extremity, bandages or tampons with geparipovy ointment and Dimexidum. Introduction to practice of antibiotics considerably narrowed use of the bacteriophages and medical serums which kept the value only at treatment of a gas infection. However introduction anti-staphylococcal at-globulpna OR plasmas is absolutely necessary in a complex of medical measures.
At a septicopyemia all formed metastatic centers are subject to opening.
Tool removal of the remains of a placenta from a cavity of the uterus is admissible only in the presence of uterine bleeding, life-threatening the patient. In the absence of bleeding it is necessary to carry out conservative therapy (the antibiotics reducing means, 5% solution of iodic tincture on 2-3 ml in a cavity of the uterus).
Patients with sepsis for treatment should be sent to large city or regional hospitals in which the round-the-clock medical observation can be provided and highly skilled help is given.