The miscarriage is complete. miscarriage infected (feverish). infectious miscarriage
A woman may complain of abdominal pain and bleeding of varying intensity. The role of the general practitioner is to:
- make sure that the life of a woman is out of danger due to an undiagnosed pregnancy and severe blood loss;
- confirm the diagnosis;
- inform the patient about the viability of the fetus and about the features of management in this situation;
- take into account the psychological and physiological needs of the patient.
Typically, women and their partners are hesitant to tell family and friends of a newly confirmed pregnancy until 12-14 weeks have passed. There are reasons for this. Up to 12-16% of all diagnosed pregnancies end in miscarriage. In reality, the number of miscarriages is even higher, since they often occur before the fact of pregnancy has been established.
Symptoms indicating early pregnancy loss
It is not uncommon for women to see their GP for bleeding early in pregnancy. Bleeding is not the main reason for referral if the cervix has not begun to open.
The availability of ultrasound has greatly facilitated the management of such women for the general practitioner.
Approximately one-quarter of women experience spotting in the first weeks of pregnancy, and half of women who bleed will have a spontaneous miscarriage.
What should a general practitioner do?
After collecting an anamnesis, an examination should be carried out. First you need to determine the main physiological indicators. Temperature may indicate sepsis, but rapid pulse, orthostatic hypotension, and reduced arterial pressure- the loss of a large volume of blood and the need for urgent intervention and stabilization of the condition.
Questions to ask a woman with first trimester bleeding
- Date of last normal menstrual period.
- Obstetric history.
- duration of bleeding.
- The amount of blood lost (how many pads or tampons did she use, were they completely soaked or only bloodstained?).
- What color was the blood (bright or dark)?
- Did clots come out?
- Did parts of the fetus come out?
- Was the bleeding accompanied by pain?
After assessing the basic physiological parameters, the general practitioner should examine the abdomen, paying attention to soreness, which may be a sign of an interrupted ectopic pregnancy. Then a pelvic exam should be done. After the correct installation of the mirrors, you need to pay attention to the presence of blood in the vagina and carefully examine the cervix. To facilitate inspection, it is sometimes necessary to remove blood and mucus covering the external pharynx with a napkin. Careful examination and assessment of pharyngeal opening with a finger can be crucial for making a diagnosis. A closed pharynx in the first trimester of pregnancy may indicate a threatened miscarriage (retention of a dead fetus in the uterus).
Sometimes in the early stages of pregnancy there is a very heavy bleeding and/or severe pain. In this case, strangulated remains are often found in the pharynx gestational sac, after the removal of which the pain and bleeding subside. Sometimes, during an abortion in progress, prolapsing embryonic membranes can be seen through the open cervix of the uterus.
If the patient's condition is stable, a transvaginal ultrasound is usually performed. Ultrasound can help in the management of the patient in two cases. Firstly, it can be used to determine the location of the fetal egg. Secondly, with a uterine pregnancy, the doctor will be able to confirm the presence or absence of a fetal heartbeat. Success depends on the duration of pregnancy and the experience of the doctor conducting the study.
The routine use of early ultrasound can lead to the diagnosis of incomplete miscarriage, anembryony or non-progressive pregnancy and, as a result, to unnecessary intervention where a complete spontaneous miscarriage would be the natural end of the process.
It is important to warn the patient that the ultrasound will be performed through the vagina and ask her if she wants to see the image on the screen. If the pregnancy was unplanned and the patient intended to have an abortion anyway, the doctor may need to position the screen out of the woman's field of vision.
Causes of spontaneous abortion in the early stages
The patient can be reassured by saying that if the pregnancy was terminated early, she "would not progress, because in this way nature fights against fetal developmental disorders." Historically, it was thought that in 50% of cases of spontaneous miscarriage, the fetus has chromosomal abnormalities. Most likely, this figure is underestimated.
The main cause of spontaneous miscarriage is genetic abnormalities fetus.
With spontaneous miscarriage, most of the chromosomal abnormalities (95%) are a violation of the number of chromosomes. Of these, 60% are trisomies, the most common is trisomy 16. In 20% of fetuses, the karyotype 45,X (Turner's syndrome) is found. Interestingly, 99% of embryos with 45,X expel spontaneously. The remaining 15% have polyploidy, more often triploidy. In the case of an anomaly in the number of fetal chromosomes, the karyotype of the parents is usually normal, so the study of the karyotype is not indicated for them.
How can a general practitioner influence the emotional consequences of a miscarriage?
If a pregnancy is planned or not even planned, but desired, losing it early can lead to psychological trauma. Expectations, plans and hopes are shattered, so the reaction can be very emotional. Now in such situations it is often not possible to provide adequate support to the woman and her partner. Often they blame themselves to some extent for what happened. It is important to organize monitoring of the patient after a spontaneous miscarriage, to make sure that she does not develop depression.
The role of the general practitioner in dealing with the psychological consequences of spontaneous miscarriage
- Try to dispel the woman's guilt that she did something that led to a miscarriage.
- Tell the woman how often spontaneous miscarriages happen.
- Help the woman and her partner recognize and accept the grief often experienced after a miscarriage.
When communicating with women and their partners who find themselves in such a difficult situation, it is important to avoid words that can cause additional suffering. Therefore, the term "miscarriage" is more preferable than "abortion".
Do all women with spontaneous miscarriage need to have a uterine curettage?
More than 80% of women with spontaneous abortion in the first trimester have fragments of embryonic tissue completely shed naturally within 2-6 weeks, while the number of complications does not differ from that of surgical intervention. In addition to the risk of anesthesia, there is a risk of infection, bleeding, less often - damage to the cervix or perforation of the uterus, Asherman's syndrome (intrauterine adhesions that obliterate its cavity to varying degrees).
Before the advent of ultrasound, it was difficult to determine whether a spontaneous miscarriage had ended at the time of presentation. Therefore, the curettage of the uterine cavity was justified: the faster the remains of the fetal egg are removed from the uterus, the lower the risk of severe bleeding or infection. Two alternative approaches have been proposed: expectant management and medical therapy with drugs such as misoprostol.
In some cases, expectant management or medical treatment of spontaneous abortion can be used. Both methods eliminate the need for surgery and anesthesia and can be considered more natural. Both are very effective (86% success rate with expectant management and up to 100% with medication), but expectant management for non-developing pregnancy or anembryos is less reliable.
Expectant management is effective in the first 2-6 weeks. pregnancies in 80-90% of women with complete miscarriage and in 65-75% of women with anembryonia (clinically manifested as scanty spotting or bleeding and ultrasound signs of embryonic death).
A feature of this tactic is the need for additional outpatient visits to the doctor.
Drug therapy involves the use of drugs such as misoprostol given vaginally or orally. Women receiving this therapy bleed more, but experience less pain than after surgery (surgical treatment also increases the risk of trauma and infectious complications).
Surgical removal is indicated for women with spontaneous miscarriage and unstable vital signs, uncontrolled bleeding, and clear signs of infection.
What do women prefer with spontaneous miscarriage: wait or seek medical help and undergo curettage of the uterine cavity?
Women more often prefer expectant management, but their decision can be largely influenced by the opinion of the doctor. The general practitioner, in turn, when determining the tactics of managing an incomplete spontaneous miscarriage in the first trimester, should offer the patient all possible options and take into account her wishes. This is especially important because the quality of life of the patient in the future depends on her correct decision.
Is it necessary to prevent the formation of anti-Rhesus antibodies?
In order to suppress the formation of antibodies, all Rh negative women in case of ectopic pregnancy and any miscarriage, regardless of the gestational age and the method of evacuation of the remnants of the fetal egg, it is necessary to prevent the formation of anti-Rh antibodies. Up to 12 weeks In pregnancy, inclusive, in order to suppress the formation of antibodies, all Rh-negative women who have not previously received prophylaxis are prescribed anti-Rh (B)-immunoglobulin at a dose of 250 IU (50 μg) with:
- spontaneous miscarriage;
- termination of pregnancy;
- ectopic pregnancy;
- taking samples of chorionic villi for research.
There is insufficient evidence to support the use of anti-Rh0(D)-immunoglobulin for bleeding before 12 weeks. pregnancy and developing pregnancy. However, if curettage of the uterine cavity is required, immunoglobulin should be prescribed. If spontaneous miscarriage or termination of pregnancy occurs after 12 weeks. pregnancy, it is necessary to prescribe 625 IU (125 mcg) and n t and - Rh 0 (I)) - immunoglobulin.
For successful immunoprophylaxis, anti-Rh0(D)-immunoglobulin should be administered as soon as possible after the sensitizing event, but no later than 72 hours (Evidence level I). If immunoglobulin is not administered within the first 72 hours, administration over the next 9–10 days may provide additional protection.
Can doctors recommend anything to a woman in order to prevent spontaneous miscarriage in the future?
Common recommendations include taking vitamins, progestogens, and bed rest. However, recent systematic reviews do not support these recommendations. Vitamin supplements, singly and in combination, given before and during pregnancy early dates, do not prevent spontaneous abortion or stillbirth. In addition, those who took vitamins were less likely to develop preeclampsia and more likely to have multiple pregnancies. Bed rest has also not been proven to be effective: there is insufficient evidence to support this approach as a prevention of spontaneous miscarriage in women. There is no evidence that routine use of progestogens is effective in preventing miscarriage in early to mid-term pregnancy. However, there is some evidence that taking progestogens may be beneficial for women with habitual miscarriage.
Is there a need for a special examination of women?
Women with recurrent miscarriage (> 3) require testing to determine the cause. In order to increase the chances of a successful pregnancy, these women are best referred to obstetricians for evaluation and follow-up. A separate group requiring counseling before conception includes women with late miscarriage, which may develop due to cervical insufficiency. This problem may occur in women who have undergone treatment for severe cervical dysplasia in the past.
Key points
- 15-20% of all pregnancies end in early miscarriage.
- Bleeding in early pregnancy usually occurs at 9-12 weeks.
- Chromosomal abnormalities are the most common (and often the only) cause of spontaneous miscarriages.
- The doctor must consider the emotional consequences of spontaneous miscarriage for his patients.
- Women should be offered a variety of treatment options to prevent miscarriage.
- In case of severe bleeding or infection, surgical treatment is preferred.
- The use of vitamins, bed rest, and progestogens does not prevent spontaneous miscarriage.
Spontaneous abortion (miscarriage) - spontaneous termination of pregnancy before the fetus reaches a viable gestational age.
According to the WHO definition, abortion is the spontaneous expulsion or extraction of an embryo or fetus weighing up to 500 g, which corresponds to a gestational age of less than 22 weeks.
ICD-10 CODE
O03 Spontaneous abortion.
O02.1 Missed miscarriage.
O20.0 Threatened abortion.
EPIDEMIOLOGY
Spontaneous abortion is the most common complication of pregnancy. Its frequency is from 10 to 20% of all clinically diagnosed pregnancies. About 80% of these losses occur before 12 weeks of gestation. When accounting for pregnancies by determining the level of hCG, the loss rate increases to 31%, with 70% of these abortions occurring before the moment when pregnancy can be recognized clinically. In the structure of sporadic early miscarriages 1/3 of pregnancies are interrupted in the period up to 8 weeks by the type of anembryony.
CLASSIFICATION
According to clinical manifestations, there are:
threatening abortion;
initiation of an abortion
abortion in progress (complete and incomplete);
non-developing pregnancy.
The classification of spontaneous abortions adopted by WHO differs slightly from that used in the Russian Federation, combining a miscarriage that has begun and an abortion in progress into one group - an inevitable abortion (i.e., continuation of the pregnancy is impossible).
ETIOLOGY (CAUSES) OF MISSION
The leading factor in the etiology of spontaneous abortion is chromosomal pathology, the frequency of which reaches 82-88%.
The most common variants of chromosomal pathology in early spontaneous miscarriages are autosomal trisomy (52%), monosomy X (19%), polyploidy (22%). Other forms are noted in 7% of cases. In 80% of cases, death occurs first, and then expulsion of the fetal egg.
The second most important among the etiological factors is metroendometritis of various etiologies, which causes inflammatory changes in the uterine mucosa and prevents normal implantation and development of the fetal egg. Chronic productive endometritis, more often of autoimmune origin, was noted in 25% of the so-called reproductively healthy women who terminated their pregnancy by induced abortion, in 63.3% of women with recurrent miscarriage and in 100% of women with NB.
Among other causes of sporadic early miscarriages, anatomical, endocrine, infectious, immunological factors are distinguished, which to a greater extent serve as the causes of habitual miscarriages.
RISK FACTORS
Age is one of the main risk factors in healthy women. Based on data from an analysis of the outcomes of 1 million pregnancies, in age group women from 20 to 30 years old, the risk of spontaneous abortion is 9-17%, at 35 years old - 20%, at 40 years old - 40%, at 45 years old - 80%.
Parity. Women with two or more pregnancies have a higher risk of miscarriage than nulliparous women, and this risk does not depend on age.
History of spontaneous abortions. The risk of miscarriage increases with the number of miscarriages. In women with one miscarriage in history, the risk is 18-20%, after two miscarriages it reaches 30%, after three miscarriages - 43%. For comparison: the risk of miscarriage in a woman whose previous pregnancy ended successfully is 5%.
Smoking. Consumption of more than 10 cigarettes per day increases the risk of spontaneous abortion in the first trimester of pregnancy. These data are most revealing in the analysis of spontaneous abortion in women with a normal chromosome set.
The use of non-steroidal anti-inflammatory drugs in the period preceding conception. Data have been obtained indicating a negative effect of the inhibition of PG synthesis on the success of implantation. When using non-steroidal anti-inflammatory drugs in the period preceding conception, and on early stages pregnancy, the miscarriage rate was 25% compared with 15% in women who did not receive drugs in this group.
Fever (hyperthermia). An increase in body temperature above 37.7 ° C leads to an increase in the frequency of early spontaneous abortions.
Trauma, including invasive methods of prenatal diagnosis (choriocentesis, amniocentesis, cordocentesis), the risk is 3–5%.
The use of caffeine. With a daily intake of more than 100 mg of caffeine (4-5 cups of coffee), the risk of early miscarriage is significantly increased, and this trend is valid for a fetus with a normal karyotype.
Exposure to teratogens (infectious agents, toxic substances, medicines with a teratogenic effect) is also a risk factor for spontaneous abortion.
Folic acid deficiency. When the concentration of folic acid in the blood serum is less than 2.19 ng / ml (4.9 nmol / l), the risk of spontaneous abortion significantly increases from 6 to 12 weeks of pregnancy, which is associated with a higher frequency of abnormal fetal karyotype formation.
Hormonal disorders, thrombophilic conditions are to a greater extent the causes of not sporadic, but habitual miscarriages, the main cause of which is an inferior luteal phase.
According to numerous publications, from 12 to 25% of pregnancies after IVF end in spontaneous abortion.
CLINICAL PICTURE (SYMPTOMS) OF SPONTANEOUS ABORTION AND DIAGNOSIS
Most patients complain about bloody issues from the genital tract, pain in the lower abdomen and in the lower back with a delay in menstruation.
Depending on the clinical symptoms, there are threatening spontaneous abortion that has begun, an abortion in progress (incomplete or complete) and a miscarriage.
Threatening abortion is manifested by pulling pains in the lower abdomen and lower back, there may be scanty bloody discharge from the genital tract. The tone of the uterus is increased, the cervix is not shortened, the internal os is closed, the body of the uterus corresponds to the gestational age. The ultrasound records the fetal heartbeat.
With the onset of abortion, pain and bloody discharge from the vagina are more pronounced, the cervical canal is ajar.
During abortion, regular cramping contractions of the myometrium are determined in the course. The size of the uterus is less than the estimated gestational age; in the later stages of pregnancy, leakage of the OM is possible. The internal and external pharynx are open, the elements of the fetal egg are in the cervical canal or in the vagina. Bleeding may be of varying intensity, often abundant.
Incomplete abortion is a condition associated with a delay in the uterine cavity of the elements of the fetal egg.
The absence of full uterine contraction and closure of its cavity leads to continued bleeding, which in some cases causes large blood loss and hypovolemic shock.
More often, incomplete abortion is observed after 12 weeks of pregnancy in the case when the miscarriage begins with the outflow of OB. In a bimanual examination, the uterus is less than the expected gestational age, bloody discharge from the cervical canal is abundant, using ultrasound in the uterine cavity, the remains of the fetal egg are determined, in the II trimester - the remains of placental tissue.
Complete abortion is more common in late pregnancy. The fertilized egg comes out completely from the uterine cavity.
The uterus contracts and the bleeding stops. On bimanual examination, the uterus is well contoured, less time gestation, the cervical canal may be closed. With a complete miscarriage, ultrasound determines the closed uterine cavity. There may be small bleeding.
Infected abortion is a condition accompanied by fever, chills, malaise, pain in the lower abdomen, bloody, sometimes purulent discharge from the genital tract. During a physical examination, tachycardia, tachypnea, defence of the muscles of the anterior abdominal wall are determined, with a bimanual examination - a painful, soft uterus; the cervical canal is dilated.
In case of an infected abortion (with mixed bacterial and viral infections and autoimmune disorders in women with recurrent miscarriage, obstetric anamnesis aggravated by antenatal fetal death, recurrent genital infections), immunoglobulins are prescribed intravenously (50–100 ml of 10% Gamimun © solution, 50–100 ml of 5% solution octagama©, etc.). They also carry out extracorporeal therapy (plasmapheresis, cascade plasma filtration), which consists in physicochemical blood purification (removal of pathogenic autoantibodies and circulating immune complexes). The use of cascade plasma filtration implies detoxification without plasma removal. In the absence of treatment, generalization of infection in the form of salpingitis, local or diffuse peritonitis, septicemia is possible.
Non-developing pregnancy (antenatal fetal death) - the death of an embryo or fetus during pregnancy for a period of less than 22 weeks in the absence of expulsion of elements of the fetal egg from the uterine cavity and often without signs of a threat of interruption. To make a diagnosis, an ultrasound is performed. The tactic of abortion is chosen depending on the gestational age. It should be noted that antenatal fetal death is often accompanied by disorders of the hemostasis system and infectious complications (see the chapter "Non-developing pregnancy").
In the diagnosis of bleeding and the development of management tactics in the first trimester of pregnancy, the assessment of the rate and volume of blood loss plays a decisive role.
With ultrasound, the following are considered unfavorable signs in terms of the development of the fetal egg during uterine pregnancy:
Absence of embryonic heartbeat with CTE more than 5 mm;
Absence of an embryo with the size of the fetal egg measured in three orthogonal planes, more than 25 mm with transabdominal scanning and more than 18 mm with transvaginal scanning.
Additional ultrasound signs that indicate an unfavorable outcome of pregnancy include:
anomalous yolk sac, not corresponding to the gestational age (more), irregular shape, displaced to the periphery or calcified;
HR of the embryo is less than 100 per minute in the period of 5-7 weeks;
large retrochorial hematoma (more than 25% of the surface of the fetal egg).
DIFFERENTIAL DIAGNOSIS
Spontaneous abortion should be differentiated from benign and malignant diseases of the cervix or vagina. During pregnancy, bleeding from the ectropion is possible. To exclude diseases of the cervix, a careful examination in the mirrors is carried out, if necessary, colposcopy and / or biopsy.
Bloody discharge during a miscarriage is differentiated from those during an anovulatory cycle, which is often observed with a delay in menstruation. There are no symptoms of pregnancy, the test for hCG b subunit is negative. On bimanual examination, the uterus normal sizes, not softened, the neck is dense, not cyanotic. There may be similar menstrual irregularities in history.
Differential diagnosis is also carried out with hydatidiform mole and ectopic pregnancy.
With a hydatidiform mole, 50% of women may have a characteristic discharge in the form of vesicles; the uterus may be longer than the expected pregnancy. Typical picture on ultrasound.
With an ectopic pregnancy, women may complain of spotting, bilateral or generalized pain; often fainting (hypovolemia), a feeling of pressure on the rectum or bladder, a test for bhCG is positive. On bimanual examination, there is pain when moving the cervix. The uterus is smaller than it should be at the time of the expected pregnancy.
You can palpate a thickened fallopian tube, often bulging of the vaults. With ultrasound in the fallopian tube, you can determine the fetal egg, if it breaks, you can detect the accumulation of blood in abdominal cavity. To clarify the diagnosis, a puncture of the abdominal cavity through the posterior fornix of the vagina or diagnostic laparoscopy is indicated.
Diagnosis example
Pregnancy 6 weeks. Started miscarriage.
TREATMENT
GOALS OF TREATMENT
The goal of treating a threatened abortion is to relax the uterus, stop bleeding and prolong pregnancy if there is a viable embryo or fetus in the uterus.
In the USA, Western European countries, a threatened miscarriage up to 12 weeks is not treated, considering that 80% of such miscarriages are “natural selection” (genetic defects, chromosomal aberrations).
In the Russian Federation, a different tactic for managing pregnant women with a threat of miscarriage is generally accepted. With this pathology, bed rest (physical and sexual rest), a complete diet, gestagens, vitamin E, methylxanthines are prescribed, and as a symptomatic treatment, antispasmodic drugs (drotaverine, suppositories with papaverine), herbal sedative drugs (decoction of motherwort, valerian).
NON-DRUG TREATMENT
Oligopeptides, polyunsaturated fatty acids must be included in the pregnant diet.
MEDICAL TREATMENT
Hormone therapy includes natural micronized progesterone 200-300 mg/day (preferred) or dydrogesterone 10 mg twice daily, vitamin E 400 IU/day.
Drotaverine is prescribed for severe pain intramuscularly at 40 mg (2 ml) 2-3 times a day, followed by the transition to oral administration from 3 to 6 tablets per day (40 mg in 1 tablet).
Methylxanthines - pentoxifylline (7 mg / kg of body weight per day). Candles with papaverine 20–40 mg twice a day are used rectally.
Approaches to the treatment of threatened abortion are fundamentally different in the Russian Federation and abroad. Most foreign authors insist on the inexpediency of maintaining a pregnancy for less than 12 weeks.
It should be noted that the effect of the use of any therapy - drug (antispasmodics, progesterone, magnesium preparations, etc.) and non-drug (protective regimen) - has not been proven in randomized multicenter studies.
The appointment of drugs that affect hemostasis (etamsylate, vikasol ©, tranexamic acid, aminocaproic acid and other drugs) in case of bloody discharge to pregnant women has no basis and proven clinical effects due to the fact that bleeding during miscarriages is due to detachment of the chorion (early placenta) rather than coagulation disorders. On the contrary, the doctor's task is to prevent blood loss, leading to violations of hemostasis.
Upon admission to the hospital, a blood test should be performed, the blood group and Rh status should be determined.
With incomplete abortion, profuse bleeding is often observed, in which emergency care is necessary - immediate instrumental removal of the remnants of the fetal egg and curettage of the walls of the uterine cavity. More gentle is the emptying of the uterus (preferably vacuum aspiration).
Due to the fact that oxytocin may have an antidiuretic effect, after emptying the uterus and stopping bleeding, the administration of large doses of oxytocin should be discontinued.
During the operation and after it, it is advisable to administer an intravenous isotonic sodium chloride solution with oxytocin (30 units per 1000 ml of solution) at a rate of 200 ml/h (in the early stages of pregnancy, the uterus is less sensitive to oxytocin). Antibacterial therapy is also carried out, if necessary, treatment of posthemorrhagic anemia. Women with Rh-negative blood are injected with immunoglobulin anti-Rhesus.
It is advisable to control the condition of the uterus by ultrasound.
With a complete abortion during pregnancy for a period of less than 14-16 weeks, it is advisable to conduct an ultrasound scan and, if necessary, curettage of the walls of the uterus, since there is a high probability of finding parts of the fetal egg and decidual tissue in the uterine cavity. At a later date, with a well-contracted uterus, curettage is not performed.
It is advisable to prescribe antibiotic therapy, treat anemia according to indications and administer anti-Rhesus immunoglobulin to women with Rh-negative blood.
SURGERY
Surgical treatment of missed pregnancy is presented in the chapter "Non-developing pregnancy".
Management of the postoperative period
In women with a history of PID (endometritis, salpingitis, oophoritis, tubo-ovarian abscess, pelvioperitonitis), antibiotic therapy should be continued for 5-7 days.
In Rh-negative women (during pregnancy from an Rh-positive partner) in the first 72 hours after vacuum aspiration or curettage during pregnancy for more than 7 weeks and in the absence of Rh AT, Rh immunization is prevented by administering anti-Rhesus immunoglobulin at a dose of 300 mcg (intramuscularly).
PREVENTION
Methods of specific prevention of sporadic miscarriage are absent. To prevent neural tube defects, which partially lead to early spontaneous abortions, it is recommended to prescribe folic acid 2-3 menstrual cycles before conception and in the first 12 weeks of pregnancy in daily dose 0.4 mg. If a woman has a history of previous pregnancies fetal neural tube defects are noted, the prophylactic dose should be increased to 4 mg / day.
INFORMATION FOR THE PATIENT
Women should be informed about the need to consult a doctor during pregnancy in case of pain in the lower abdomen, in the lower back, in the event of bleeding from the genital tract.
FURTHER MANAGEMENT
After curettage of the uterine cavity or vacuum aspiration, it is recommended to exclude the use of tampons and refrain from sexual intercourse for 2 weeks.
FORECAST
As a rule, the prognosis is favorable. After one spontaneous miscarriage, the risk of losing the next pregnancy increases slightly and reaches 18-20% compared to 15% in the absence of a history of miscarriage. In the presence of two consecutive spontaneous abortions, it is recommended to conduct an examination before the desired pregnancy occurs to identify the causes of miscarriage in this married couple.
7. Miscarriage. Spontaneous miscarriage Key words: classification, diagnostics, obstetric tactics. Premature birth: features of the course and management.
Miscarriage.
Miscarriage- This is a spontaneous abortion at 37 weeks.
Depending on the term of termination of pregnancy, there are:
a) spontaneous miscarriage or abortion (up to 22 weeks) - fetal weight up to 500 g, height 25 cm (early - termination of pregnancy up to 12 weeks, late - from 13 to 22 weeks)
b) premature birth (22-37 weeks) - fetal weight 500 g or more, height more than 25 cm.
The presence of 2 or more consecutive cases of miscarriage in history is the basis for the diagnosis habitual miscarriage.
Etiology:
1. Pathological conditions of the woman's body
a) anatomical changes in the genital organs: infantilism, malformations of the uterus, CI (congenital, acquired), traumatic injuries of the cervix and uterus, tumors of the genital organs
b) functional disorders: infectious diseases in childhood and puberty, artificial abortions, inflammatory diseases of the genital organs, disorders of the functional state of the endocrine glands (pituitary, thyroid, adrenal glands, etc.), dysfunction of the ovaries and placenta
2. Immunological disorders in the mother-placenta-fetus system
3. Gene and chromosomal disorders
4. Socio-biological (environmental factors) - mechanical, physiological, biological, chemical.
Depending on the clinical symptoms And gestational age is distinguished: a) threatening abortion, b) abortion that has begun, b) abortion in progress, c) incomplete abortion, d) complete abortion, e) failed abortion, f) premature birth.
Diagnostics: 1. Anamnesis, 2. Medical genetic examination, 3. Ultrasound, 4. Hysterosalpingography, 5. Hysteroscopy, 6. Laparoscopy, 7. Examination by functional diagnostic tests, 8. Hormonal studies (estrogens, progesterone, 17-CS, chorionic gonadotropin, placental lactogen)
Treatment:
1. Hospitalization, medical and protective regimen.
2. Psychotherapy, auto-training.
3. Sedatives (tazepam 0.01; seduxen 0.005; n-ka motherwort 25 cap. 3 r / day; valerian 0.02 1-2 r / day)
4. Antispasmodics (no-shpa 2 ml, papaverine 2% 2 ml, baralgin 2 ml, magnesia 25% 5 ml per day)
5. Physiotherapy:
Endonasal electrophoresis.
Magnesium electrophoresis using the device "Amplipulse-3 or 4" 5 procedures, 2 weeks break, 10-15 procedures per course.
Electroanalgesia of the uterus using an alternating sinusoidal current in the frequency range of 50-500 Hz, the duration of the procedure is 30 minutes, for a course of 1.-3 procedures.
Acupuncture.
6. Immunosuppressive therapy.
7. Allogeneic skin transplantation.
8. Treatment with allogeneic lymphocytes.
9. Hormone therapy according to indications:
at 6-7 weeks. microfollin 1/4 tab (0.0125 mg), increasing to 1/2 tab;
with the appearance of spotting at 6-10 weeks. Treatment begins with estrogen hemostasis according to the scheme: on the 1st day, 1 ml of 0.1% solution of estradiol dipropionate i / m 3 r / day; on the 2nd day 2 r / day; on the 3rd day 1 r / day; from the 4th day you can switch to microfollin 1/3 or 1/2 tab., max 1 tab/day; from the 5th day, the dose of microfollin is gradually reduced. At the same time, 10 mg of progesterone is administered 1 r / day;
dufaston (gestagen) 5-10 mg 1-2 r / day.
hormone therapy can last up to 15-16 weeks. pregnancy until the formation of the placenta is completed; microfollin is stopped at 10-12 weeks.
glucocorticoids (dexamethasone, prednisolone) are pathogenetic therapy for AGS - with an erased form, they start taking from the moment the diagnosis is established and stop at 32-33 weeks; in the clinical form, treatment is carried out throughout pregnancy. Prednisolone 5 mg 2 r / day for 7-10 days, then 5 mg 1 r / day. Dexamethasone with 0.5 mg or 0.375 (3/4 tab.) for 7-10 days, then the dose is reduced to 0.125 mg (1/4 tab.).
10. Tocolytics (β-agonists): alupent, partusisten, ritodrin, ginipral
11. Prostaglandin inhibitors: indomethacin 50 mg 4 times a day for 2-3 days; 50 mg 2 r / day, then 50 mg 1 r / day orally or in suppositories. Inhibition of contractile activity begins 2-3 hours after administration, the maximum effect occurs after 4 days; the duration of treatment is 5-9 days, the total dose is not more than 1000 mg.
12. Treatment of CCI:
1) surgical correction:
a) narrowing of the internal pharynx - a circular lavsan suture is applied under the mucous membrane or on its surface, which I remove at the end of pregnancy;
b) suturing the external pharynx according to Szendi - removal of the mucous membrane of the cervical canal around the gaping external pharynx and connecting its edges with catgut sutures, the resulting scar is easily destroyed before childbirth;
c) the formation of tissue duplication around the cervix.
2) conservative: the introduction of an obstetric unloading pessary or a pessary-ring on the cervix according to Golgi.
Spontaneous miscarriage.
Spontaneous miscarriage or abortion- termination of pregnancy before 22 weeks. Distinguish early- termination of pregnancy before 12 weeks and late- from 13 to 22 weeks of miscarriages.
Etiology:
1) pathology of the uterus - anomalies in the development of the Mullerian duct (septum, saddle-shaped, bicornuate uterus), synechia in the uterine cavity, isthmic-cervical insufficiency, uterine hypoplasia, fibroids
2) anomalies of the chromosomal apparatus - structural disorders or quantitative aberrations of chromosomes.
3) immunological disorders - disorders of cellular and humoral immunity, the role of isoserological incompatibility in the group and Rh factor of the blood of the mother and fetus, autoimmune reactions to phospholipids
4) endocrine pathology - ovarian hypofunction, etc.
5) infectious factors - chronic infectious diseases of the mother, local lesions of the genital apparatus caused by bacterial flora, mycoplasmas, chlamydia, toxoplasma, listeria, viruses, fungi
6) somatic diseases and intoxications
7) psychogenic factors
8) complicated course of pregnancy.
Pathogenesis. Any of the causes ultimately leads to an increase in the contractile activity of the uterus, the separation of the fetal egg from the uterine wall and its expulsion. In the I and the beginning of the II trimester (until the placenta is fully formed), the fetal egg is separated and released from the uterus without opening the fetal bladder. At a later date, with a formed placenta, abortion occurs according to the type of birth act: the cervix opens, amniotic fluid, the fetus is born, and then the afterbirth.
clinical picture. There are forms (stages) of spontaneous miscarriage: threatened miscarriage, incipient miscarriage, "on the go" abortion, complete and incomplete abortion, failed abortion.
For threatened miscarriage an increase in the contractile activity of the muscles of the uterus is characteristic, however, the fetal egg completely retains its connection with the uterus. Clinically, this form of miscarriage is manifested by mild aching pains in the lower abdomen and in the sacrum. Bleeding is minor. The cervix is completely preserved, the external os is closed.
At miscarriage increased contractile activity of the myometrium leads to partial detachment of the fetal egg and the appearance of small bleeding from the cervical canal. The pains intensify, sometimes acquire a cramping character in the lower abdomen, in the sacrum. The cervix is preserved, the external os is open. The size of the uterus corresponds to the gestational age.
Further progression of abortion is indicated as abortion on the go- irreversible abortion. The fetal egg loses contact with the fetus and descends into the lower uterus or into the cervical canal. Abortion "on the go" is accompanied by severe cramping pain in the lower abdomen and significant and profuse bleeding. With a rigid external pharynx, the fetal egg can be completely expelled from the uterine cavity into the cervical canal. The cervix increases significantly in volume, and the body contracts. This type of abortion "on the go" is called cervical abortion.
incomplete abortion- a condition in which part of the fetal egg has left the uterus, and only its remains are contained in the uterine cavity . The severity of the course is determined by the amount of blood loss - from small to profuse, leading to the development of hemorrhagic shock. During vaginal examination, blood clots are found, the cervix is softened, shortened, the cervical canal is ajar and freely passes a finger. The uterus has a softish consistency, during the study it contracts, becomes denser.
At completeabortion the fetal egg is rejected entirely, only parts of the decidua can remain in the uterus. It proceeds according to the type of normal childbirth: the water leaves, the fetus is born, the afterbirth is expelled. Vaginal examination: the size of the uterus is much smaller than the gestational age, the consistency is dense, the cervical canal is ajar. Discharge from the uterus is bloody, insignificant.
Missed abortion- a condition in which, despite the death of the fetus, the uterus does not develop contractile activity. A fertilized egg can linger in the uterine cavity for several months. It undergoes necrosis, autolysis, sometimes mummification and petrification occur. It is clinically manifested by uterine growth retardation, the disappearance of signs of pregnancy, and sometimes a deterioration in well-being.
Diagnostics.
1. Complaints(see above). The general condition of the patient may be due to the presence of the pregnancy itself and the degree of blood loss. With threatening and incipient miscarriages, the condition of women is usually satisfactory. With an abortion "in progress", incomplete and complete abortion, the patient's condition depends on the duration, intensity and degree of blood loss. Prolonged, small bleeding leads to anemia of the patient, the severity of which determines the condition of the woman. Acute blood loss can lead to shock.
2. Data gynecological examination with a threatened miscarriage, they indicate that the size of the uterus corresponds to the delay in menstruation. The uterus reacts to palpation with a contraction. There are no structural changes in the cervix. With the onset of a miscarriage, the cervix may be somewhat shortened with a slightly gaping external os. The spasmodic body of the uterus corresponding to the gestational age, the lower pole of the fetal egg, easily reached through the cervical canal, indicate an abortion "in progress". With an incomplete abortion, the size of the uterus does not correspond (smaller) to the gestational age, and the cervical canal or external os is ajar.
3. Laboratory and instrumental methods.
a) Colpocytological examination. Karyopyknotic index (KPI) in the first 12 weeks. pregnancy should not exceed 10%, at 13-16 weeks. it is equal to 3-9%, in later terms the KPI is kept within 5%. An increase in CPI indicates a threat of termination of pregnancy.
b) Determination of the content of hormones in the blood plasma. For example, human choriogonic gonadotropin in the blood serum of a pregnant woman is 45,000-200,000 IU / l in the first trimester, and 70,000-100,000 IU / l in the second trimester.
c) Echographic signs of a threatened miscarriage in early pregnancy are the location of the ovum in the lower uterus, the appearance of fuzzy contours, deformation, constriction of the ovum, local tension of the myometrium. From the end of the first trimester of pregnancy, with the threat of its interruption, it is possible to identify areas of placental abruption, measure the diameter of the isthmus, which should not exceed 5 mm.
Treatment. With the threat of spontaneous miscarriage, treatment should be carried out taking into account the duration of pregnancy, the stage of the clinical course and the cause of the disease.
1. Treatment of threatened and incipient miscarriage. Treatment should be carried out only in stationary conditions: 1) a complete, balanced, vitamin-rich diet; 2) bed rest; 3) non-drug methods of exposure; 4) drugs that reduce psycho-emotional stress and relax the smooth muscles of the body of the uterus.
a) sedatives are used to relieve psycho-emotional stress. In the first trimester, an infusion of valerian root, motherwort herb is used, in the second trimester - tranquilizers (sibazon, relanium).
b) to reduce the tone and contractile activity of the uterus, antispasmodics are used - papaverine, no-shpa, metacin, baralgin. Relaxation of the muscles of the uterus can be facilitated by the intramuscular injection of a 25% solution of magnesium sulfate, 10 ml at an interval of 12 hours. Some b-agonists have an inhibitory effect on the contractile activity of the myometrium: partusisten, ritodrine, alupent. They are used from the 20th week of pregnancy.
c) with a decrease in the function of the corpus luteum, gestagens are prescribed - turinal, progesterone, duphaston, utrozhestan. In women with hypoplasia and uterine malformations, with ovarian hypofunction established before pregnancy, when bleeding occurs, gestagens are combined with estrogens - ethinyl estradiol (microfollin), folliculin or estradiol valerate preparations. Estrogens can be prescribed from the 5th week of pregnancy. In women with potentially correctable ovarian hypofunction, a positive result is the inclusion of choriogonin in the complex of therapeutic agents. At the same time, estrogens and gestagens continue to be taken.
d) with hyperandrogenism, corticosteroids are prescribed in small doses - prednisolone or dexamethasone. e) in all cases of a miscarriage that has begun, accompanied by bleeding, the use of symptomatic agents is not excluded - ascorutin, etamzilat.
e) the inclusion of physical factors in order to reduce the drug load on the body of the mother and the developing fetus in the complex of therapeutic measures: endonasal galvanization; magnesium electrophoresis with sinusoidal modulated current; inductothermy of the kidney area; electrorelaxation of the uterus using an alternating sinusoidal current.
f) treatment of HF (see above)
2. Treatment abortion in progress is active therapy aimed at stopping bleeding.
3. Treatment incomplete and complete abortion is to remove the contents of the uterus.
4. When failed labor adhere to expectant tactics or active removal of the contents of the uterus.
premature birth.
preterm birth- spontaneous or artificial termination of pregnancy in terms of 22-37 weeks, as a result of which a premature baby is born.
Risk factors for miscarriage: 1) socio-biological reasons (age, occupation, bad habits, living conditions); 2) obstetric and gynecological history (the nature of the menstrual cycle, outcomes of previous pregnancies and childbirth, gynecological diseases, malformations of the uterus); 3) extragenital diseases (acute infections during pregnancy, heart defects, hypertension, kidney disease, diabetes mellitus); 4) complications of this pregnancy (severe OPG-gestosis, Rh sensitization, antiphospholipid syndrome, polyhydramnios, multiple pregnancy, placenta previa).
clinical picture. According to clinical manifestations, preterm labor is divided into threatening and begun.
Threatened preterm birth characterized by minor pain in the lower abdomen or lower back. Sometimes there are no complaints at all. Palpation of the uterus reveals increased tone and excitability. There may be small bloody discharge from the genital tract. Vaginal examination: the cervix is preserved or shortened, sometimes smoothed; the external os is closed or passes the tip of the finger. The fetal heart rate is not affected.
At incipient preterm birth the pains intensify, acquire a cramping character. Vaginal examination reveals a shortened or flattened cervix. Often there is an outpouring of amniotic fluid. Cervical dilatation up to 4 cm indicates the latent phase of the first stage of labor, dilatation from 4 cm or more indicates the active phase.
Birth management. The tactics of conducting labor depends on the following factors: 1) the stage of the course (threatening, beginning); 2) gestational age; 3) mother's condition (somatic diseases, late preeclampsia); 4) the state of the fetus (fetal hypoxia, fetal malformations); 5) the state of the fetal bladder (intact, opened); 6) degree of cervical dilatation (up to 4 cm, more than 4 cm); 7) the presence and intensity of bleeding; 8) the presence or absence of infection.
1. Conservative-waiting tactics(pregnancy prolongation) is indicated for threatened or commenced labor up to 36 weeks, in general amniotic sac, opening of the pharynx up to 3 cm, good condition of the fetus, in the absence of severe obstetric and somatic pathology and signs of infection.
Complex treatment of threatening and latent phases of the onset of preterm labor:
1) bed rest;
2) a light, vitamin-rich diet;
3). reflex and psychotherapy;
4) physiotherapy - magnesium electrophoresis, sinusoidal modulated current;
5) medicines.
a) to relieve psycho-emotional stress, preparations of valerian and motherwort, tazepam, sibazon, seduxen are prescribed.
b) to reduce the excitability of the uterus, antispasmodics (methacin, no-shpa, papaverine), b-adrenergic agonists (partusisten, brikanil, alupent), indomethacin are used.
c) with the threat of termination of pregnancy before the 34-week period, the prevention of respiratory distress syndrome in the newborn is carried out. Within 3 days, pregnant women receive corticosteroids (dexamethasone at a daily dose of 8 mg or prednisolone - 60 mg), which promote the synthesis of surfactant and the maturation of the lungs of the fetus. A week later, the course of corticosteroid therapy can be repeated.
Particular attention should be paid to a group of women with threatening and onset of preterm labor when the cervix is less than 4 cm dilated against the background of amniotic fluid effusion. In the absence of infection, good condition of the mother and fetus and gestational age of 28-34 weeks. it is possible to prolong pregnancy, strictly observing all the rules of asepsis and antisepsis (sterile liners, disinfection of the external genital organs, insertion of suppositories or antibacterial tablets into the vagina). It is necessary to exercise strict control over the identification of the first signs of infection of the birth canal (thermometry, blood tests, bacteriological examination of vaginal discharge). At the same time, glucocorticoids are prescribed, which contribute to the maturation of the lungs of the fetus. When signs of infection appear, labor inducing therapy is prescribed.
2. Active tacticsthreatening and begun childbirth through the natural birth canal. It is carried out for severe somatic diseases of a pregnant woman, severe gestosis, fetal hypoxia, fetal malformations and death, signs of infection.
Preterm labor that has begun is carried out through the natural birth canal under constant cardiac monitoring. Premature births require special care. It is necessary to widely use antispasmodics, apply adequate pain relief without narcotic drugs. Regulation of labor activity in case of its violations should be carried out carefully. The weakness of labor activity is corrected by intravenous administration of prostaglandins or oxytocin under careful control of cardiotocography.
Preterm labor is often complicated by a rapid or rapid course, in these cases the use of tocolytics or magnesium sulfate is indicated. Be sure to prevent fetal hypoxia.
The period of exile for a premature baby is a great danger, therefore, in order to prevent birth trauma to the fetus, it should be carried out very carefully, without protection of the perineum. Pudendal anesthesia or perineotomy is indicated to reduce pelvic floor muscle resistance.
In the subsequent period, measures are taken to prevent bleeding.
3. Kesarevo segenia. Indications: placenta previa, premature detachment of a normally located placenta, eclampsia, transverse position of the fetus.
Complications: premature rupture of amniotic fluid, labor anomalies, bleeding, infectious complications in childbirth and the postpartum period, fetal hypoxia.
Prevention of miscarriage. The main role in solving this complex problem belongs to antenatal clinics, which identify women at risk for miscarriage, carry out dispensary observation of them, develop an individual plan of preventive measures, hospitalize pregnant women at early and critical (12.16, 28 weeks) terms and during corresponding to an abortion in the past.
480 rub. | 150 UAH | $7.5 ", MOUSEOFF, FGCOLOR, "#FFFFCC",BGCOLOR, "#393939");" onMouseOut="return nd();"> Thesis - 480 rubles, shipping 10 minutes 24 hours a day, seven days a week and holidays
Golovin Yuri Valentinovich Infected miscarriage (clinical and laboratory diagnostics, treatment): dissertation... candidate of medical sciences: 14.00.01 / Golovin Yuriy Valentinovich; [Place of protection: State educational institution of higher professional education "Siberian State Medical University"]. - Tomsk, 2004. - 147 p. RSL OD,
Introduction
CHAPTER 1. Literature review 10
1.1. Frequency, causes, classification of infected miscarriages.. 11
1.2. Causes of Infected Miscarriages 11
1.3. Classification of infected miscarriages 13
1.4. Clinical forms and symptomatology of an infected miscarriage 16
1.4.1. Uncomplicated infected miscarriage 16
1.4.2. Complicated infected miscarriage 18
1.4.3. Septic miscarriage 19
1.5. Methods for diagnosing an infected miscarriage 28
1.6. Microbiological diagnostics 32
1.7. Plasma chemiluminescence 35
1.8. Treatment of patients with infected miscarriage 40
1.8.1. Efferent methods in the treatment of patients with infected miscarriage 43
1.8.2. Surgical methods of treatment of patients with infected miscarriage 45
CHAPTER 2 Material and research methods 48
2.1. Clinical characteristics study groups of patients with infected abortion 48
2.2. Research methods 55
2.2.1. The study of quantitative indicators of blood and acute phase characteristics inflammatory process 56
2.2.2. Plasma chemiluminescence 57
2.2.3. Evaluation of the characteristics of systemic hemodynamics 57
2.2.4. Evaluation of the characteristics of the blood coagulation system 57
2.2.5. Bacteriological examination 58
2.2.6. Methods of statistical analysis 58
CHAPTER 3. Results of the study 59
3.1. Features of the clinical course of various forms of infected miscarriage 59
3.2. Features of the laboratory characteristics of patients with various forms of infected miscarriage 78
3.2.1.. Results of bacteriological examination of patients with infected miscarriage 78
3.2.2. Blood counts in women with infected and septic miscarriage 82
3.3. Conservative and surgical tactics for the treatment of patients with infected and septic miscarriage 103
3.3.1. Discrete plasmapheresis and ultraviolet blood irradiation in the complex treatment of patients with septic abortion 109
Conclusion 113
References 129
Introduction to work
The relevance of research. Issues related to the diagnosis and treatment of infected and septic abortion still remain relevant. This is due to the continuing high frequency of artificial termination of pregnancy, including in later dates gestation. Have not lost their significance and criminal interventions, which are most often accompanied by severe infectious complications.
The non-decreasing number of complicated miscarriages and high mortality from associated purulent-septic complications dictate the need to study and improve the tactics of treating patients with infected and septic abortion.
Importance in the nature of the course of an infected abortion has etiological factor and its resistance to antibiotic therapy. At the same time, information regarding the structure of pathogens of the infectious process, the role of aerobic and anaerobic flora is very contradictory. This greatly complicates the conduct of etiotropic therapy in the first hours from the admission of sick women to the gynecological hospital.
Of particular difficulty is the differential diagnosis of various forms of infected and septic abortion, the assessment of the prevalence pathological process, while the choice of optimal tactics for treating patients, the use of conservative and surgical methods of therapy largely depends on this.
Solving the problems of differential diagnosis of various forms of infected abortion is possible only with a comprehensive assessment of clinical and laboratory data. In this regard, considerable attention is paid to the search for new highly informative laboratory criteria and the assessment of their sensitivity and specificity. Of particular interest are diagnostic methods based on
6 based on the use of indicators of the concentration of various proteins of the acute phase, as well as chemiluminescence induced by hydrogen peroxide in the blood plasma of sick women.
The most dangerous complication of abortion is the development of septic conditions, which are accompanied by the most high rates disability and mortality, reaching, according to some, 9%. Septic abortion is accompanied by severe dysfunctions of all links of homeostasis, systemic hemodynamics and the development of disseminated blood coagulation syndrome. At the same time, the diagnosis of septic abortion is often associated with significant difficulties, due to the absence of characteristic symptoms, which can lead to a belated use of the most important stage in the treatment of such patients - the surgical removal of a purulent focus.
The tasks of postoperative management of patients with septic abortion remain insufficiently developed, in particular, the possibility and effectiveness of the use of extracorporeal detoxification methods, among which discrete plasmapheresis and ultraviolet blood irradiation occupy a special place.
Currently, there are no clear, pathogenetically substantiated recommendations for the management of patients with infected and septic abortion, which would take into account the regional characteristics of the disease. Meanwhile, the development of such recommendations based on a comprehensive study of the clinical and laboratory characteristics of various forms of infected and septic abortion and the effectiveness modern methods therapy is an extremely urgent task that will allow timely diagnosis and management of complications using the most effective diagnostic criteria and therapeutic interventions.
Thus, issues related to the diagnosis and treatment of infected and septic abortion are among the most relevant in society.
temporary gynecology, and the problems associated with them require solutions based on comprehensive scientific research.
Purpose of the study. To establish the features of the course of infected and septic abortions to optimize methods of diagnosis and treatment.
Research objectives.
To study clinical, laboratory and microbiological characteristics in patients with various forms of infected miscarriage and septic abortion.
To conduct a comparative analysis of blood plasma chemiluminescence in patients with infected and septic miscarriage.
To assess the relationship between clinical and laboratory characteristics in various forms of infected and septic abortion, to identify the most informative diagnostic and prognostic laboratory criteria.
To study the effectiveness of efferent therapy using discrete plasmapheresis and ultraviolet blood irradiation in the postoperative period in patients with septic abortion.
To develop an optimal algorithm for the diagnosis and treatment of patients with infected and septic miscarriage.
Scientific novelty. In this work, for the first time, a comprehensive assessment of clinical and laboratory characteristics was carried out in patients with various forms of infected and septic abortions, the most informative diagnostic criteria for complications were identified, and their prognostic value in relation to the clinical outcome and effectiveness of therapy was determined. The study of peroxide chemiluminescence of blood plasma in patients with infected and septic miscarriage was performed for the first time, and the high sensitivity of this method in assessing the severity of the complication was revealed. Based on new
data concerning the characteristics of the course of various forms of infected miscarriage, an optimal, pathogenetically substantiated algorithm for the diagnosis and treatment of patients with complicated infected miscarriage and septic abortion has been developed.
Practical significance. The data obtained allow for timely diagnosis and assessment of the severity of purulent-septic complications after an abortion, substantiate the procedure for carrying out measures for intensive care, surgical treatment, and the use of extracorporeal detoxification methods in these patients.
The results of the study concerning the laboratory features of various forms of infected miscarriage make it possible to use the most informative criteria for identifying and predicting the course of a complication, as well as evaluating the effectiveness of the treatment.
Based on the information obtained, an optimal algorithm for the diagnosis and treatment of patients with infected and septic miscarriage was developed and introduced into clinical practice.
Provisions rendered for protection.
In patients with infected and septic abortion, there are no reliable clinical and microbiological characteristics that allow accurate differential diagnosis between various forms of complications, while the use of plasma peroxide chemiluminescence as a diagnostic criterion, along with a complex indicator of endogenous intoxication, including leukocyte index of intoxication, serum levels of polypeptides of medium molecular weight, haptoglobin and antitrypsin can increase the overall sensitivity and specificity of diagnosing complications.
The use of the combined method of plasmapheresis and ultraviolet blood irradiation in the treatment of sick women with septic
breathing in the postoperative period is accompanied by a faster disappearance of clinical manifestations of intoxication and inflammation, normalization of acute phase parameters and peroxide chemiluminescence of blood plasma compared with patients who received standard therapy.
Implementation into practice. A set of measures for the management of patients with infected and septic abortion has been introduced into the practice of the City Clinical Emergency Hospital No. 1 in Omsk. The dissertation materials are used in lecturing and conducting practical classes with students of the medical faculty of the Omsk State Medical Academy, interns and clinical residents at the Department of Obstetrics and Gynecology of the State Medical Academy.
Approbation of work. The main results of the work were reported and discussed at the meeting of the association of obstetricians and gynecologists of the Omsk region (2003), at the scientific and practical conference of obstetricians and gynecologists of the Omsk region (2003).
The structure and scope of the dissertation. The dissertation is presented on [і47 pages of typewritten text, contains 25 tables, illustrated with 6 figures and consists of an introduction, literature review (first chapter), research material and methods (second chapter), research results (third chapter), conclusion, conclusions, practical recommendations and list of references. The bibliographic index contains 214 literature sources, of which 124 are in Russian and 90 are in foreign languages.
The author expresses deep gratitude for the advisory assistance provided to the head of the Department of Anesthesiology and Resuscitation of the State Medical Academy, Professor V.Y. A.V. Indutny.
Frequency, causes classification of infected miscarriages
An analysis of the causes of out-of-hospital miscarriages showed that in the vast majority of cases they are subjective, difficult to eliminate: the desire to hide the pregnancy from others, the undesirability of hospitalization, late interruption pregnancy at a time when artificial abortion is no longer possible. A number of reasons lead to the occurrence of an infected abortion: spontaneous abortion caused by a common infectious disease; prolonged stay of the patient outside the medical institution after a spontaneous abortion of any etiology; retention of parts of the fetal egg in the uterine cavity after artificial or spontaneous abortion. The most severe course of the disease is observed after criminal interventions. Generally, an infected miscarriage is most commonly seen in criminal intervention.
The motives for community abortions largely coincide with those for artificial abortions: unwillingness to have children, material and housing difficulties, family troubles, the presence of a small child, etc. . Currently, there are cases when women, due to falsely understood moral obligations and, wanting to hide the fact of criminal interference from others, do not report true data about the method of abortion.
Criminal abortion is currently not so rare in clinical practice. This is due to a number of serious reasons: late pregnancy (more than 12 weeks), when the antenatal clinic is denied referral for a medical abortion; refusal to perform an abortion earlier than 6 months after an already performed medical abortion; refusal to refer for an abortion due to the presence of contraindications. Of some importance is also the often lengthy procedure for admission to a hospital; the false notion that an abortion is faster at home than in a hospital. A number of women have a criminal abortion due to fear of the "curettage" operation.
The greatest number of patients arrives on holidays, pre-holidays, weekends. This is due to the desire to end the miscarriage without prejudice to their home and office affairs, without unnecessary publicity.
When indicating or suspecting an intervention that has taken place, one should always keep in mind the risk of infection and, more importantly, injury during the intervention (perforation of the uterus or other internal organs), the ingress of foreign bodies and various liquids (a solution of soap, alcohol, iodine, etc.). .d.) in the tissues of the genital organs and in the abdominal cavity.
To terminate a pregnancy outside a medical institution, foreign bodies are usually used - metal, rubber, plastic catheters or tubes, ficus or agave leaves, which are inserted into the uterine cavity. In addition, during criminal intervention, various solutions are often introduced into the uterine cavity: iodine, alcohol, potassium permanganate, rivanol, soap, as well as modern detergents, etc. .
The general serious condition of the patient with signs of poisoning with hemolytic poisons or with signs of anaerobic infection, the infection spread outside the uterus, while the fetal egg remains in it, sudden heavy bleeding, sometimes the fetus comes out without contractions, suggests criminal intervention.
An indisputable objective sign of criminal intervention is fresh traumatic damage to the mucous membrane of the vagina or cervix, the presence of burns (of medical origin), traces of zero forceps, etc. .
Clinical forms and symptomatology of an infected miscarriage
According to the classification of S.V. Sazonov and A.V. Bartels, at the first stage of the spread of infection, the pathological process is limited to the fetal egg and the decidua of the uterus. Clinical forms given state are chorioamnionitis and endometritis.
Endometritis accounts for about 30% of all types of post-abortion infectious diseases. At the same time, several clinical variants of the course of the disease are distinguished.
The most studied is the "classic" form of post-abortion endometritis, which currently occurs only in 35% of cases. At the same time, patients have an increase in body temperature up to 38-40C, often chills, tachycardia up to 100-120 beats per minute or more. Usually, an increase in heart rate corresponds to an increase in body temperature. There is leukocytosis in the range of 10-20 109/l and an increase in ESR up to 50 mm/h or more. With a two-handed gynecological examination in patients, an enlarged, painful uterus is usually determined. Discharge from the genital tract is bloody with an admixture of pus, which later turns into purulent.
With the "abortive" form of endometritis, the body temperature rises to 38C, less often it has higher values. The patient has chills, tachycardia up to 90-120 beats per minute, an increase in ESR up to 15-50 mm/h, leukocytosis in the range of 10-15 107 l, a moderate shift of the leukocyte formula to the left. Bimanual examination usually reveals uterine enlargement and tenderness. Discharge from the vagina is bloody, rarely purulent.
After the start of treatment, body temperature in patients with "abortive" form of endometritis normalizes within 2-4 days. The uterus decreases to normal size, but its soreness usually disappears not earlier than the fifth day. Normalization of peripheral blood parameters occurs within 6-7 days, somewhat faster than with the "classic" form of endometritis (8-12 days).
The widespread and often irrational use of antibacterial drugs has led to the fact that post-abortion endometritis in 50-60% of cases acquires an erased clinical course.
With an erased form of endometritis, the body temperature in most patients ranges from 37.5C to 38C. Chills are extremely rare. However, even at subfebrile body temperature, patients often have tachycardia of up to 100 or more beats in 1 minute. In the peripheral blood, leukocytosis of 10-14 109/l is observed, an increase in ESR to 45 mm/h is noted. The leukocytic shift to the left in the blood formula in these patients is slightly expressed. Soreness of the uterus on palpation is weakly expressed, brown discharge, which after a few days becomes sanious-purulent, with a sharp fetid odor.
During treatment, body temperature in patients with erased forms endometritis normalizes within 5-10 days, but sometimes low-grade fever persists for a long time. Involution of the uterus also slowly occurs, which usually reaches its normal size not earlier than after 10-12 days. Normalization of blood parameters lasts especially long - up to 15 days from the start of therapy. In 20% of patients, 3-4 days after the normalization of body temperature and peripheral blood parameters, a relapse of the disease is observed, characterized by the same symptoms.
Clinical characteristics of the studied groups of patients with infected abortion
This study was performed on the basis of the Department of Purulent Gynecology of the City Clinical Emergency Hospital No. Omsk for the period from 1993 to 2001. The work included the results of examination and treatment of 375 patients with infected abortion, which were divided into three clinical groups depending on the form of the disease. The first group (group 1) consisted of 192 patients with uncomplicated infected abortion who were diagnosed with acute endometritis. The second and third groups (groups 2 and 3) included 102 patients with complicated infected miscarriage and 81 women with septic abortion, respectively. As a control group, 21 women after an uncomplicated medical abortion were included in the study. The main clinical form of complicated infected miscarriage was endomyometritis (88 patients) and pelvioperitonitis (10). In this group of patients, acute salpingo-oophoritis (2) and metrothrombophlebitis (2) were also diagnosed. Among women with septic abortion, 75 patients were diagnosed with sepsis, while the remaining six patients developed peritonitis. The gestational age at which a miscarriage occurred in patients of the studied groups averaged 12±5 weeks. At the same time, there was a tendency to increase the term of an interrupted pregnancy with an increase in the prevalence of the pathological process. Of the 375 sick women included in this study, 267 (71.2%) had a community-acquired spontaneous abortion, while in 108 (28.8%) patients, the termination of pregnancy was of a criminal nature. The structure of patients with various forms of infected miscarriage, depending on the nature of the abortion that occurred, is presented in Table. 2. Most patients with infected miscarriage were aged 20 to 35 years (Table 2). As can be seen from the presented data, socially unadapted, non-working women made up the bulk of the patients. In the present study, an infected miscarriage was more often observed at a gestational age of 16 or more weeks (33.9%), which, apparently, is associated with a larger area of the wound surface in the uterine cavity during miscarriage in late gestation (Table 4). A relatively small part of the patients 49 out of 375 (13.1%) were registered at the dispensary in the antenatal clinic during this pregnancy, while the remaining women 326 (86.9%) were not observed by the doctor. Attention was drawn to the large specific number of women who had a history of abortions. Only one fourth of 92 (24.5%) patients indicated the absence of abortion in history. One abortion was noted in 100 (26.7%) patients, two or more - in 183 (48.8%) patients. The fact of criminal intervention was established in almost a third (108 of 375; 28.8%) of patients. At the same time, the methods of criminal termination of pregnancy differed significantly (Table 6). The most common methods of criminal intervention in patients of the studied groups was the introduction into the uterine cavity foreign body, chemical and other solutions (67 out of 108 patients; 62%). An analysis of the prevalence of extragenital pathology in patients with an infected miscarriage revealed that a significant (42.9%) part of the patients suffered from various diseases of the internal organs (Table 7). Analysis of the frequency of extragenital diseases among patients with various forms of infected miscarriage revealed the presence of pathology in a significant number of women with complicated infected miscarriage and septic abortion. In particular, in sick women with complicated infected miscarriage, extragenital pathology was noted in 51 out of 102 (50%) patients, while in women with septic abortion - in 47 (58%). In the group of women with uncomplicated infected miscarriage various pathology internal organs was observed in 63 (32.8%) women (p = 0.003 and p 0.001 when compared with the second and third groups, respectively). It is possible that such a significant prevalence of extragenital diseases among patients with complicated infected and septic miscarriage contributed to the progression of the infectious process in these groups of women. 170 (45.3%) female patients had a history of gynecological pathology. At the same time, among patients of the 1st group on various diseases genital organs were indicated by 80 (41.6%) patients, while in the 2nd and 3rd groups - 46 (45.1%) and 42 (51.9%) patients, respectively (% = 2.15; p=0.146) (Table 8).
Features of the clinical course of various forms of infected miscarriage
Clinical assessment of the condition of patients with infected miscarriage included in the present study made it possible to distinguish three main forms of the disease, in particular, uncomplicated infected (febrile) miscarriage, complicated infected miscarriage and septic miscarriage.
The main manifestations of diseases in patients with uncomplicated infected miscarriage were chorioamnionitis and endometritis. At the same time, the prevalence of the infectious process was limited to the fetal egg and the decidua of the uterus.
According to the results of monitoring patients with acute endometritis after an infected miscarriage, it was possible to identify different clinical variants of the course of the disease. (52.6%) and 70 (36.5%) women, respectively.
Patients with uncomplicated infected miscarriage were characterized by complaints of fever, pain in the lower abdomen, bloody discharge from the genital tract: These women had an increase in body temperature to an average of 38.9 ± 0.4 C, tachycardia 112 ± 8 beats per minute . Increased heart rate in most cases corresponded to an increase in temperature, and the condition of the patients was assessed as moderate.
During the gynecological examination in patients of this group, structural changes in the cervix were determined in the form of softening, shortening, opening of the cervical canal, as well as an increase, soreness of the uterus on palpation, bloody-purulent discharge with an ichorous odor.
In the peripheral blood of patients of the first group, leukocytosis was noted 9.63+2.10, a shift of the leukocyte formula to the left, an increase of an average of 21.5+8.4 mm/h.
Leukocytosis, a shift of the leukocyte formula to the left and an increase in ESR, combined with a rise in temperature, tachycardia, apparently indicated high activity infectious and inflammatory process. Clinical manifestations of an acute inflammatory process persisted in this group of patients for 3-10 days (average 4.6±1.7 days). During therapy, body temperature returned to normal, uterine tenderness disappeared during vaginal examination.
More than half of the patients of the first group had an abortive form of endometritis, which, in our opinion, was the result of early removal of the infected remnants of the fetal egg and active complex therapy. Among these patients, the relief of the inflammatory process occurred within 3-4 days (average 3.1 ± 0.8 days) from the onset of the disease.
Among the women of the first group, who were diagnosed with erased forms of endometritis, there were significant fluctuations in body temperature (from subfebrile values to 38.5 C). At the same time, chills were noted among them only in 3 cases. Despite an increase in the total content of leukocytes in the peripheral blood, the degree of leukocytosis among patients with erased forms of endometritis was moderate and there was a relatively small leukocyte shift to the left.
During vaginal examination in patients with erased forms of endometritis, there was a slight soreness of the uterus, sanious-purulent discharge with a sharp unpleasant odor.
According to the data obtained in patients of the 1st group, an increase in body temperature up to 38-39 C was observed in 98 (51.0%) cases, more than 39 C - in 24 (12.5%) women. A significant number (70 out of 192; 36.5%) of patients had subfebrile temperature. At the same time, tachycardia up to 100-120 beats per minute was present in 147 (76.6%) patients.
Only 30 of 192 (15.6%) patients of the first group had chills. Leukocytosis from 10 109/l to 15 109/l was observed in 136 (70.8%) patients. Leukocytosis above 15 109/l was present in a relatively small proportion (8 of 192; 4.2%o) of patients. A shift to the left in the formula of white blood was noted in 101 (52.6%) cases. Among other manifestations of endometritis, pain in the lower abdomen (189; 98.4%) and bloody-purulent discharge from the genital tract (187; (97.4%)) were most often noted.
Thus, the clinic of an infected miscarriage in the present study was characterized by febrile temperature, tachycardia, pain in the lower abdomen, bloody-purulent discharge from the genital tract with an ichorous odor, leukocytosis with a shift of the leukocyte count to the left.
Farrakhova, Lilia Nailevna
Infected community-acquired abortion occurs in 18-20% of gynecological patients, often accompanied by severe complications, surgical interventions, and sometimes leads to death. Occurs as a result of direct entry of pathogenic microbes into the uterus (more often with criminal interventions), drift by lymphogenous or hematogenous routes, as well as during legal abortion if there are contraindications to it (inflammatory diseases of the genitals - colpitis, adnexitis, endometritis; infectious diseases of extragenital origin - ARI, influenza, tonsillitis, pneumonia, pyelonephritis, etc.), due to subinvolution of the uterus or remnants of the fetal egg after an abortion.
The spread of infection is facilitated by factors such as:
The presence of a wound surface of the uterus, ruptures and injuries of the cervix, which are the entrance gate for infection;
Chorion and its remnants, which have a suction capacity, which facilitates the further spread into the bloodstream of both the microbes themselves, their toxins, decay products, and aggressive chemicals introduced into the uterus in order to terminate the pregnancy;
Burn, injury, necrobiotic changes in the uterus caused by chemicals used to terminate pregnancy (solutions of vodka, alcohol, soap, etc.);
Blood loss and anemia, which reduce the body's resistance to infection.
A significant role in the spread of infection belongs to the body's natural resistance, the initial level of immunodeficiency during pregnancy, and sensitization processes.
The most common causative agents of purulent-septic infection (GSI) after abortion are associations of gram-negative anaerobes, bacteroids (Bacteroides fragilis, Bacteroides melaninogenes, etc.), fusobacteria, peptococci, peptostreptococci with opportunistic pathogens (staphylococcus aureus, Pseudomonas aeruginosa, Proteus vulgaris, streptococcus and etc.). For the development of localized forms of infection (infected abortion), an average degree of contamination is sufficient: 104-105 CFU per 1 ml of biosubstrate (CFU - colony-forming unit).
In response to the introduction of the pathogen into the uterus, with a decrease in overall reactivity, an inflammation center appears with its inherent stages of development. The rate of development of deeper pathological changes is associated with the peculiarity and power of exposure to toxins secreted by gram-positive and gram-negative bacteria, as well as with the intensity of inflammatory changes in the uterus. At the same time, the exotoxin of gram-positive microbes has a cytotoxic effect, causes cell proteolysis (lysis of erythrocytes and leukocytes) with the formation and release of kinin-like substances into the bloodstream, leading to stimulation of the sympathetic nervous system and increased release of catecholamines.
Endotoxin, released during the destruction of gram-negative bacteria, forms complex complexes in the bloodstream with sympathomimetic activity, which leads to sharp disturbances in microcirculation and in the blood coagulation system.
As a result of the impact of these biologically active substances on the vascular wall, a spasm of arterioles occurs with redistribution of blood, its deposition and a decrease in BCC.
Classification of purulent-septic diseases after abortion
To determine the clinical forms of purulent-septic diseases after an abortion, it is more expedient to use the classification of postpartum purulent-septic complications of SV. Sazonov and A.V. Bartels (1973), adapted and supplemented by us. In this case, it is necessary to distinguish between 3 stages of the spread of infection that pass one into another:
Stage 1 - uncomplicated infected (feverish) abortion, in which the infection is limited to the ovum and decidua of the uterus;
stage 2 - complicated infected abortion, in which the infection went beyond the uterus, but remained localized in the small pelvis (uterine muscles, uterine veins, tubes, ovaries, parametric fiber and pelvic peritoneum are affected);
Stage 3 - septic abortion, in which the infection spread beyond the small pelvis and became generalized (septicemia - sepsis without visible metastases, septicopyemia - sepsis with metastases, septic shock, anaerobic sepsis, peritoneal sepsis).
The 4th stage of the spread of infection - a complicated infected abortion should be distinguished into a special borderline form - purulent-resorptive fever (GRF), often interpreted as a septic condition, sepsis (?), septic abortion. This clinical form of infection is borderline between a localized and a generalized process. With GRL, there is always a suppuration factor with an imperfect restrictive granulation process and a resorption factor. Any active surgical intervention in the uterus without prior treatment will contribute to the "breakthrough" of the infectious agent into the blood and the generalization of the infection with a possible fatal outcome due to rapidly developing septic shock.
Uncomplicated infected (febrile) abortion
Patients with this pathology complain of body temperature above 37.5 ° C, a single chill, a slight headache, the presence of bloody or bloody-purulent discharge from the uterus.
The method of criminal intervention (in the early stages of pregnancy - up to 14 weeks): more often intrauterine introduction of a catheter and solutions, less often - drugs of general action. Patients are admitted to the hospital 5-7 days after the intervention, sometimes with significant bleeding. The general condition of patients at admission is satisfactory or moderate; bleeding is not strong, but prolonged, leading to anemia (pallor, weakness, tachycardia, hemoglobin content less than 100 g / l). High body temperature persists for 5-7 days, then passes into subfebrile, especially with inadequate self-medication.
A miscarriage (often incomplete) can occur at home or in a hospital. A special gynecological examination reveals structural changes in the cervix (softening, shortening, opening of the cervical canal), the presence of injuries on the mucous membrane of the cervix, softening and soreness of the uterus during examination, the presence of bloody, purulent-bloody or putrefactive discharge. Hourly diuresis is sufficient, urinalysis is unchanged. Arterial pressure is normal, tachycardia corresponds to body temperature, there is no shortness of breath.
When examining the patient's blood, anemia is detected with significant and prolonged blood loss, moderate leukocytosis up to 10.0-12.0 10 9/l; no toxic changes, LII no more than 4; a moderate decrease in the content of total protein due to a decrease in the albumin fraction; high titer of C-reactive protein (+++ or ++++).
Morphological changes are local in nature: endomyometritis with necrosis of the decidual tissue, small cell leukocyte infiltration in the adjacent muscle layer, dilated blood and lymphatic vessels.
Complicated infected abortion
With a complicated infected abortion (a variant of the course - purulent-resorptive fever), patients present the following complaints: fever up to 38 ° C or more, chills, general weakness, headaches, loss of appetite, bad dream, nausea, sometimes vomiting, pain in the lower abdomen, bloody-purulent discharge.
Pregnancy is interrupted most often in terms of more than 14 weeks by intrauterine introduction of a catheter and various chemicals (vodka, alcohol, solutions of soap with vodka, potassium permanganate, etc.). Patients are admitted to the hospital late - usually on the 7-14th day after the intervention, often after inadequate treatment at home by other specialists or after non-core hospitalization.
The general condition of patients upon admission is moderate or severe due to a pronounced intoxication syndrome: lethargy or euphoria, pallor of the skin, flushing of the face, pulse more than 100 beats / min, respiratory rate up to 22-26 per minute, anemia of a toxic nature, body temperature 39- -40 ° C with chills, sweats and severe weakness.
Infected fetus or parts of it are often in the uterus, being a favorable environment for increasing contamination, resorption of microbes, toxins, decay products, aggressive substances and contributing to the processes of necrobiosis in the uterus.
In a gynecological examination, it is often possible to detect traces of a cervical injury with necrotic deposits, traces of a burn of the vaginal mucosa, softening of the cervix; the cervical canal can pass 1-2 fingers through the internal pharynx; sometimes parts of the fetus in the uterus are palpated; waters often pour out earlier; the uterus is enlarged, soft, painful locally or over the entire surface, does not contract on palpation. Adnexa of the uterus are edematous, painful, there are positive symptoms of irritation of the pelvic peritoneum, sometimes smoothness or overhanging of the posterior fornix is determined due to the accumulation of fluid in the shallow areas of the small pelvis, movements of the uterus behind the neck are painful, discharge from the cervical canal is purulent-bloody, putrid, with an ichorous odor , the phenomena of cervicitis and often colpitis.
Daily diuresis is somewhat reduced before admission, hourly diuresis during treatment is normal, however, urine examination reveals protein, single erythrocytes, leukocyturia, hyaline casts. Blood pressure is normal or slightly elevated, severe tachycardia (pulse 100-120 beats / min), tachypnea - up to 22-30 breaths per minute. The heart sounds are clear, sometimes a slight systolic murmur is heard at the apex, the ECG shows sinus tachycardia, often muscle changes. In the lungs during auscultation, dry rales may be noted, on the x-ray - an increase in the pulmonary pattern. The liver and spleen are not enlarged, there is moderate bloating, poor gas discharge, sometimes liquid stool.
A blood test reveals: moderate anemia of a toxic nature (without indicating significant blood loss), hypochromia, leukocytosis up to 12.0-18.0 109 / l, moderate lymphopenia, shift of the formula to the left, LII 4-6, severe dysproteinemia with a decrease in the content of total protein, especially its albumin fraction, increased levels
α- and β- globulins with no significant changes inγ- globulin fraction, high titer of C-reactive protein (+++ or ++++), signs of metabolic acidosis, a significant decrease in the number of T- and B-lymphocytes.Morphological picture. Endomiometritis and metrothrombophlebitis in complicated infected abortion, which proceeds as a purulent-rorbative fever, are characterized by the spread of infection through the lymphatic clefts and vessels deep into the myometrium. Inflammatory changes and necrosis capture the inner layer of the muscles of the uterus, small cell infiltration is observed in the deep layers of the myometrium and in some of its sections reaches the serous cover of the uterus. The infectious process can spread to the uterine appendages, leading to edema and infiltration of the fallopian tubes, edema and infiltration of the pelvic peritoneum.
Septic abortion
Among all infected abortions, the frequency of septic abortions ranges from 0.9 to 4.6%, while mortality reaches 26% (Abramchenko V.V., Kostyuchek D.F., Khadzhieva E.D., 2000).
Septic abortion is a common generalized process due to the body's response to infectious aggression. It can occur in the form of septicemia (sepsis without metastases), septicopyemia (sepsis with metastases), anaerobic sepsis, septic shock with complications (acute renal, hepatic, pulmonary and adrenal insufficiency, DIC), post-abortion peritonitis. During a septic abortion, 3 phases can be distinguished:
Phase of tension (compensatory-protective reaction of the macroorganism in response to the aggression of pathogens);
Catabolic phase (progressive breakdown of enzyme and structural systems with their subsequent decompensation);
Anabolic phase (gradual restoration of lost reserve resources of the body).
Septicemia (sepsis without metastases) is a severe acute disease that occurs with bacteremia and severe intoxication of the body. It can have a rapid and stormy or fulminant course, often develops at a later date after criminal intervention. With a long course, it often goes into the next stage of the spread of infection - septicopyemia. A complication may develop - septic shock, which was previously interpreted as a fulminant form of septicemia.
With septicemia, it is not always possible to detect pathogens in the blood, however, severe clinical manifestations do not exclude their presence in the body of the patient. Bacteria can reside in intercellular spaces and release toxins. Diagnostic screening tests for septicemia are as follows.
1. Complaints of patients: high body temperature (up to 40-41 ° C), repeated chills, accompanied by severe weakness, heavy sweats, persistent headache, poor sleep, lack of appetite, sometimes joint pain, difficulty walking, purulent discharge from the genital tract.
2. Term of interrupted pregnancy: more often from 14 to 27 weeks.
3. The method of criminal intervention is often denied by patients, but a thorough questioning of them reveals intrauterine administration of chemical solutions.
4. Late hospitalization of patients, often after 4-5 days of treatment at home, with doctors of other specialties, on an outpatient basis or in non-core departments.
5. The general condition of patients is severe or extremely severe, characterized by an early onset of the disease after the intervention, an increase in body temperature up to 40-41 ° C with repeated chills and rapidly increasing intoxication. Patients experience hallucinations, delirium, euphoria or weakness, drowsiness or insomnia, increasing weakness. Skin pale, with an icteric tint or gray-earthy color, bluish tint of the nail phalanges and mucous membrane of the lips, sometimes there are petechial hemorrhages on the conjunctiva, on the face in the shape of a butterfly, earlobes, chest, extremities due to capillary damage. Similar vascular lesions occur in the internal organs, the brain, on the mucous membranes. Bladder, stomach, intestines. Often there is pastosity of the face, legs, swelling of the outer surfaces of the thighs.
6. An increase in body temperature up to 40-41 ° C is observed in 18-20% of patients, in the rest - up to 38-39 ° C (with fluctuations up to 3 ° C). Chills are repeated 1-2 times, if more often (up to 3-5 times a day), then the prognosis of the disease becomes doubtful.
7. An infected fetus or parts of it may be in the patient's uterus.
8. With a special gynecological examination, traces of criminal interference can be found on the cervix, vaginal mucosa. The cervical canal is open by 1-2 cm, the uterus is enlarged and painful, there are purulent discharges, sometimes local pallor along the ribs of the uterus, indicating thrombophlebitis of the uterine veins. Local changes are less significant than the general serious condition of the patient.
9. The appendages of the uterus can be changed due to the ingress of toxins from the uterus into the bloodstream and the increase in signs of intoxication. But with a long course of septicemia, there may be inflammatory changes in the appendages and fiber of parametria in the form of lateral, anterior or posterior parametritis, accompanied by infiltration, thrombosis, suppuration, the appearance of a serous or purulent effusion in the small pelvis. With criminal intervention, the spread of the inflammatory process to the fiber of parametria should be considered as a manifestation of septicopyemia, that is, as a secondary infectious process, the resolution of which is possible only in exceptional cases with conservative and long-term treatment. The main and main primary source of suppuration is the uterus with or without infected remnants of the fetal egg. In the vessels of the uterus - vasculitis and infected blood clots. The breakthrough of the abscess into the hollow organs, the abdominal cavity or a long suppurative process with the melting of the cellulose of the small pelvis often leads to death if adequate surgical treatment is not taken in a timely manner.
10. Severe oliguria is observed, protein appears, leukocyturia, erythrocyturia, casts, mucus, bacteria are detected.
11. Blood pressure is reduced in a third of patients, most patients have tachycardia up to 120-140 beats / min and tachypnea - up to 30 breaths per minute, signs of overload of the right heart. The tongue is often dry, covered with a brown coating, the lips are dry, often with herpetic eruptions. The liver is enlarged, its edge is painful on palpation, the spleen is not always enlarged. The abdomen is moderately swollen, there may be fetid diarrhea of toxic origin, involuntary urination and stool due to the paretic state of the sphincters.
12. A blood test reveals anemia of a toxic nature, significant leukocytosis (up to 20.0-30.0 109 / l) only in a quarter of patients, the rest have a slightly higher leukocyte count or leukopenia is observed, which is unfavorable prognostically and indicates inhibition of bone function. brain. The appearance of young forms of neutrophils, the absence of eosinophils, the number of neutrophils significantly increases due to stab forms, lymphopenia, monocytopenia, high ESR, pronounced toxic maturity of neutrophils, plasma cells, anisocytosis, poikilocytosis, hypochromia are observed.
The combination of anemia, leukopenia, lymphocytopenia and monocytopenia with high ESR (up to 70 mm/h) is a poor prognostic sign. There is a high LII (more than 6-8), an increased content of C-reactive protein, hypoproteinemia with a decrease in the level of albumin (by 25-30%). Content
γ- globulins at the beginning of the disease is slightly increased, then begins to decrease. At the onset of the disease, there is an increase in the content of all classes of immunoglobulins, then the levels of IgA, circulating immune complexes (CIC) increase significantly, and the number and functional activity of T-lymphocytes decrease.In the ascorbate redox system, oxidized forms predominate, up to the destruction of ascorbic acid, the ratio of the amount of ascorbic acid and its oxidized forms (AA / RP coefficient) is reduced by 2.5-4 times.
13. Morphological picture. In the uterus, the phenomena of endomyometritis and metrothrombophlebitis, necrotic changes in the endometrium, often necrotic remnants of the fetal egg, deep lympho- and leukocyte infiltration of the myometrium, vasculitis with infected blood clots. The fallopian tubes are edematous, with signs of endosalpingitis. Ovarian tissue is edematous, with hemorrhages, often infected blood clots in the ligamentous apparatus.
Septicopyemia (sepsis with metastases). Septicopyemia in septic abortion is the next stage of septicemia, or sepsis with metastases. It is characterized by the formation of purulent foci in various organs and tissues - the lungs (pneumonia, pulmonary infarction, lung abscess, purulent pleurisy), kidneys (pyelonephritis, subcapsular abscesses, carbuncle of the kidneys), endocardium (septic endocarditis with the formation of necrotic ulceration of the heart valves), brain ( purulent meningoencephalitis and encephalitis). There are purulent lesions of the liver and spleen, carbuncle of the eye, soft tissue abscesses, joint damage, etc. Septicopyemia may develop after the removal of patients from septic shock. Screening symptoms of septicopyemia are as follows.
1. Complaints of patients are the same as with septicemia, with the addition of complaints depending on the location of the lesion: shortness of breath, shortness of breath, cough, suffocation - with damage to the lungs and heart; dysuric disorders, chills, high fever, pyuria - with kidney damage; pain, jaundice - with damage to the liver, spleen; persistent headaches, lethargy or agitation, meningism phenomena - with brain damage; swelling of the joints, difficulty walking, pain - with damage to the joints (infiltration, hyperemia); fluctuation of soft tissue abscesses, etc.
2. Hospitalization of patients is late, due to the erased course of sepsis or inadequate treatment of pyemic foci.
3. Septicopyemia begins 10-15 days after the criminal intervention, characterized by an undulating course with periods of severe intoxication and bacteremia, followed by short remissions. Often, septicopyemia occurs after the evacuation of the fetal egg in a generalized process.
4. The general condition of patients is severe or extremely severe. Against the background of a slight remission, there is an increase in body temperature to 40-41 ° C with recurring chills, lethargy or arousal; pronounced adynamia, delirium is replaced by insomnia, apathy - by excitement; there are pains in the calf muscles and joints; with brain damage - unbearable headaches, stiffness in the back of the head. The skin is pale, with an icteric tinge, cyanosis of the nail phalanges and the mucous membrane of the lips, pronounced symptoms of heart failure (tachycardia - up to 120-140 beats / min), tachypnea - up to 25-40 breaths per minute. Muffled heart sounds, hypotension, systolic or diastolic murmur at the apex or aorta, arrhythmia, expansion of the heart, sometimes pericardial rub. The liver and spleen are enlarged. Diarrhea is often noted, body weight decreases. Facial expression becomes indifferent. Lesions appear on the skin in the form of cracks, crusts, petechial rash, join clinical symptoms from the organs affected by purulent metastases.
5. In a gynecological examination, one can observe the phenomena of endocervicitis, small purulent discharge, a slightly enlarged uterus without changes in the appendages in the absence of remnants of the fetal egg in the uterus, or the same changes as with septicemia.
6. Oliguria with a significant loss of protein, cylindruria, leukocyturia, erythrocyturia, a significant amount of bacteria are detected. With appropriate therapy, diuresis and the concentration ability of the kidneys are normalized.
7. The blood picture depends on when the blood was taken for research. During the period of exacerbation, severe anemia is detected with a decrease in the number of erythrocytes, the appearance of normoblasts and phytroblasts, poikilocytosis and anisocytosis. Leukopenia (up to 5.0 109/l), lymphopenia and monocytopenia, absence of eosinophils are often observed, toxic granularity of neutrophils persists. During remission, white blood counts improve, but toxic anemia continues to persist until the next wave of exacerbation, as well as high ESR (up to 60-70 mm/h).
Hypoproteinemia with a further decrease in the amount of albumin is due to the continued circulation of toxic products in the blood. The potassium content is reduced, the sodium content is not changed, hyperbilirubinemia appears, the amount of creatinine, residual nitrogen, urea, glucocorticoids increases, the content of total lipids and cholesterol decreases, the number of T- and B-lymphocytes and their functional activity decrease significantly, the CEC level increases.
In the ascorbate redox system, a significant increase in oxidized forms is observed during the period of formation of new metastatic foci, however, even during the period of remission, the antioxidant system is significantly inhibited, the balance of AA and RP does not restore, and a significant deficit of reduced forms is observed.
8. Morphological picture. In the absence of remnants of the fetal egg in the uterus, there are vasculitis and infected blood clots in the vessels.
anaerobic sepsis. Occurs exclusively in criminal abortions due to infection with Cl. perfringens, which are anaerobic bacteria. The pathogen releases a toxin that has lethal, necrotic and hemolytic properties. Under its action, the chemical structure of hemoglobin is destroyed, which turns into methemoglobin, hemolysis of erythrocytes, a partial change in platelets, plasma proteins, which cause the development of capillary toxicosis, which contributes to extravasation and tissue edema, are observed. Under the influence of collagenase produced by the pathogen, tissue proteins and collagen structures are destroyed, while muscle tissue can melt with the formation of gas bubbles that are released from the uterus along with tissue discharge.
The disease begins acutely, with an increase in body temperature to 39-40 ° C, chills, vomiting, muscle pain, jaundice, within a few hours the skin acquires a bronze tint. A triad of symptoms occurs, known as the Nuremberg triad: bronze color of the skin, urine the color of meat slops, dark brown color of blood plasma (hemolyzed blood). Severe intoxication and acute renal failure develop rapidly. The condition of patients becomes critical due to increasing hypoxia, uremia (lethargy, drowsiness, smell of acetone from the mouth, vomiting, paretic abdomen, fluid in sloping places, Kussmaul breathing, azotemia), increasing tachycardia up to 140-160 beats / min. Patients die in 90% of cases, especially when uterine gangrene and peritonitis develop. If patients do not die from uremia, then on the 10-11th day diuresis increases, polyuria appears, hemoglobin levels increase, vomiting stops, and edema disappears.
As a result of hemolysis of erythrocytes, the level of hemoglobin decreases, the number of leukocytes increases (30.0-50.0 109/l and more). In the leukocyte formula, young forms appear (myelocytes, young), the number of stab neutrophils increases to 20-40%, lympho- and monocytopenia is noted, the level of bilirubin increases 20-30 times. Rapidly growing dysproteinemia with severe hypoalbuminemia, hypokalemia, tissue acidosis; increased vascular permeability is accompanied by ulceration of the oral mucosa. Since with anaerobic sepsis, kidney damage occurs very quickly, during the first hours or days, due to shock and necrotic action of toxins, already at the onset of the disease, a sharp decrease in the number and functional activity of T-lymphocytes and a significant increase in the number of CEC are observed. In the ascorbate system, oxidized forms of ascorbic acid predominate, up to its destruction.
Septic shock (SS) can complicate the course of both localized forms of GSI after abortion and any generalized form of this infection. Any surgical intervention (curettage of the uterine cavity, surgical treatment of abscesses, wounds, active antibacterial therapy leading to rapid lysis of bacteria, labor activity, etc.) can provoke the development of SS. At the same time, microbial invasion in combination with damage to the immune system and humoral regulation in patients quickly leads to a violation of the adequacy of tissue perfusion with oxygenated blood due to the development of severe systemic disorders. There are lesions of parenchymal organs with a violation of their function: acute renal failure (ARF) ("shock kidney"), acute liver failure (ALF) ("shock liver"), acute pulmonary insufficiency ("shock lung"), DIC develops. Quite often, patients are admitted to the hospital with these complications of SS.
With the rapid entry into the blood of endotoxins of gram-negative bacteria, as well as exotoxins of gram-positive microbes, a pyrogenic reaction occurs, leading to spasm of arterioles with redistribution of blood, its deposition and a decrease in BCC. A short-term redistribution of blood prevents the development of a hemodynamic crisis, a longer vasospasm leads to organ ischemia and irreversible changes in them. The occurrence of local and general reactions proceeds according to the type of the Sanarelli-Schwartzmann phenomenon and is currently considered as a “breakdown” of immunity.
The clinical picture of SS is characterized by a combination of symptoms of an acute purulent process and dysfunction of organs and body systems. It is conditionally necessary to distinguish 6 symptoms of SS:
Symptoms of infection (fever, chills, bacteremia, anemia, leukocytosis);
Changes from the side of the central nervous system (inadequate behavior, agitation, soporous-coma state);
Hemodynamic disorders (hyper- and hypodynamic syndrome, impaired automatism and heart rhythm with tachycardia up to 110-120 beats / min, myocardial ischemia, microcirculation disorders, coagulopathy);
Respiratory disorders (tachypnea more than 30 breaths per minute), hypoxia, radiographic signs of "shock lung";
Violations of the functions of the kidneys and liver (signs of acute renal failure with oliguria 20-30 ml / h and acute renal failure);
Metabolic disorders (dysproteinemia, hyperglycemia, metabolic acidosis, hyperlactatemia, hyperosmolality, decreased blood oncotic pressure).
A blood test reveals a decrease in hemoglobin content and the number of erythrocytes, their anisocytosis and poikilocytosis, leukocytosis of at least 15.0 109/l (sometimes 50.0-70.0 109/l) or moderate leukopenia, LII of at least 9-10, hypoproteinemia with a decrease in the level of albumin, a slight increase in the content of immunoglobulins of all classes. There is a decrease in the prothrombin index, the amount of fibrinogen, fibrinolytic activity of the blood, an increase in the level of oxidized forms of ascorbic acid and a decrease in the level of its reduced forms.
Urinalysis: relative density is reduced to 1005-1009, isostenuria, moderate proteinuria (up to 1 g/l), cylindruria, hematuria up to 15-20 erythrocytes per field of view, anuria or oliguria up to 30 ml/h. There is an increase during the day of creatinine, urea, residual nitrogen, bilirubin by 2-3 times.
If the patient cannot be brought out of the state of SS, she either dies very soon, or the disease passes into a stage characterized by impaired function of vital organs. At the same time, uremia, acute renal failure, acute renal failure, DIC-syndrome progress, and with the symptoms of increasing pulmonary heart failure, the patient dies. Early diagnosis of SS, an adequate set of resuscitation and surgical measures, followed by intensive therapy, can reduce mortality in this formidable complication.
Post-abortion peritonitis. It occurs when the uterus and abdominal organs are damaged or when microbes spread from the uterus to the peritoneum by the lymphogenous, hematogenous route or through the fallopian tubes, most often during criminal interventions to terminate a pregnancy. The course of post-abortion peritonitis has a number of features due to the fact that it is a dynamically developing process, passing from a delimited (local), more often serous, to a diffuse (general) fibrinous-purulent or purulent. Local peritonitis is a consequence of the spread of the infectious process from the infected uterus in the first 2-3 days, while diffuse peritonitis develops within a few hours with perforation of the uterus with or without trauma to the abdominal organs (bladder, intestines, mesentery, omentum). ), pyosalpinx, pyovarium, pelvic abscesses, with the retention of infected parts of the fetus for a long time (1-2 weeks).
The impact of pathogenic microorganisms on the peritoneum is manifested by a response hyperergic reaction in the form of edema, hyperemia, exudation with the formation of fibrinous deposits. Endo- and exotoxins of pathogens increase intoxication with disturbance and discoordination of metabolic processes, reflex changes in the activity of the cardiovascular and respiratory systems, inhibition of the activity of the gastrointestinal tract, deplete energy resources with the gradual development of irreversible changes in the patient's body. Only timely diagnosis, adequate surgical and intensive treatment can provide a favorable prognosis.
In the diagnosis of post-abortion peritonitis, the following screening symptoms and laboratory data are important.
1. Complaints of patients: fever (more than 38 ° C), chills, sudden sharp and progressive pain in the abdomen, general weakness, nausea, vomiting, hiccups, painful and frequent urination, flatulence, loose stools, the need to search for a forced position.
2. Occurs at any stage of pregnancy.
3. The method of criminal intervention: intrauterine introduction of metal or wooden objects, tools for emptying the uterus, tips, the introduction of toxic solutions-i thieves.
4. Duration of hospitalization: during the first 2-3 hours or 2-3 days from the moment of intervention or when severe abdominal pain occurs.
5. The general condition of patients is severe, with progressive deterioration due to increasing intoxication of the body. Its characteristic features are:
CNS disorders (slowness of consciousness, sometimes euphoria, inappropriate behavior, hallucinations, psychosis, delirium), severe weakness, fatigue, pallor or earthiness of the skin, subicteric sclera and skin, tachypnea - up to 36-40 breaths per minute, tachycardia - up to 120-150 beats / min with reduced pulse properties, acrocyanosis, forced position (on the back), increased pain during movement;
Disorders of the motor activity of the intestines: nausea, hiccups, vomiting, vomit of a stagnant nature and color coffee grounds with a putrid and then fecal odor, the tongue is dry or dry, with a brown coating, the lips are dry, a feeling of intense thirst, intestinal paresis, distention of the intestinal loops, difficulty breathing due to a raised diaphragm, tension of the abdominal wall with positive symptoms of peritoneal irritation, no flatus , loose stools, the appearance of splashing noise during auscultation of the intestine and the absence of intestinal motility, dullness of sound (exudate) in sloping places;
The liver can protrude from under the edge of the costal arch, its edge is painful (toxic damage), the spleen is not palpable due to the tension of the abdominal wall;
Heart sounds are muffled, functional systolic murmur at the apex, ECG shows sinus tachycardia with signs of electrolyte disturbances;
In the lungs, weakened breathing, congestion.
6. Heat body (39-40 °C) is preserved and has a hectic character.
7. The fetus or parts of the fetus are most often in the uterus; when it is perforated, intestinal loops, greater omentum, and bladder can be infringed in the perforation; foreign bodies may be left in the uterus and abdominal cavity.
8. In a gynecological examination, information is scarce due to the tension of the abdominal wall: the uterus is poorly contoured, sharply painful movement of the uterus around the cervix, sometimes a tumor conglomerate containing the uterus, appendages, soldered loops of the intestine and omentum, pain on palpation of the sacro-uterine ligaments, pastosity or protrusion of the posterior fornix due to accumulated effusion, which may displace the uterus upwards and laterally. With the criminal intervention that took place, the cervical canal was opened by 2-3 cm, the discharge from the uterus was bloody or purulent, with an ichorous smell.
9. Adnexa of the uterus are not determined due to the tension of the anterior abdominal wall. In the presence of perforation of the tubo-ovarian formation, a dense painful conglomerate without clear contours is palpated, its high location is revealed due to soldered loops of the intestine and omentum, infiltration of the pelvic peritoneum and the region of the lateral arches, sometimes reaching the pelvic wall.
10. Daily and hourly diuresis is reduced due to significant hypovolemia and impairment of the filtration function of the kidneys due to intoxication.
11. Severe anemization is not observed if there is no perforation of the uterus with significant internal bleeding, but there is significant leukocytosis (up to 12.0-26.0 109 / l) with an increase in the number of neutrophils, the appearance of young, immature forms of leukocytes, the disappearance of eosinophils, a decrease in the number lymphocytes and monocytes, increased ESR and LII (more than 12). There is a toxic granularity of neutrophils. An extremely unfavorable prognostic sign is leukopenia in combination with lymph and monocytopenia.
Protein metabolism disorders are caused by an extensive purulent process and intoxication. The resulting dysproteinemia due to increased protein catabolism, disturbances in the permeability of the vascular wall and the protein-forming function of the liver is characterized by a decrease in the content of total protein in the blood (up to 50 g/l), a significant decrease in the amount of albumin leaving the bed (34-35 g/l); globulin fractions enter the bloodstream from the liver, the amount of which is significantly increased, mainly due to
γ- globulins containing specific and nonspecific antibodies.Metabolic alkalosis is observed, the concentration of potassium decreases, the concentration of sodium increases, dysfunction of the adrenal cortex occurs, expressed in a relative increase in the content of 17-deoxycortico compounds, the level of total lipids decreases (up to 3.3 g / l), which are the main energy resource of the body.
A significant suppression of the activity of the macrophage link of immunological hemostasis is revealed: the number and functional activity of T-lymphocytes decrease with a simultaneous increase in the level of CEC, the level of IgG increases compensatory, especially on the first day of the disease at a low concentration of IgM.
In the ascorbate redox system, there is a decrease in the number of reduced forms of ascorbic acid and a significant increase in the number of its oxidized forms with an increase in the AA / RP coefficient by 2-2.5 times.
Urinalysis: low relative density, high protein content (sometimes 1 g / l or more), leukocyturia, erythrocyturia, hyaline and granular casts, often bacteria.
12. Morphological picture. The first local response to infectious aggression (reaction to bacterial exotoxins) is edema, swelling and clumpy disintegration of collagen fibers. The suppurative process in the abdominal cavity contributes to the development of a high absorption capacity of the peritoneum: toxins of a protein nature (albumin) are absorbed, reaching the general bloodstream, and crystalloid toxins, capable of causing a sharp antigenic rearrangement of the body, both in isolation and in various combinations - stress due to an increase in histamine production, serotonin, heparin, ammonia. They are fast and in large numbers enter the liver, disrupting its detoxification function. Both the products of perverted protein metabolism (polypeptides, tissue proteases), which are formed during the destruction of bacteria, and the bacteria themselves, both living and dead, are absorbed.
Therapeutic tactics in septic abortion
Treatment of patients with septic abortion should be intensive and multicomponent. It should include:
Carrying out preoperative preparation or a complex of resuscitation measures;
Surgical removal of the main source of infection;
Intensive postoperative therapy of the underlying disease and its complications;
Rehabilitation measures at the hospital stage;
Post-hospital rehabilitation and dispensary observation of patients.
Pathogenetic preoperative (or resuscitation) preparation of patients includes:
Elimination of hypovolemia and hypovolemic shock by the introduction of colloid and crystalloid solutions;
Stabilization of hemodynamic parameters by the introduction of large doses of glucocorticoids, vasopressors, cardiotonic drugs, vitamins;
Antibacterial therapy with two to three antibiotics a wide range actions, the use of protease inhibitors to prevent tissue damage and potentiate the action of antibiotics;
If necessary, forcing diuresis using osmodiuretics and antispasmodics;
The introduction of polyvalent antigangrenous serum for suspected anaerobic sepsis;
Constant saturation of the body with oxygen, with increasing respiratory failure - early and prolonged artificial ventilation of the lungs.
Surgical removal of the main source of infection in septic abortion involves extirpation of the uterus with removal of the fallopian tubes, revision and drainage of the abdominal cavity as soon as possible after the diagnosis of sepsis, regardless of the variant of its course. A necessary condition is the stabilization of central hemodynamics for the successful implementation of anesthesia and the operation itself. Within 2-3 hours for peritonitis and 6-8 hours for other variants of sepsis, the question of the possibility of performing the operation or refusing it should be resolved.
Refuse to perform surgical treatment should be in the terminal state of the patient or progressive DIC. In other cases, purulent-septic changes in the uterus itself, impaired perfusion of "target organs", pyemic foci are so significant that conservative measures never completely eliminate the infection, so patients are doomed to develop chronic sepsis or multiple organ lesions.
The operation of removing inflammatory-changed genitals presents technical difficulties. The uterus is always flabby, when clamps are applied, it is injured, abscesses in the area of the appendages, small pelvis and fiber of the parameters make it difficult to mobilize them and orient themselves with adjacent organs. Ulcers are in close proximity to the ureters, which can be compressed by abscesses. Increased bleeding sometimes makes it difficult to perform the operation in full. In addition, when the main source of infection is removed, the treatment of its complications is facilitated. With septicopyemia, after the removal of the uterus, opening, revision and drainage of pyemic foci are necessary, as well as careful care and sanitation of possible sources of formation of metastatic purulent foci (catheterized veins, drainage holes, vaginal stump, etc.).
Intensive care in the postoperative period includes:
Continuation of antibacterial therapy with broad-spectrum antibiotics in compliance with the basic rules for their use (combination of thienam, meronem, augmentin with metragil, nitrofurans, antifungal and other antiprotozoal drugs);
Intensive infusion therapy, which is carried out both during the operation and after it in the intensive care unit, taking into account the regulation of all types of metabolism (the introduction of amino acids, blood substitutes, colloidal and crystalloid solutions, proteins, sometimes blood transfusion);
Detoxification therapy: hemosorption from the second day after the operation (3-6 sessions every other day), HBO (5-6 sessions), UVR of blood from the second day after the operation daily (8-10 sessions), intravenous administration of a 5% unithiol solution with ascorbic acid 2-3 times a day in order to improve redox processes, increase the bactericidal activity of blood serum, improve tissue respiration, eliminate hypoxia, improve microcirculation, the function of parenchymal organs and intestinal motility;
The use of antihistamines (suprastin, diphenhydramine, etc.) to provide sedative, decongestant and antihistamine effects;
Increasing the body's resistance to infection by introducing antistaphylococcal
γ- globulin, antistaphylococcal plasma, polyglobulin, thymalin, T-activin, UVI blood;Continuation of hormonal therapy in decreasing doses (hydrocortisone, prednisolone) during convalescence, especially with septicopyemia;
The use of heparin at 5000 IU with an interval of 6 hours to improve the rheological properties of blood and prevent thrombus formation, as well as for anti-inflammatory purposes;
The use of cardiotonic and cardiostimulating agents (cocarboxylase, cardiac glycosides, chimes, ATP, digoxin, cytochrome C, vitamin complex) to stabilize cardiac activity and ECG parameters;
Improving intestinal motility from the first day after surgery by using agents that stimulate intestinal motility, HBO, epidural blockade, lipolytic enzymes, therapeutic exercises, good nutrition, etc .;
Continuation of infusion therapy balanced in terms of volume and composition, daily sessions of hemosorption, HBO, UVR of blood in case of developing renal failure, lack of effect from measures to force diuresis; with increasing and critical indicators of azotemia - hemodialysis sessions;
The introduction of hepatotropic agents (glutamic acid, essentiale, riboxin, corsil), choleretic agents and antispasmodics, potassium preparations, enzymes in case of acute renal failure in order to improve liver function;
Early use of general and local ultraviolet irradiation, drug electrophoresis, phonophoresis, therapeutic exercises, herbal medicine.
Rehabilitation measures at the hospital stage after a period of clinical recovery include:
Treatment of residual effects of acute renal failure, acute renal failure, pneumonia, post-thrombophlebitic syndrome, myocardial dystrophy, local infiltrates and astheno-vegetative disorders in specialized departments and rehabilitation centers for 1-1.5 months;
The appointment of hepatotropic and cardiovascular agents, vitamins, herbal medicine, physiotherapy, a complete diet, exercise therapy, which help prevent the development of chronic sepsis.
Patients with generalized forms of infection need within 3 months. in therapeutic measures aimed at preventing relapses of the disease and treating residual manifestations of sepsis (treatment by a gynecologist and other specialists - an endocrinologist, surgeon, therapist, otolaryngologist, psychiatrist, neuropathologist). The appearance of chills, high body temperature, weakness, headaches and joint pain in a patient indicates a relapse
sepsis requires urgent hospitalization and intensive care. Therapeutic measures for residual manifestations of sepsis include anti-inflammatory anti-relapse therapy, physiotherapy, phyto-, acupuncture and reflexology, restorative treatment, regulation of work and rest, spa and balneotherapy (radon and hydrogen sulfide baths no earlier than a year later).
Post-hospital rehabilitation and dispensary observation of patients. Those who have undergone localized forms of GSI need to continue anti-inflammatory treatment on an outpatient basis with the inclusion of repeated courses of physiotherapy, vitamin therapy, biostimulants, with correction of menstrual function for 2-3 months, in spa and balneotherapy (not earlier than 6 months after treatment).
All patients who have undergone a septic process should be under the supervision of a doctor at the antenatal clinic and the district clinic for 3 years. They should annually undergo an outpatient or inpatient examination (biochemical and clinical blood tests, ECG, fluorogram, bacteriological culture of urine, blood separated from the cervical canal, functional tests of the kidneys, liver).
Therapeutic measures during the dispensary observation should be aimed at the treatment of neuroendocrine disorders, disorders of menstrual and generative functions, formed organ pathology. Deregistration of the patient is carried out after 3 years in the absence of recurrence of the disease, with the restoration of working capacity and the absence of organic changes in the genital and other organs.
Case study 1
Patient K., 23 years old, was admitted to the gynecological department with complaints of moderate bloody discharge from the genital tract, mild pain in the lower abdomen, fever up to 37.5 °C. The day before there was a miscarriage during pregnancy 12-13 weeks, blood loss of about 300 ml. I didn't go to the doctor right away.
Upon admission, the patient's condition is moderate, the skin is pale, the face is hyperemic, the body temperature is 37.4 ° C, the pulse is 100 beats / min, satisfactory filling, blood pressure is 110/60 mm Hg. Art.
Vaginal examination revealed that the cervix is shortened, the cervical canal is passable for one finger behind the internal os, where the placental tissue is determined. The uterus is enlarged, its size corresponds to 11-12 weeks of pregnancy, soft, slightly painful on examination, bloody discharge, insignificant. Urination is not disturbed, diuresis is sufficient.
Doctor tactics
1. Diagnosis. The diagnosis is established on the basis of data on abortions that took place at a gestational age of 12-13 weeks, low fever, tachycardia, blood loss, the results of a special examination confirming the presence of inflammation in the uterus (endometritis), as well as on the basis of symptoms of incomplete miscarriage (structural changes in the cervix , soreness and enlargement of the uterus, the presence of internal os parts of the fetal egg, moderate bleeding).
Diagnosis: incomplete infected community-acquired abortion at 12-13 weeks' gestation.
2. The sequence of therapeutic measures. Necessary additional methods of examination (sowing from the cervical canal, urethra), clinical blood and urine tests, ultrasound. Dynamic monitoring of the general condition of the patient, blood pressure, respiratory rate and pulse rate, hourly diuresis.
The safest is a conservative-expectant method of treatment for life-threatening bleeding - emptying the uterus from the fetal egg. Sequentially held:
Intensive antibacterial preparatory therapy with two broad-spectrum antibiotics (preferably cephalosporins or semi-synthetic drugs of the penicillin group - ampicillin, ampiox in combination with aminoglycosides, gentamicin and metrogil in maximum therapeutic doses) intravenously and intramuscularly after taking swabs and biosubstrates to determine flora and sensitivity, followed by a change antibiotics according to the antibiogram;
Infusion therapy by intravenous administration of colloidal and crystalloid solutions (Ringer-Locke solutions, polyfer, rheopolyglucin, polyglucin, polyionic solutions, gemodez, polydez, albumin, dry or native plasma, protein), blood transfusion according to indications; the total amount of injected solutions is not less than 1.5-2 l;
Vitamin therapy (ascorbic acid with unithiol, B vitamins);
Desensitizing therapy (diphenhydramine, tavegil, pipolfen), tranquilizers, sleeping pills, cardiotonic drugs, bed rest;
Delayed for 12-24 hours (after stabilization of body temperature and improvement of the general condition of the patient) gentle emptying of the uterus from infected remnants or fetal egg with an abortion collet and a blunt curette using the in situ method under intravenous anesthesia (calypsol, diprivan);
Note. In case of profuse and ongoing bleeding (more than 400-500 ml), according to vital indications, the free-lying part of the fetus and curettage with a blunt curette should be immediately performed with an abortion tube, simultaneously antibacterial and infusion therapy, if necessary, blood transfusion. With a long gestation period (more than 15-16 weeks), the presence of a fetus in the uterus and the impossibility of its simultaneous emptying, without waiting for a decrease in body temperature, the patient is prescribed labor induction with intravenous administration of prostaglandins, oxytocin and antispasmodics according to the traditional scheme. At the same time, intensive therapy with small doses of corticosteroids is carried out.
Use after curettage of uterine-reducing agents (oxytocin, methylergometryl), locally - ice on the lower abdomen, bed rest.
Intensive antibacterial, infusion, restorative, anti-inflammatory therapy continues until clinical recovery and normalization of laboratory parameters. Discharge from the hospital no earlier than 12-13 days after the operation.
Case study 2
Patient R., 19 years old, during pregnancy 16 weeks, 2 days before hospitalization, introduced a soap-vodka solution into the uterine cavity through a catheter in order to terminate the pregnancy. At home, she noted repeated chills, an increase in body temperature up to 38 ° C; amniotic fluid broke. This is the first pregnancy, the menstrual cycle is not disturbed, she does not notice any diseases. Not registered for pregnancy. Upon admission, the condition was severe, body temperature was 38.7 °C, pulse was 106 beats/min, blood pressure was 110/70 mm Hg. Art., respiratory rate up to 28 per minute. The skin is pale, the abdomen is soft, painful above the womb, the liver is not enlarged, diuresis is normal.
During internal examination: we pass the canal up to 2 cm behind the internal os, the uterus is enlarged by 14-16 weeks of pregnancy, soft, painful, amniotic fluid leaks.
Blood test: Hb 102 g/l; er. 3.8 1012/l; l. 27.0 109/l; tr. 240.0 109/l; p. 12%; With. 77%; limf. 9%; mon. 2%; ESR 29 mm/h.
Urinalysis: protein 0.33 g/l, leukocytes 20-30 in p/a, hyaline cylinders 1-2 in p/a, bacteria.
Doctor tactics
1. Diagnosis. The diagnosis is established on the basis of data on intrauterine intervention with aggressive means to terminate pregnancy, a long pregnancy, fever, tachycardia, tachypnea, anemia, high leukocytosis and a shift in the blood count to the left, metroendometritis phenomena.
Diagnosis: complicated infected community-acquired abortion during pregnancy 14-16 weeks; purulent-resorptive fever.
2. The sequence of therapeutic measures. With the indicated diagnosis without signs of an obvious generalization of the process, i.e., without symptoms of septic shock, peritonitis, acute renal, hepatic and cardiopulmonary insufficiency, thrombohemorrhagic syndrome, the most sparing is expectant-active tactics with a delayed emptying by 6-8 hours uterus from an infected fetal egg or its remains.
Often, the similarity of the manifestations of HRL and septicemia allows you to clarify the diagnosis within 6-8 hours of observation of the patient. This time is sufficient to examine the patient, monitor observation, consultative examination by specialists and evaluate the results of therapy.
With expectant-active management of the patient, preoperative preoperative therapy is balanced in terms of volume and composition. Apply:
Two broad-spectrum antibiotics (augmantin, cephalosporins, cloforan, kefzol, cefamisin, aminoglycosides, semi-synthetic penicillins, metagyl) with bactericidal properties in massive doses by intravenous administration (subclavian vein catheterization is performed);
Infusion therapy in conditions of hypervolemic hemodilution with protein preparations (albumin, protein, dry native plasma), low- and high-molecular dextrans and crystalloids (hemodez, polydez, reopoliglyukin, polyglukin, gelatinol, polyionic solutions, lactosol, trisamine, hemotransfusion according to indications);
Cardiac glycosides, antihistamines, vitamins, small doses of hormones (prednisolone, hydrocortisone).
Under the condition of possible simultaneous emptying of the uterus after 6-8 hours of observation, without waiting for the normalization of body temperature and general condition, the infected fetal egg or its remnants are removed with an abortion collet and a blunt curette under short-term intravenous anesthesia (calypsol, diprivan). At the same time, the goal is to remove from the uterus a fetal egg infected with anaerobic microbes and staphylococcus, which have necrobiotic properties, as early as possible.
When the infection spreads deep into the myometrium, subsequent active antibiotic therapy makes it possible to eliminate it. At the same time, it is not possible to create a sufficient therapeutic concentration of antibiotics in the remains of the ovum. Long-term presence of these residues in the uterus can lead to a further stage of the spread of infection - sepsis.
In case of heavy bleeding in a patient, it is necessary to remove the parts of the fetus freely lying in the uterus with an abortion tse until the bleeding stops, and at the same time to carry out intensive therapy.
At long terms of pregnancy, simultaneously with intensive therapy, the patient should undergo labor induction with the introduction of prostaglandins and antispasmodics.
15-20 minutes after the operation of curettage of the uterine cavity and stabilization of hemostasis, the patient must undergo a hemosorption session in order to remove bacterial endo- and exotoxins, toxic products of tissue autolysis from the body, resorbed and entered the blood after instrumental intervention. The massive intake of these substances into the blood, as a result of a "breakthrough of the infection", often causes a picture of septicemia and septic shock.
Immediately after curettage of the uterine cavity, the patient may experience chills, fever up to 39-40 ° C, shortness of breath, acrocyanosis, tachycardia up to 120-140 beats / min, blood pressure 140-150 mm Hg. Art., oliguria. Exo- and endotoxins, having the structure of medium molecular weight oligopeptides, are well adsorbed by activated carbon granules, so hemosorption helps to prevent serious complications.
After a session of hemosorption, intensive antibacterial, infusion therapy, vitamin therapy, the introduction of immunostimulants (antistaphylococcal
γ- globulin and plasma, thymolin, decaris, etc.) until the patient's clinical recovery. The average length of stay in the hospital is 14-15 days.One session of hemosorption allows you to sanitize the main focus of infection. The reaction of the body in response to the entry of an infectious-toxic agent into the blood during instrumental intervention in the uterine cavity is stopped by the use of extracorporeal detoxification, which prevents the development of necrobiotic changes in the uterus and other organs and allows the young woman to preserve specific functions.
Case study 3
Patient G., aged 32, has a history of 2 births and 2 medical abortions. 9 days before admission during pregnancy 5-6 weeks, a catheter was inserted into the uterus for 12 hours. During the week, she was treated by a therapist about intercostal neuralgia. Body temperature increased to 38.5 °C, diuresis decreased a day before admission.
The patient was taken to the hospital in serious condition: body temperature 41.5 °C, euphoria, pale skin with acrocyanosis, pulse 130-140 beats/min, respiratory rate 28-30 per minute, blood pressure 90/60 mm Hg. Art., hard breathing in the lungs, wheezing, the liver is enlarged by 1.5 cm, diuresis is reduced (for 3 hours of observation, 100 ml of urine was released against the background of infusion), severe headache. The uterus is enlarged up to 7 weeks of pregnancy, soft, painful, the cervical canal is open by 1 cm, purulent-bloody moderate discharge.
Blood test: Hb 94 g/l; l. 20.0 109/l; p. 16%; With. 75%; mon. 4%; limf. 5%; ESR 45 mm/h. Hypoproteinemia (50.1 g/l), hypokalemia (2.2 mmol/l), bilirubinemia (14.2 µmol/l), urea 4.2 mmol/l, creatinine 121 mmol/l.
Urinalysis: protein 0.033%, l. 40-50 in l / sp.
Doctor tactics
1. Diagnosis The diagnosis is established on the basis of the hectic nature of temperature, tachycardia, tachypnea, hypotension, oliguria, toxic anemia, criminal intervention in the uterus during 7 weeks of pregnancy, metroendometritis phenomena.
Diagnosis: incomplete septic miscarriage during pregnancy 7 weeks, metroendometritis, oliguria, septicopyemia.
2. The sequence of therapeutic measures. For 6 hours, the patient underwent intensive therapy: kefzol, kanamycin; infusion therapy in the amount of 3.5 liters with forcing diuresis, hormones, cardiotonic drugs. The patient's condition progressively worsened: intoxication, oliguria increased, hypotension persisted. In this regard, 6 hours after admission, the uterus was extirpated with the removal of the fallopian tubes and drainage of the abdominal cavity.
Within 10 days after the operation, the patient's condition was severe due to severe intestinal paresis, septic pneumonia, exudative pleurisy, and electrolyte disturbances. Until the 17th day, the state of moderate severity persisted, phlebitis of the veins of the left leg, pericarditis joined, there was a partial divergence of the sutures (with secondary tension). In addition to intensive care, in the postoperative period, the patient received 2 sessions of hemosorption, 4 sessions of HBO and 6 sessions of ultraviolet blood.
Staphylococcus aureus sensitive to kanamycin, chloramphenicol, streptomycin was isolated from the uterus and cervical canal in bacterial cultures. Antibiotics were changed based on the antibiogram.
Morphological picture: purulent metroendometritis, remnants of necrotic placental tissue, phlebothrombosis of the uterine veins.
At the prehospital stage, patient G., who had an infected criminal abortion, was diagnosed with intercostal neuralgia, and therefore she received inadequate therapy for a week. Apparently, she already had septic pneumonia. Shortness of breath, tachycardia, wheezing on auscultation, severe condition of the patient on admission, enlargement of the liver, oliguria, anemia, local purulent metroendometritis indicated a septic process, for which a radical removal of the uterus, the main source of infection, was undertaken. Energetic intensive therapy with the use of hemosorption, HBO and UVR of blood was required to eliminate the complications that arose. The presence of several pyemic foci (septic pneumonia, pericarditis, phlebitis of the leg veins, suppuration of the wound) created a danger to life. However, the use of detoxification methods, immunostimulation with antistaphylococcal plasma, blood transfusion, UVI of blood made it possible to quickly stop complications and discharge the patient on the 24th day in a satisfactory condition.
