Endometritis acute postpartum treatment. What is endometritis? Treatment of Postpartum Endometritis

Frequency postpartum endometritis in the general population of puerperas is from 2.6 to 7%, and in the structure of postpartum purulent-inflammatory diseases - more than 40%. Postpartum endometritis most often occurs in a mild form and ends with recovery. However, in approximately 1/4 of observations, a severe course of this complication is noted, accompanied by purulent-resorptive fever and the possibility of generalization of infection.

Postpartum endometritis should be considered a manifestation of a wound infection, since the inner surface of the uterus after separation of the placenta is an extensive wound surface. Epithelialization and regeneration of the endometrium ends only 5-6 weeks after birth. The process of endometrial repair in the postpartum period is a wound healing characterized by a number of histological features.

What provokes / Causes of Postpartum Endometritis:

Currently, the leading role in the etiology of postpartum endometritis belongs to associations of opportunistic microorganisms. Among facultative anaerobes, the most common pathogens are gram-negative bacteria of the family Enterobacteriaceae (Escherichiicoli, Klebsiella, Proteus). In 25-60% of cases, bacterial cultures of puerperas with endometritis contain Gardnerellavaginalis. The proportion of Gram-positive cocci has increased, such as Streptococcus group D (37-52%). S. aureus, on the contrary, it is quite rare (in 3-7% of cases).

Obligate anaerobic non-spore-forming microorganisms are often detected. These include bacteroids and gram-positive cocci: peptococci and peptostreptococci.

This complication is often caused by Mycoplasmahominis, Ureaplasmaurealyticum and Chlamydiatrachomatis.

Symptoms of postpartum endometritis:

Light form begins relatively late, on the 5-12th day of the postpartum period. Body temperature rises to 38-39 °C. Occasionally, chills are observed at the first rise in temperature. The pulse quickens to 80-100 beats / min, and its increase corresponds to a rise in temperature. On the part of the blood picture, leukocytosis is noted in the range of 9.0-12.0-109/l, a slight neutrophilic shift, and an increase in ESR to 30-50 mm/h. The content of total blood protein and residual nitrogen remains within normal limits. The general well-being of puerperas does not significantly suffer. Patients have soreness of the uterus, which persists for 3-7 days. The size of the uterus is somewhat increased, and the lochia remains bloody for a long time. The assessment of the severity of the patient's condition and the effectiveness of complex treatment is based on the results of dynamic monitoring over the next 24 hours. At the same time, hemodynamics, respiration, urination, the condition of the uterus, the nature of lochia, and laboratory data are monitored.

Severe form begins, as a rule, earlier, on the 2-4th day after birth. At the same time, in almost 1/4 of cases, this complication develops against the background of chorionamnionitis, after complicated childbirth or surgery.

With dynamic observation in patients with severe form of postpartum endometritis, there is no improvement per day, and in a number of observations there is even a negative dynamics of the process. The patient is worried about headaches, weakness, pain in the lower abdomen. There is a violation of sleep, appetite, tachycardia up to 90-120 beats / min. Body temperature often rises to 39 ° C and above, accompanied by chills. The number of leukocytes rises to 14.0-30.0. 109/l, ESR increases from 15 to 50 mm/h. All patients have a neutrophilic shift, anemia and arterial hypotension are often noted.

On examination, soreness and slowing of uterine involution are revealed. Lochia from 3-4 days become brown and later acquire a purulent character.

After the start of treatment, body temperature usually returns to normal within 2-4 days.

The disappearance of pain on palpation and the normalization of the nature of the lochia occur by the 5-7th day of treatment. The blood picture improves by the 6-9th day.

However, most often in practice, the clinical picture of the disease does not reflect the severity of the patient's condition. Postpartum endometritis has an erased character, and its identification presents certain difficulties.

Erased form can occur both after spontaneous and after surgical delivery. The disease often begins on the 3-4th day. In some patients, postpartum endometritis may begin to appear both on the 1st day and on the 5-7th day after childbirth. In most patients, the body temperature does not initially exceed 38 ° C, and chills are rarely observed. There is leukocytosis in the blood up to 10.0-14.0 * 109/l and an increase in ESR up to 16-45 mm/h. In more than half of the cases, there is no neutrophilic shift, while in the rest it is weakly expressed. In most patients, the lochia is brown at the beginning, turns into sanious and, in some cases, purulent with a specific ichorous odor. Soreness of the uterus persists for 3-8 days, and sometimes continues until the 14th-16th day of the disease.

Against the background of the treatment, body temperature returns to normal within 5-10 days. However, in some patients, subfebrile temperature can persist up to 12-46 days. The involution of the uterus is slowed down. Normalization of the blood picture most often occurs on the 6-15th day of the disease.

Often, after normalization of body temperature and improvement of the blood picture, the disease recurs with the same clinical signs as at the beginning, and lasts from 2 to 8 days.

The erased form of postpartum endometritis can also lead to generalization of infection against the background of underestimation of the severity of the patient and inadequate therapy.

Distinguish abortive form , which manifests itself on the 2-4th day. A distinctive feature of this form is that with the onset of intensive treatment, all symptoms of the disease completely disappear. The average duration of the abortive form is 7 days.

Postpartum endometritis after caesarean section . The frequency of this complication after caesarean section largely depends on the urgency of the operation. After a planned caesarean section, the frequency of endometritis is 5-6%, and after emergency abdominal delivery - from 22 to 85%.

Postpartum endometritis after cesarean section most often occurs in severe form due to the fact that there is a primary infection of the area of ​​the restored incision on the uterus and the rapid spread of the inflammatory process beyond the mucous membrane, followed by the development of myometritis, lymphadenitis and metrothrombophlebitis. Under conditions of inflammation, reparative processes in the dissected wall of the uterus are disrupted, the suture material in some cases also contributes to the spread of infection to the myometrium and small pelvis. In addition, the contractile activity of the uterus is also reduced, which makes it difficult for the outflow of lochia.

The disease often begins on the 1st or 2nd day after surgery, and in some cases on the 4th or 5th day. Body temperature rises to 38-39 ° C or more, accompanied by chills and tachycardia. In some patients, subfebrile temperature is also observed. An increase in heart rate usually corresponds to a rise in body temperature. From the side of the blood picture: there is an increase in ESR from 26 to 45 mm / h; the number of leukocytes ranges from 14.0 * 109 / l to 30.0 * 109 / l, all patients have a neutrophilic shift in the leukocyte count of the blood and anemia often develops. Such changes in the blood indicate the presence of a pronounced infectious process. An increase in body temperature in most patients is accompanied by headaches, weakness, sleep disturbance, appetite, pain in the lower abdomen. Involution of the uterus in postpartum endometritis after caesarean section is slow. Lochia by the 4-6th day become cloudy, abundant, watery, sometimes have the color of meat slops or take on a purulent character. Discharge from the uterus becomes normal by the 9-11th day. The blood picture returns to normal only by the 10-24th day after the operation.

Postoperative postpartum endometritis can be complicated by intestinal paresis, especially in patients who have experienced large blood loss during surgery, which has not been adequately replenished.

In patients with endometritis after caesarean section, there is a decrease in the function of the ACTH system - glucocorticosteroids. Insufficiency of glucocorticoid function, in particular, is a prerequisite for the generalization of infection. At the same time, there are violations of the sympathetic-adrenal system and changes in the histamine - histaminase system with an increase in histamine production. At the same time, disturbances in hemodynamics and microcirculation, water and electrolyte balance and hormonal homeostasis develop. There are signs of hypovolemia, hypoproteinemia and hypokalemia. The resulting metabolic disorders can cause a clinical syndrome accompanied by intestinal paresis and intoxication. Hypokalemia contributes to the development of disorders of micro- and macrocirculation in the organs of the gastrointestinal tract. With severe intestinal paresis, microcirculation disturbance causes not only changes in the absorption capacity of its wall, but also the barrier function of the intestine with the penetration of microbial flora into the abdominal cavity, which contributes to the development of peritonitis.

In a number of observations, there is swelling of the postoperative suture, which contributes to the retention of blood clots, remnants of membranes and placental tissue in the cavity and creates conditions for prolonged resorption of bacterial and tissue toxins. In this case, local signs of inflammation may not be expressed. This situation, especially with inadequate therapy, is fraught with the risk of relapses in combination with other complications (adnexitis, parametritis, divergence of the postoperative suture, development of peritonitis).

Depending on the severity of the adaptive-compensatory reactions of the body, postpartum endometritis can be:

• compensated;
• subcompensated;
• decompensated character.

Compensated endometritis characterized by intrauterine localization of the focus of infection with sporadic short-term inclusion of general adaptive mechanisms. It is also characterized by short-term (no more than 3 days) resorptive fever, there are no signs of subinvolution of the uterus, a decrease in the pH of the uterine contents and an increase in the proportion of macrophages are noted.

Subcompensated endometritis accompanied by more significant damage to the uterus with the obligatory connection of general compensation mechanisms and their reversible changes. This form of endometritis includes:

• endomyometritis after caesarean section;
• endomyometritis with involvement in the inflammatory process of the surrounding tissue, uterine appendages;
• endomyometritis, which develops in the presence of additional local purulent foci in the body, contributing to the weakening of the general mechanisms of resistance, or against the background of the initial multiple organ failure;
• endomyometritis with a protracted course and clinically mild local and general manifestations.

The subcompensated form is characterized by the presence of high fever, which does not decrease during the therapy, there is a pronounced subinvolution of the uterus, metabolic acidosis of the intrauterine environment.

Decompensated endometritis characterized by the transition to severe forms of postpartum purulent-inflammatory diseases (peritonitis, sepsis, septic shock) and is accompanied by irreversible damage to organs, significant violations of general adaptive mechanisms.

Diagnosis of postpartum endometritis:

Considering the possibility of developing obliterated forms postpartum endometritis, a comprehensive assessment of the severity of the condition of puerperas should be carried out based on an assessment of clinical data (body temperature, respiration, hemodynamics, urination, etc.) and laboratory results (indicators of immunity, water-electrolyte and protein metabolism, CBS).

It is also necessary to carry out microbiological control and assessment of the state of the uterus (ultrasound, hysteroscopy).

The most characteristic are the following clinical diagnostic criteria:

• repeated rise in temperature over 37.5 ° C from 2 days after delivery;
• soreness and pastosity of the uterus on palpation;
• purulent lochia.

At echographic study come to light:

• violations of the processes of involution of the uterus;
• enlargement and expansion of the uterine cavity;
• various in size and echogenicity inclusions in the uterine cavity;
• linear echo-positive structures on the walls of the uterus in the form of an intermittent or continuous contour, representing the imposition of fibrin;
• heterogeneity of the structure of the myometrium;
• strengthening of the vascular pattern, the appearance of sharply dilated vessels, mainly in the region of the posterior wall of the uterus;
• accumulation of gas in the uterine cavity.
• In the presence of postpartum endometritis after cesarean section, additional echographic diagnostic signs appear:
• local change in the structure of the myometrium in the area of ​​​​sutures in the form of areas of reduced echogenicity;
• deformation of the uterine cavity in the area of ​​the scar ("niche") with the failure of the suture on the uterus;
• lack of positive dynamics in the presence of hematomas in the projection of the postoperative suture;

Hysteroscopy along with visualization of the endometrium and a direct assessment of its condition, it makes it possible to detail the nature of pathological inclusions in the uterine cavity (blood clots, suture material, membranes, decidual or placental tissue, gas). The information content of hysteroscopy as an early diagnostic method is about 90%.

With postpartum endometritis, a fairly characteristic hysteroscopic picture is observed. The mucous membrane is edematous, cyanotic with a large number of injected, easily bleeding vessels and foci of hemorrhages.

On the walls of the uterus, a whitish plaque (fibrin deposits) is determined due to fibrinous inflammation, the severity of which depends on the duration and severity of the complication, sometimes with an admixture of pus. There are bleeding areas of rejection and small areas of yellow-orange regeneration in the area of ​​the tubal angles and fundus of the uterus. Forming synechiae may be visible.

In the presence of necrosis of the decidual tissue, amorphous layers of a grayish-black color, stringy in nature, of various sizes, lying parietal and free in the uterine cavity, are determined.

If postpartum endometritis was caused by retention of placental tissue, then the study reveals a stranded structure with a bluish tint, which sharply contours and stands out against the background of the walls of the uterus. Blood clots are visualized as oval, rounded black structures.

In the event of failure of the suture on the uterus after cesarean section, a defect in the postoperative suture in the form of a niche is revealed during hysteroscopy. In places, cut or loose threads of the suture material and gas bubbles in the area of ​​the defect in the suture are visible.

Laboratory diagnostic methods:

Clinical and biochemical analysis of blood. The most characteristic changes in peripheral blood parameters in postpartum endometritis:

• leukocytosis 12.0 * 109/l and more;
• stab neutrophils 10% or more;
• hypochromic anemia;
• increase in ESR;
• decrease in the level of total plasma protein.

bacteriological research. A reliable sign of developed postpartum endometritis is the release of etiologically significant microorganisms in an amount equal to or more than 104 CFU / ml.

There is a direct relationship between the degree of microbial contamination and the severity of the clinical course of the process. With an uncomplicated course of the postpartum period, the contamination rate is 103 CFU / ml. In severe cases of endometritis, the rate of contamination of the uterine cavity is more often noted in the range of 105-108 CFU / ml.

Treatment of postpartum endometritis:

Treatment should be complex and aimed at localizing the inflammatory process, fighting infection, activating the body's defenses, detoxifying and correcting homeostasis. Before starting treatment, material from the uterine cavity and vagina is taken for sowing to determine the nature of the causative agents of the complication and their sensitivity to antibiotics.

Integral components of the complex conservative treatment of postpartum endometritis are antibacterial, infusion and detoxification therapy, the use of uterine contracting agents, desensitizing and restorative therapy. To limit inflammation and activate the body's defenses, a therapeutic and protective regimen and sedative therapy are prescribed, which contributes to the normalization of the state of the central nervous system. The patient must be protected from negative emotions and pain. A nutritious diet with a high content of proteins and vitamins is important.

Antibacterial therapy. When prescribing antibiotic therapy, it should be borne in mind that infection with bacterial associations leads to the development of postpartum endometritis. It must be remembered that there are a number of strains of resistant bacteria, and in this regard, prescribe those drugs for which resistance is low. When obtaining the results of microbiological studies, it is necessary to use those antibiotics to which the detected microflora is most sensitive. In the focus of infection, a concentration of the drug should be created that suppresses the growth and development of microflora.

Antibacterial therapy regimens are as follows.

Main mode:lincomycin group(lincomycin or clindamycin) in combination with aminoglycosides (gentamicin, etc.).

Alternative Modes:

• II-IV generation cephalosporins (cefuroxime, cefotaxime, ceftriaxone, cefoperazone) in combination with metronidazole or antibiotics of the lincomycin group (lincomycin or clindamycin).
• Fluoroquinolones (ciprofloxacin or ofloxacin) in combination with metronidazole or antibiotics of the lincomycin group (lincomycin or clindamycin).
• Carbapenems.

In late endometritis, additional oral administration of doxycycline or macrolides (azithromycin once, erythromycin, clarithromycin or spiramycin) is necessary.

Treatment can be completed 24-48 hours after clinical improvement. Further oral administration of drugs is not required, except in cases of late postpartum endometritis.

Breastfeeding during antibiotic therapy is generally not recommended.

• Combination of penicillins with β-lactam antibiotics:
  • Augmentin in a single dose of 1.2 g is administered intravenously 4 times a day. During hysteroscopy, 1.2 g is administered intravenously;
  • unazine in a single dose of 1.5 g is administered intramuscularly 4 times a day.
• II generation cephalosporins in combination with nitroimidazoles and aminoglycosides:
  • cefuroxime (zinacef, cefogen, ketocef) in a single dose of 0.75 g is administered intravenously 3 times a day;
  • metrogil in a single dose of 0.5 g is administered intravenously 3 times a day;
  • gentamicin in a single dose of 0.08 g intramuscularly 3 times a day.

During hysteroscopy, 1.5 g of cefuroxime and 0.5 g of metrogil are administered intravenously.

• I generation cephalosporins in combination with nitroimidazoles and aminoglycosides:
  • cefazolin in a single dose of 1 g is administered intramuscularly 3 times a day;
  • metrogil in a single dose of 0.5 g 3 times a day, intravenously;
  • gentamicin in a single dose of 0.08 g is administered intramuscularly 3 times a day.

During hysteroscopy, 2 g of cefazolin and 0.5 g of metrogil are administered intravenously.

In severe cases of endometritis, thiens are prescribed intravenously at 500 mg 3-4 times a day.

For the prevention of candidiasis and dysbacteriosis, the treatment regimen for postpartum endometritis includes nystatin 500,000 IU 4 times a day, levorin 250,000 IU 4 times a day.

After the end of antibiotic therapy, it is necessary to correct the biocenosis of the vagina and intestines with therapeutic doses of probiotics (bifidumbacterin, lactobacterin, acilact, 10 doses 3 times a day for 7-10 days), growth stimulants of the normal intestinal microflora (Hilak Forte, 40-60 drops 3 times per day for a week), enzymes (festal 1-2 tablets, mezim forte 1-2 tablets at each meal).

Surgery. Surgical treatment of the uterine cavity includes hysteroscopy, vacuum aspiration of the contents of the uterus, washing its cavity with cooled solutions (8-10 ° C) of antiseptics (furatsilin, 1% dioxidine, sodium hypochlorite in a volume of 1200 ml).

Washing the uterine cavity solutions of antiseptics are recommended to reduce the absorption of decay products and toxins in case of severe violations of the processes of involution, the presence of abundant and pus-like secretions, or when the latter are delayed. The procedure is performed no earlier than 4-5 days after childbirth through the natural birth canal and 5-6 days after caesarean section.

Contraindications for washing the uterine cavity are:

• postpartum endometritis after caesarean section with signs of uterine suture failure;
• beginning or developing peritonitis;
• the presence of purulent-inflammatory diseases in the pelvic area outside the uterus;
• extremely severe general condition of the patient, septic shock.

Before starting the procedure, the puerperal is placed on the gynecological chair; produce treatment of the external genital organs; the cervix is ​​exposed with the help of mirrors, treated with Lugol's solution; the contents of the uterine cavity are aspirated with a Brown syringe for bacteriological examination; conduct careful probing to determine the length of the uterine cavity; the drainage and supply tubes connected together are inserted through the cervical canal into the uterine cavity. It is important that the supply tube is inserted to the bottom of the uterus, which contributes to the full and uniform irrigation of the endometrial surface. In patients with postpartum endometritis after caesarean section, the tubes should be passed with extreme care along the anterior wall of the uterus so as not to damage the sutures in the lower segment. After the insertion of the inflow tube to the bottom of the uterus, the outflow holes on the drainage tube should be located above the area of ​​​​the internal os. A vial with a sterile solution of furacilin at a dilution of 1:5000 is placed in a freezer 2-3 hours before use until the first ice crystals form in it, which indicates a decrease in temperature in it to +4 ° C. The first portion of the cooled solution is injected in a stream for 20 minutes to quickly remove the liquid contents of the uterine cavity and achieve a hypothermic effect. After clarification of the washing liquid, the solution injection rate is set to 10 ml/min. One procedure requires 2.5-3.5 liters of solution. The total duration of washing is 1.5-2 hours. During the procedure, the general condition of the patient and hemodynamic parameters (pulse, blood pressure) should be monitored. It is necessary to constantly monitor the free outflow of fluid from the uterine cavity. After the end of the introduction of furacilin through the supply tube, 20-30 ml of a 1% dioxidine solution or a single dose of the antibiotic used in this patient with novocaine (0.25% solution) or with 0.9% sodium chloride solution can be injected into the uterine cavity.

The general course is from 2-3 to 5 procedures, which can be carried out daily or after the 3rd procedure - every other day. Against the background of washing the uterine cavity, in a number of cases, the use of only a 3-5-day course of antibiotic therapy with antibiotic-my-synergists is sufficient. The main criteria for deciding whether to cancel the procedure are improving the patient's well-being, reducing tachycardia, normalizing body temperature, blood indicators, stopping pain and progressive uterine contraction. After washing is canceled, the puerperal woman continues to carry out general strengthening and non-specific anti-inflammatory therapy for 3-5 days. The absence of a recurrence of the disease, the progressive improvement of the patient's condition, the disappearance of local signs of the inflammatory process against the background of the normalization of laboratory parameters indicate the recovery of the patient.

With a delay in the uterus of parts of the fetal egg and their further infection, there is a danger of toxins and biologically active substances entering the patient's body from the focus of infection, contributing to the growth of intoxication and the aggravation of the course of the disease. In this case, measures should be taken to remove them by scraping or vacuum aspiration. The latter is preferred due to the lower risk of interference. Removal of parts of the placenta is advisable in patients with a limited inflammatory process, while the infection is within the uterus. With a wider prevalence of the process and generalization of infection, instrumental exposure is contraindicated. Removal of parts of the afterbirth is carried out under general anesthesia, under the control of hysteroscopy, against the background of the complex use of antibiotics, infusion, detoxification and desensitizing therapy.

In the absence of a significant amount of contents in the uterine cavity, it can be limited only to the expansion of the cervical canal under anesthesia to create a reliable outflow.

Surgical treatment of the uterine cavity in postpartum endometritis after spontaneous childbirth can reduce the bacterial contamination of the uterine cavity. The effectiveness of surgical treatment practically does not depend on the degree of initial bacterial contamination.

Infusion and detoxification therapy. Infusion therapy is designed to restore normal hemodynamics by eliminating hypovolemia, which often occurs in postpartum purulent-inflammatory diseases, and especially in puerperas who have undergone preeclampsia, increased blood loss during childbirth or surgery.

It is advisable to compare the volume and composition of infusion therapy with the data of colloid osmotic pressure and osmogram parameters. On average, the volume of intravenous infusions is up to 1000-1500 ml per day for 3-5 days.

The following are used as components of infusion therapy:

• crystalloids and correctors of electrolyte metabolism (5% and 10% glucose solutions, lactasol, isotonic sodium chloride solution, disol, acesol);
• plasma-substituting colloids (hemodez, reopoliglyukin, gelatinol, infucol HES 6% or 10%);
• protein preparations (FFP, 5%, 10% and 20% albumin);
• drugs that improve the rheological properties of blood (trental 10 ml, chimes 4 ml, adding to infusion media).

In the hyperoncotic state, the ratio between colloidal and crystalloid solutions should be 1:2-1:3.

In normooncotic and hypooncotic conditions, this ratio should be 1:1. In the latter case, preference should be given to more concentrated solutions of albumin. The total volume of infusion therapy per day is 2.0-2.5 liters. With an increase in body temperature of more than 37 ° C for each degree, it is recommended to increase the volume of infusion therapy by 10%.

The water and electrolyte balance should be monitored, taking into account the amount of fluid administered under the control of diuresis.

Treatment of intestinal paresis and prevention of paralytic ileus. A special place among these therapeutic measures is the restoration of electrolyte balance. Elimination of hypokalemia, improvement of blood circulation due to moderate hemodilution and the use of vasodilators can avoid a severe outcome. Nasogastric catheterization should be an early and ongoing intervention. With developed intestinal paresis, the use of hypertonic solutions in an enema is contraindicated. By replacing potassium ions, sodium exacerbates hypokalemia and contributes to the progression of paresis. To restore the function of the intestine and empty it, the safest thing is to aspirate its contents through a probe, which is first introduced into the stomach and then passed into the small intestine.

extracorporeal methods. In severe forms of postpartum endometritis, plasmapheresis may be used. The main mechanism of its therapeutic action is the removal of pathological plasma ingredients, cryoglobulins, microbes and their toxins. In addition, there is a pronounced positive effect on the hemostasis system, rheological properties of blood, the state of the immune system, which greatly improves the course of the postpartum period in women with postpartum endometritis and accelerates reparative processes in the uterus.

Desensitizing and antihistamine therapy. With purulent-inflammatory diseases in the body, the content of free histamine and histamine-like substances increases. In addition, antibiotic therapy can also be accompanied by allergic reactions. In this regard, it is recommended to include antihistamines in the complex of therapy for postpartum endometritis. Diphenhydramine is used at 0.05 g 2 times a day orally or 1 ml of a 1% solution 1-2 times a day intramuscularly. Suprastin 0.025 g 2 times a day orally or 1 ml of a 2% solution 1-2 times a day intramuscularly.

Uterotonic funds. Given that in the presence of postpartum endometritis, there is a violation of the contractile activity of the myometrium, it is necessary to prescribe means that reduce the uterus. It also contributes to a better outflow of lochia, a reduction in the wound surface, and reduces the absorption of decay products during the inflammatory process. For this purpose, it is necessary to introduce 1.0 ml (5 IU) of oxytocin intramuscularly 2-3 times a day or intravenously drip with 5-10% glucose solution 200.0 ml or isotonic sodium chloride solution.

Immunocorrective drugs. Assign thymalin or taktivin 10 mcg daily for 10 days, rectal suppositories "Viferon" 500,000 IU 2 times a day for 5 days.

Vitamin therapy. Considering that purulent-inflammatory diseases are accompanied by the development of hypovitaminosis, and also that the use of antibiotics against the background of an infectious process leads to a decrease in the content of vitamins in the body, appropriate therapy is carried out with vitamins C at 250-300 mg and group B (B6 - 50 mg).

Drugs that accelerate reparative processes. Apply actovegin 5-10 ml intravenously or solcoseryl 4-6 ml intravenously drip for 5 days.

Physiotherapeutic methods of treatment.Therapy with interference currents according to Nemek. It is based on the use of low and medium frequency currents (about 4000 Hz) in two independent circuits using four electrodes. Low-frequency interference currents have a distinct, rapidly onset analgesic effect, improve the functional state of the neuromuscular system and peripheral circulation, promote vasodilation, accelerate and improve metabolism. In addition, rapid resorption of edema of various origins, including traumatic ones, is ensured. Carrying out after cesarean section physioprophylaxis of subinvolution of the uterus and postpartum endometritis by interference currents according to Nemek allows to achieve the same results as with the appointment of drug uterotonic therapy. However, the possibility of reducing the drug load on the body of puerperas and reducing the total cost of the treatment makes it more reasonable to use physical methods for preventing uterine subinvolution.

Low frequency impulse currents, galvanization areas of the mammary glands constant low frequency magnetic field it is recommended to use after stopping the inflammatory reaction of the body for the purpose of early rehabilitation, elimination of the asthenic condition, to enhance the contractility of the uterus.

Acupuncture. Recently, the method has become more and more widespread. A beneficial effect of acupuncture on the hemostasis system in puerperas with postpartum endometritis has been proven, a positive effect on the state of activity of factors of nonspecific resistance of the body, an immunostimulating effect has been noted.

External and intracavitary irradiation with a low-intensity laser. Laser irradiation has the following favorable properties: general stimulating, anti-inflammatory, analgesic, immunostimulating, contributes to the normalization of microcirculation, reduces intracellular and interstitial tissue edema, stimulates metabolic processes and local protective factors, reduces the pathogenicity of individual strains of microorganisms, expands the spectrum of microorganism sensitivity to antibiotics.

The effectiveness of complex intensive care for postpartum endometritis should be evaluated no earlier than 7 days after the start of treatment. In the absence of the effectiveness of the therapy, even against the background of a satisfactory state of health of the patient, but persistent clinical and laboratory signs of inflammation, it is necessary to decide on the removal of the uterus.

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Childbirth for every woman is an exciting and touching moment. The first days of a baby's life are happiness for everyone. But unfortunately not always...

The postpartum period can be saddened by alarming symptoms on the part of the puerperal, most often a high temperature, indicating the development of a particular infection.

The prevalence of infections in the postpartum period is difficult to quantify. It is known that inflammation of the uterus occurs in 5-7% of puerperas after caesarean section, but the real prevalence remains underestimated.

In a Cochrane review (2012), endometritis was identified in 1-3% of cases after vaginal delivery. Postpartum endometritis after caesarean section occurs 5-10 times more often.

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1. Introduction to terminology

Inflammation of the endometrium in the postpartum period is the most common infection of the uterus. Postpartum endometritis (endomyometritis) refers to an infection of the decidua (i.e. the endometrium after pregnancy).

With endometritis, inflammation is limited to the uterine mucosa, but this situation is extremely rare, since the endometrial layer is very thin and does not prevent the spread of the inflammatory process to nearby layers of the uterus and tissues.

The infection can also spread to the myometrium (called endomyometritis) or the parametrium (called parametritis).

Endomiometritis affects both the endometrium and myometrium, the infection can progress beyond the uterus and provoke the development of an abscess, peritonitis, even pelvic thrombophlebitis.

This condition is historically called puerperal fever, in which early (within 24-48 hours) and late (more than 48 hours after birth) variants are distinguished.

Fever is often the first symptom of endometritis after childbirth, it is combined with soreness of the uterus, bleeding, and an unpleasant smell of vaginal discharge.

The infection can progress and provoke systemic inflammatory response syndrome and sepsis. The starting point of inflammation of the upper genital tract is almost always the cervix.

It is the cervix that is the "barrier" in the area of ​​​​the internal uterine os, due to which the uterine mucosa is protected from infection.

Any violation of this barrier, either naturally (childbirth, miscarriage, menstruation) or through medical intervention (curettage, probing of the uterine cavity, hysteroscopy, hystero-/radiography, trauma to the uterine cavity, catheterization of the tubes, intrauterine contraception, if an abortion is performed incorrectly) increases the risk of penetration infections in the uterine cavity.

Most often this happens after childbirth, when bacteria living in the vagina gain access to the upper genital tract.

Postpartum endometritis is manifested by body temperature ≥38.0 degrees Celsius during any 2 of the first 10 days after delivery, but not the first 24 hours.

The first 24 hours are not taken into account, as low-grade fever, that is, temperatures up to 38 degrees Celsius, is common during this period. It often resolves spontaneously, especially after vaginal delivery.

Other scientists define endometritis as a condition that includes a temperature of 38.5 ° C or more within a day after childbirth, or 38 C or higher for at least 4 hours in a row after that.

Endometritis can be a component of post-surgical wound infection, but can also occur after vaginal delivery.

The inner surface of the postpartum uterus in this case is a kind of extensive wound, the healing of which occurs in accordance with general biological laws.

The cleansing of the inner surface of the uterus through inflammation is replaced by epithelialization and regeneration of the endometrium.

2. Predisposing factors

Risk factors important for the development of postpartum endometritis include a long period between rupture of membranes and delivery, infection with group A or B streptococci, chorioamnionitis, prolonged surgery, bacterial vaginosis, fetal monitoring with intravaginal sensors, frequent vaginal examinations.

What else increases the likelihood of developing endomyometritis?

Of course, the accumulation in the cavity of the postpartum uterus of blood, which is an excellent breeding ground for bacteria. If there were genital tract infections before or during childbirth, there will almost always be endomyometritis, but there is a chance to prevent it with timely antibiotic therapy.

Progesterone depresses the immune system, and a decrease in immunity, which is aggravated by blood loss during childbirth, is a favorable background for endomyometritis. In some cases, voluntarily or on medical advice, the puerperal has to give up breastfeeding, and this is reflected in a decrease in uterine contractility.

Diabetes mellitus, long-term use of various steroid drugs, obesity, smoking addiction, and chronic infections during pregnancy, such as intrafetal bladder infection and vaginal dysbiosis, are discussed as preoperative risk factors for the development of an inflammatory process.

The duration of the surgical intervention and the use of suture material further increases the risk of an infectious process in the area of ​​the postoperative wound.

Risk factors for the development of endometritis after childbirth are also previous pregnancies, low social status, decreased immunity, chronic inflammatory processes in the female genital organs, infectious pathology outside the genital organs, and a variety of somatic diseases of the pregnant woman.

There are also risk factors associated with the course of this pregnancy, namely: preeclampsia, the threat of miscarriage, exacerbation of chronic diseases, anemia. The most significant risk factors associated with the moment of delivery are: the duration of labor, the anhydrous period, various anomalies of labor, frequent vaginal examinations, increased blood loss, trauma to the birth canal, operations (caesarean section).

3. Main pathogens

A characteristic feature of modern endomyometritis is its polyetiology, that is, endomyometritis is caused by many causative agents.

Endomiometritis can be caused by opportunistic bacteria, various mycoplasmas, occasionally chlamydia, even less often viruses, etc.

Staphylococcus aureus is the most common cause of postoperative wound infection in obstetrics, but gram-negative rods, enterococci, group B streptococci, and anaerobes are also significant pathogens in obstetric operations.

In the vast majority of observations, the causative factor is several microorganisms that make up the microflora of the genital tract in women: Enterococcus faecalis, Escherichia coli, Bacteroides fragilis.

Less commonly, these are bacteria of the genera Enterobacter, Proteus, Klebsiella, Fusobacterium, Peptococcus, Streptococcus, Peptostreptococcus, Staphylococcus, etc. Chlamydia trachomatis occasionally causes late forms of endomyometritis, that is, developing in a month ̶ a month and a half after birth.

Even cases of postpartum endometritis caused by the causative agent of tuberculosis are described.

The spread of infection in postpartum endomyometritis is possible in the following ways:

1. 1 ascending (through the cervix);
2. 2 Hematogenous (through blood vessels);
3. 3 Lymphogenic (through the lymphatic system, which is facilitated by extensive endometrial defects and trauma to the genital organs);
4. 4 Intra-amniotic (as a result of invasive research methods) ways.

Most authors distinguish three variants of the course of postpartum endomyometritis, which correspond to various forms of local damage to the uterus: the so-called "pure" endomyometritis, endomyometritis with decidual tissue necrosis, endomyometritis with retained placental tissue.

4. Symptoms of postpartum endometritis

Endometritis, which develops in the presence of placental tissue in the uterine cavity, is formed by the seventh day and later, is characterized by less pronounced clinical symptoms.

More pronounced symptoms of intoxication and a more severe course of the disease are observed with endometritis without ultrasound signs of tissue remnants ("clean" endometritis).

Pain is often the first sign of an infection. Deep hematomas or seromas may begin to ooze from the surgical wound or be detected as a fluctuating area near the incision. A deeper infection may be seen on ultrasound after surgery as a patch of fluid or gas in the pelvis.

Treatment of wound complications includes antibiotic therapy and sanitation of the primary focus. Localized infection can be treated empirically with Gram-positive antibiotics such as cefazolin and vancomycin.

Diagnostic criteria for various clinical forms of postpartum endometritis have not yet been finally approved.

Clinical forms may include different symptoms in varying degrees of severity (fever, intoxication, local manifestations), laboratory data, duration of treatment.

The timing of the appearance of the first symptoms of postpartum endometritis depends on the nature of the course of the disease. In severe and moderate forms, the first symptoms of the disease occur on the 2nd-3rd day.

In puerperas who are diagnosed with a mild course of postpartum endometritis, typical manifestations of the disease can be seen on the 3rd–5th day.

The diagnosis of endometritis is established clinically, as imaging methods, including ultrasound, have low diagnostic accuracy.

At the same time, if any clinical or ultrasound signs of endomyometritis are detected after spontaneous and, above all, operative labor, all puerperas are shown to undergo hysteroscopy, which will help in the diagnosis of postpartum and postoperative endomyometritis in 92% of cases.

Patients with signs of severe systemic disease, stool disorder (diarrhea) and/or abdominal pain raise suspicion of group A streptococcal infection, which requires urgent treatment with antibiotics.

Streptococcal infection makes surgical treatment possible due to the risk of toxic shock syndrome, necrotizing fasciitis, and even death.

Outbreaks of streptococcal infection in the postpartum period in women can be associated with the infection of the health workers themselves, so medical staff regularly undergo appropriate screenings.

Late postpartum endomyometritis (after 7 days after birth) should raise suspicion of. should be performed for endomyometritis occurring 7 days after delivery, as well as in patients with a high risk of infection, such as adolescents.

5. Treatment of the disease

Endometritis is a very serious postpartum infection that most often requires hospitalization. After the diagnosis is established, the puerperal is transferred to the ward, where it is possible to take into account hourly changes in body temperature, blood pressure, pulse, diuresis, and all ongoing activities are recorded.

Treatment of endomyometritis in the postpartum period begins with the sanitation of the focus of pus (for example, under hysteroscopic control, dead tissue or remnants of placental tissue are removed, and even a hysterectomy may be necessary). Antimicrobial treatment with broad-spectrum drugs is also carried out, and detoxification therapy is also important.

The most common cause of fever during the first 24 hours is dehydration, so plenty of fluids are needed, and sometimes fluid therapy.

Before starting treatment with antibacterial drugs, it is necessary to take secretions from the cavity of the postpartum uterus in order to conduct a bacteriological study, and if a pathogen is isolated, it is also possible to determine sensitivity to antibiotics for further optimization of treatment.

A 2015 Cochrane review of antibiotic therapy for postpartum endometritis analyzed 42 studies (treating more than 4,000 patients).

There were fewer treatment failures in patients treated with clindamycin with aminoglycosides compared with patients treated with cephalosporins (RR 0.69, 95% CI 0.49 - 0.99) or penicillins (RR 0.65, 95% CI 0.46 - 0.90).

There were significantly fewer wound infections in patients treated with clindamycin plus aminoglycosides compared with patients treated with cephalosporins (RR 0.53, 95% CI 0.30 ̶ 0.93).

Similarly, there were more treatment failures in those treated with gentamicin/benzylpenicillin compared with patients treated with gentamicin/clindamycin (RR 2.57, 95% CI 1.48 ̶ 4.46). The review group concluded that the combination of clindamycin and gentamicin is appropriate for the treatment of endometritis.

Regimens with activity against penicillin-resistant anaerobic bacteria are better than those with little activity against penicillin-resistant anaerobic bacteria. There is no evidence that any one regimen of antibiotic therapy is associated with fewer side effects.

The combination of clindamycin and aminoglycosides (gentamicin is most common) is an effective treatment regimen for postpartum endomyometritis, but treatment is always based on multiple factors, thereby precluding the possibility of self-treatment.

Among other possible antibiotic therapy regimens, one can name a combination of amoxicillin with clavulanic acid, cephalosporins of 2-3 generations can also be prescribed, but always in combination with metronidazole.

Other broad-spectrum drugs, such as imipenem, may be chosen as an alternative. Treatment can only be prescribed on an individual basis, there is no universal treatment.

Parenteral treatment with one or another antibacterial drug should be continued until the temperature reacts, pain decreases, and the number of leukocytes normalizes.

Failure to improve within 72 hours of starting antibiotic therapy or recurrence of symptoms and signs usually indicates abdominal problems, wound infection in 50% of cases, septic pelvic thrombophlebitis, or enterococcal superinfection.

The combination of clindamycin and gentamicin remains the gold standard, with the addition of ampicillin or vancomycin as a third agent if enterococcal infection is suspected.

After the condition improves, it is possible to switch to tableted antibacterial drugs.

6. When can antibiotics be discontinued?

After the sanitation of the focus of infection, as well as the return of the temperature to normal within two to three days. For women with mild disease, treatment with oral antibiotics (including doxycycline or erythromycin with metronidazole) may also be considered.

According to modern researchers, such schemes are quite effective: clindamycin orally + gentamicin intramuscularly, amoxicillin-clavulanate orally, cefotetan intramuscularly, meropenem or imipenem-cilastatin intramuscularly, amoxicillin orally in combination with metronidazole.

The later the diagnosis is made, the faster the infection spreads. There can be no talk of any self-treatment!

7. Symptomatic remedies

Treatment of endomyometritis requires a holistic, integrated approach and should include anti-inflammatory drugs, drugs aimed at reducing the sensitization of the body of the puerperal, infusion therapy, and sedatives.

It is important to remember that with endomyometritis, the contractile capabilities of the uterus are disrupted, so contracting drugs are required.

Proteolytic drugs may also be prescribed, which increase the effectiveness of antibacterial drugs.

If remnants of the placenta (by ultrasound), fetal membranes, blood, pus are found, it is very important to perform surgical sanitation of the uterus (optimally, vacuum aspiration, but curettage is often necessary). It is possible to introduce highly effective antiseptics into the uterine cavity.

For all women during cesarean section, antibiotic prophylaxis is very important, which will help in preventing wound infection and the development of endomyometritis.

A meta-analysis of randomized controlled trials comparing penicillin or cephalosporin with placebo before elective caesarean section showed a significant reduction in the incidence of endomyometritis (RR 0.05 95% CI 0.01–0.38) and postoperative fever (RR 0.25 95% CI 0.14–0.44 ) in the case of prophylaxis with antibacterial drugs.

8. What is important to remember?

If there are any changes in the condition of the puerperal, it is necessary to consult an obstetrician-gynecologist. But what should be especially alarming in relation to endomiometritis?

The appearance in the postpartum period of elevated body temperature, an unpleasant smell of lochia (discharge from the vagina in the postpartum period), pain in the abdomen (below, in the stomach area, anywhere) all this requires an immediate consultation with an obstetrician-gynecologist !!! And not a moment of thought!

Young mothers caring for newborns often overlook the deterioration of their own well-being. At the same time, the restructuring of the body and the weakening of its protective functions is an excellent opportunity for infections to penetrate the most vulnerable organ of a woman who has just recently given birth to a baby - her uterus. So, the puerperal may develop endometritis.

What is endometritis?

Endometritis is an inflammation of the inner mucous layer of the uterus of a purulent nature. Often such a painful condition occurs in the early postpartum period, when an extensive wound area forms inside the uterus after separation of the placenta during natural childbirth or additional surgical trauma after a cesarean section.

Endometritis occurs in 3-7% of women who give birth vaginally. After a caesarean section, the probability of getting such a complication rises to 15%, and in the case of emergency surgery, the risk of developing endometritis reaches 20%. Fortunately, in most cases the course of the disease is mild or moderate. Acute purulent forms with severe complications develop only in a quarter of cases.

Causes of postpartum endometritis

After delivery, the uterine mucosa does not recover immediately - it usually takes 5-6 weeks. During this time, conditionally pathogenic microflora from the vagina, as well as many other infectious agents: staphylococci, gonococci, mycoplasmas, enterobacteria, can enter the damaged endometrium in an ascending way. They become the source of an acute inflammatory process. Less commonly, microorganisms enter the uterine cavity from foci of chronic infection in the body with blood and lymph flow, for example, with pyelonephritis that worsens during pregnancy.

The following categories of women are especially vulnerable:

1. Women in childbirth with reduced immune resistance;
2. those who gave birth at a young age;
3. Patients with chronic diseases of the genitourinary system, especially in case of their recurrence in the third trimester of pregnancy;
4. Patients with endocrine disorders;
5. Suffering from immunodeficiencies and autoimmune diseases;
6. Anemia-prone puerperas;
7. Mothers belonging to the low-income segments of the population and having a low social level: unbalanced diet and unhealthy habits;
8. Postpartum women with a history of abortion, curettage, and a long history of using intrauterine contraceptives.

It is also worth highlighting the features of the course of pregnancy and childbirth, which can aggravate the condition of the endometrium and cause inflammatory processes:

1. Low localization and placenta previa;
2. Suturing the cervix, installing an obstetric pessary;
3. Invasive screening procedures (amnio- and cordocentesis, chorion biopsy);
4. Severe anemia and preeclampsia;
5. Late rupture of the membranes of the fetus;
6. Protracted attempts;
7. Untimely discharge of amniotic fluid and a long anhydrous period (more than 12 hours);
8. Polyhydramnios and multiple pregnancy, leading to overstretching of the uterus;
9. Intrauterine monitoring during childbirth and multiple vaginal examinations;
10. Chorioamnionitis (polymicrobial infection of the fetal membranes and amniotic fluid);
11. Injury to the perineum;
12. Separation of the placenta manually;
13. Pathological blood loss or its uncompensated replenishment;
14. Intrauterine infections in a newborn (pneumonia, blood poisoning);
15. Insufficient hygiene of the genitals after childbirth.

Symptoms of postpartum endometritis

Symptoms of postpartum endometritis depend on the form in which the disease occurs:

1. Light the form develops within 1-2 weeks after the birth of the child. It is characterized by:

• minor fever and chills;
• An increase in body temperature up to 37.5-38 ° C;
• Increased heart rate;
• Strengthening lochia;
• Pain in the lower segment of the abdominal wall;
• Deceleration of uterine involution.

At the same time, the general condition of the puerperal remains satisfactory.

2. heavy the form develops sharply already 2-3 days after birth. It is distinguished by such features:

• Significant weakness;
• Headache and dizziness;
• An increase in body temperature up to 39 ° C and above;
• Severe chills;
• Pain in the lower abdomen and lumbar region;
• Loss of appetite;
• Nausea;
• Tachycardia;
• Bloody discharge becomes profuse, thick and cloudy with a fetid odor;
• The contraction of the uterus is very slow.

All of these symptoms require immediate medical attention. Both severe and milder forms of the disease threaten the emergence of dangerous purulent-inflammatory conditions that affect not only the uterus, but also nearby organs and systems and the entire body as a whole. So, the puerperal may develop sepsis, peritonitis, pelvic abscess, paralysis of the intestinal muscles.

In some cases, signs of endometritis may appear relatively late - 3-4 weeks after childbirth and have a fuzzy clinic. This type of disease is dangerous for a protracted course and possible relapses.

Diagnostics

Adequate diagnosis of endometritis is important not only for the choice of treatment tactics, but also for differentiating the disease from other pathologies, for example, parametritis (inflammation of the connective tissue surrounding the uterus), thrombophlebitis of the pelvic veins.

To confirm the diagnosis of endometritis, the following studies will be required:

1. Two-handed palpation by a gynecologist: soreness is found in the fundus of the uterus and its lateral segments;
2. Examination of the cervix in the mirrors to assess the condition of the cervical canal: cloudy lochia and redness suggest the presence of endometritis;
3. Analysis of urine;
4. Complete blood count, which reveals a rise in ESR and pronounced leukocytosis;
5. Blood culture (with severe endometritis and the threat of sepsis);
6. Bacteriological culture of the separated uterine mucosa to determine the type of pathogens and their sensitivity to antibacterial drugs;
7. Ultrasound diagnosis of the small pelvis: shows a pathological increase in the volume of the uterus, a change in its shape, tissue infiltration, hematomas, as well as suture failure after surgery;
8. Hysteroscopy (examination of the uterine cavity using a special optical system inserted through the vagina): necessary to visualize swelling and cyanosis of the endometrium, detect placental remnants, blood clots, purulent masses, and plaque on the walls of the uterus.

Treatment of endometritis

With clinically diagnosed endometritis, therapy should begin as soon as possible. The main treatment measures include:

1. Hospitalization in a hospital in case of acute endometritis in the moderate and severe stages.
2. Bed rest.
3. Antibiotic therapy with broad-spectrum drugs (cephalosporins, ampicillins, metronidazole), usually by intravenous infusion. With a mild form of the disease, the use of one drug is acceptable; in severe cases, combinations of various antibiotics are used, depending on the spectrum of pathogens detected.
4. The complex use of drugs that promote uterine contraction (Oxytocin) and antispasmodics (Drotaverine, No-shpa) to improve the outflow of lochia.
5. Antihistamines as a prophylaxis of allergic reactions against the background of powerful antibiotic therapy.
6. Hemosorption, plasmapheresis for additional detoxification of the body and immunocorrection.
7. When remnants of the placenta or membranes are found, they resort to vacuum aspiration or curettage of the uterine cavity (preferably under the control of hysteroscopy), drainage and treatment of the uterine cavity with disinfectants.
8. Anticoagulant therapy to reduce blood clotting.
9. At the end of the acute phase - physiotherapy to consolidate the results of treatment: magnetotherapy, electrophoresis, ultraviolet radiation, acupuncture.
10. A diet rich in proteins and vitamins.

In rare cases, in the absence of a positive effect from treatment within 7 days and a threat to the life of the patient, the question arises of surgical removal of the uterus - hysterectomy.

Prevention

Measures to prevent endometritis include:

1. Timely registration in the antenatal clinic to monitor pregnancy.
2. Treatment of foci of acute and chronic infections in the body, especially urogenital ones.
3. Compliance with an adequate regime of work and rest during the bearing of a child.
4. Proper nutrition and intake of vitamin complexes recommended by the doctor.
5. Careful hygiene of the genitals in the postpartum period: it is necessary to carry out hygiene procedures after each visit to the toilet, and also treat the stitches on the perineum with antiseptic preparations.
6. Joint isolated stay of mother and baby in a medical facility.
7. Change sanitary napkins at least every 4-5 hours. Important! The use of tampons in the postpartum period is prohibited.
8. Prophylactic antibiotic therapy after caesarean section and perineal incisions (episiotomy, perineotomy).

Thus, endometritis is a relatively rare, but serious complication of the postpartum period, which necessarily requires close attention. The integrity and normal functioning of the endometrium of the uterus is the key to maintaining a woman's fertility and the successful course of subsequent pregnancies.

Specially for- Elena Kichak

Endometritis is an inflammation of the inner layer of the uterus (endometrium). Why is talking about this disease relevant? Firstly, every young mother can face such a problem. Secondly, the integrity and full functioning of the endometrium is extremely important to ensure the successful course of subsequent pregnancies. The inner lining of the uterus changes its structure under the influence of hormones during the menstrual cycle. During the entire menstrual cycle, the uterus prepares to receive a fertilized egg. If pregnancy does not occur, the functional layer of the uterus is rejected (menstruation passes). Figuratively speaking, the uterus “mourns” the failed pregnancy with bloody tears. If inflammation occurs in the uterus after childbirth, then the changes that normally occur in the inner membrane are violated, which can lead to various complications - from infertility to miscarriage and various disorders during pregnancy.

The frequency of endometritis after spontaneous delivery is 2-5%, after caesarean section - 10-20%.

Why does endometritis develop?

The cause of endometritis is the entry of microbes that cause inflammation into the uterus, where after separation of the placenta an extensive wound surface is formed, since at the time of separation of the afterbirth, the vessels connecting the placenta and the wall of the uterus are torn.

Microbes can enter the uterus in the following ways:

1. From the vagina- more often these are conditionally pathogenic (conditionally pathogenic) microorganisms that live in the vagina of a pregnant woman. They constantly live on the skin and mucous membranes, without disturbing their "owner", but under certain conditions they can cause a disease. This is especially characteristic of nonspecific microbes - staphylococci, streptococci. And childbirth, especially difficult, traumatic, can become this favorable condition for the activation of microbes. The cause of endometritis can also be sexually transmitted infections (ureaplasma, chlamydia, etc.).
2. From foci of chronic infectionstions- by hematogenous, lymphogenous way, that is, microbes can enter the uterus with blood and lymph, for example, from the tonsils in chronic tonsillitis, from the kidneys in chronic nephritis, etc.

The occurrence of endometritis is especially likely in the following cases:

• with various forms of infertility, after hormonal or surgical correction of miscarriage;
• if a woman has been diagnosed with certain infectious diseases during pregnancy, including urogenital infections;
• after caesarean section;
• after using research methods such as amnioscopy 1 , amniocentesis 2 , during which medical instruments are introduced into the uterine cavity;
• with various chronic diseases of the lungs, heart, etc.;
• in cases of non-compliance with the rules of personal hygiene;
• with prolonged childbirth;
• with a long anhydrous period during childbirth - when a lot of time passes from the moment the amniotic fluid is discharged to the birth of a child - more than 12 hours;
• in cases of various complications during childbirth (weakness of labor, bleeding), with manual examination of the uterus, etc.;
• with repeated childbirth, polyhydramnios, multiple pregnancy - all this leads to the fact that the uterus during pregnancy is overly stretched, which prevents it from contracting well after childbirth;
• in the case of an unfavorable course of the third stage of labor, when the placenta is poorly separated and parts of the fetal membranes, the placenta, remain in the uterus.

Manifestations of the disease

Endometritis can develop both a few hours after childbirth, and after a few weeks, up to the 6th - 8th week of the postpartum period. In other words, signs of the disease can appear both in the maternity hospital, where the woman is under the supervision of doctors, and during the period when the young mother is already at home (in the latter case, you need to be especially attentive to your condition). The earlier endometritis begins, the more severe its course, however, even with a mild course of the disease, its long-term consequences can be deplorable, up to infertility.

With the development of endometritis, a woman's temperature rises. With a mild course, the temperature increase is insignificant, with a severe one, the temperature can reach 40 - 41 ° C. An increase in temperature is accompanied by a feeling of chills, weakness, weakness, headache. It should be borne in mind that fever in the postpartum period occurs in most women and coincides with the period of milk arrival, and weakness accompanies many young mothers. But, knowing this, you should not neglect the change in your state of health, you need to tell the doctor about the slightest changes in your condition. If the temperature rises when you have already been discharged from the hospital, you should immediately contact your doctor.

Endometritis is accompanied by the appearance of pain in the lower abdomen, in the lower back. In contrast to the pain caused by uterine contractions, which normally accompany the postpartum period and are characteristic of feeding time, pain with endometritis is permanent, although it can also increase during feeding.

With endometritis, the nature of postpartum discharge changes. Normally, the first 2-3 days after childbirth are accompanied by fairly abundant bloody discharge, subsequently the discharge becomes smaller, it changes character, becomes sanious - brownish, then yellowish, and disappears completely by the 6-8th week. With endometritis, the discharge for a long time has the character of bloody, abundant, or against the background of seemingly ceasing sanious discharge, bloody resumes. Often the discharge becomes offensive, sometimes greenish or yellowish.

Another symptom of the disease is a slowdown in uterine contractions. Even in the normal course of the postpartum period, the uterus does not immediately acquire the same dimensions that it had before pregnancy - it shrinks gradually. With endometritis, uterine contraction is slowed down.

For the timely detection of endometritis, young mothers at risk, especially those who have undergone a manual examination of the uterus, are asked to take a general blood test. With the development of endometritis, this analysis determines a significant increase in the number of leukocytes.

Separately, it should be said about ultrasound, which is often used in diagnosis. The efficiency of ultrasound is about 50%. It has diagnostic value for determining pathological inclusions in the uterine cavity (for example, remnants of placental tissue, etc.), against which endometritis develops. However, in the diagnosis of the disease itself, this method is not used in most countries of the world.

Treatment

If at the time of the onset of the disease, the woman was still in the maternity hospital, then she is transferred to a special (2nd obstetric) department, where women with various complications of the postpartum period are observed. If the young mother was already at home, then hospitalization in the gynecological department of the maternity hospital is necessary.

With endometritis, antibiotics are prescribed, usually in the form of injections. When choosing a medicine, it is taken into account that a young mother should breastfeed her baby, but the issue of breastfeeding is decided individually in each case. In severe cases, two antibiotics are prescribed at the same time.

In addition to antibacterial drugs, endometritis therapy includes a complex of other therapeutic measures. So, intravenous administration of medicinal liquids is performed, ozonized solutions are used.

To improve the contractile activity of the uterus, apply OXYTOCIN after pre-injection BUT-SHPY. This helps to improve the outflow of uterine secretions, reduce the area of ​​the wound surface and reduce the absorption of decay products during the inflammatory process in the uterine cavity. In addition to medications, physical methods can be used to improve the contractile activity of the uterus in the postpartum period - ice is placed on the area of ​​\u200b\u200bthe uterus.

Of the immunocorrective drugs used KIPFERON or VIFERON, as well as infusions NORMAL HUMAN IMMUNOGLOBULIN. With an exacerbation of a concomitant viral infection, antiviral drugs are prescribed.

In the complex therapy of endometritis, one of the leading places belongs to local therapy - vacuum aspiration of the contents of the uterine cavity to remove the contents of the uterus.

Recently, a new local treatment for postpartum endometritis has been proposed - "enzymatic curettage" of the walls of the uterus with special enzymes that dissolve dead tissue.

In most cases, timely treatment of endometritis leads to good results, which avoids complications of pregnancy and childbirth.

Prevention

In order to exclude, if possible, purulent-inflammatory postpartum diseases, doctors at the stage of monitoring pregnant women identify expectant mothers who are at high risk of developing a bacterial infection or with its manifestations.

The prevention of endometritis includes the exclusion of factors predisposing to the occurrence of an inflammatory disease. This is a timely treatment of sexually transmitted infections and all complications that occur during childbirth.

During and after caesarean section, women who are at risk for the occurrence of postpartum inflammatory complications during and after childbirth are given antibacterial drugs.

In maternity hospitals, hygiene rules are carefully observed, which in the language of doctors are called asepsis and antiseptics. Early attachment of the newborn to the breast, the system of isolated joint stay of mother and child with subsequent early discharge from the maternity hospital can also be attributed to endometritis prevention measures.

In the postpartum department, women at risk undergo an ultrasound examination. And although, as already mentioned, this method does not make it possible with absolute certainty to exclude the presence of postpartum endometritis, nevertheless, in the presence of blood clots, placenta and ovum remnants, it allows you to take appropriate measures in a timely manner - from the introduction of reducing drugs to vacuum aspiration of the contents of the uterus.

In order to avoid the disease, it is important to follow the doctor's prescriptions accurately and in a timely manner. This will be the key to the health and well-being of a young mother.

1 Amnioscopy - the study of amniotic fluid using a special tool - an amnioscope, which is inserted inside through the abdominal wall. Cervical amnioscopy, performed later in pregnancy, allows various instruments to examine the contents of the amniotic sac through the cervix. During such an examination, the fluid contained inside the cavity can be taken for analysis without puncture (piercing) of the fetal bladder; meconium analysis may also be done.

A woman who has given birth to a child is in the postpartum ward under close attention. The doctor monitors her body temperature, vaginal discharge, uterine contractions. The information received is very important, because thanks to them it is possible to diagnose various complications in a timely manner. One of them may be postpartum endometritis. It is a rather serious and life-threatening disease.

The inner cavity of the uterus is lined with endometrium. Due to the penetration of infections after childbirth, the membrane may become inflamed. This process is called endometritis.

According to the form, inflammation is divided into 2 types: acute and chronic. Their symptoms are the same, but in the 2nd form they are a little "blurred". Chronic endometritis is more difficult to recognize and treat. That is why at the first signs of endometritis, you should immediately contact the clinic.

Symptoms of acute endometritis

As a rule, the disease begins with the following symptoms:

• increase in body temperature to 38-39 degrees;
• the occurrence of pain in the lower abdomen, radiating to the sacrum;
• the appearance of bloody-purulent, serous-purulent, serous discharge from the vagina;
• malaise (weakness, weakness, headache).

Particular attention should be focused on such symptoms of postpartum endometritis as discharge. Normally, after the birth of a child, abundant discharge with blood goes on for a couple of days. Then they become scarce and take on brownish and yellowish hues.

By the 8th week, the discharge completely stops. With endometritis, they are abundant and bloody for a long time. Their color may even be greenish.

Symptoms of chronic endometritis

The characteristic signs of a chronic form of inflammation of the inner lining of the uterus include:

• not falling body temperature;
• uterine bleeding that occurs from time to time (irregularly);
• discharge from the genital tract, having an unpleasant (putrefactive) odor;
• pain during defecation.

Causes of endometritis

The main cause of inflammation of the inner lining of the uterus is the entry of microorganisms into the organ on the damaged surface that has arisen after the separation of the placenta. They can enter the uterus in 2 ways:

• from the vagina;
• from foci of chronic infection.

In the vagina of a woman, opportunistic microbes can live. For a long time, they can live on mucous membranes and not disturb their mistress. However, when living conditions change, they can cause various diseases. This is especially true for streptococci and staphylococci. Microorganisms can be activated due to difficult childbirth. The cause of postpartum endometritis can also be those infections that are sexually transmitted.

Microorganisms can enter the uterus from foci of chronic infections by the hematogenous, lymphogenous route (that is, with blood or lymph). For example, this can happen if a woman suffers from chronic tonsillitis, nephritis.

Predisposing factors for the development of inflammation and risk groups

Predisposing factors of postpartum endometritis include:

• preeclampsia (a complication of the 2nd half of the “interesting position” of a woman, manifested by an increase in blood pressure, the appearance of protein in the urine, and edema);
• prolonged labor, premature discharge of amniotic fluid and a long anhydrous period;
• incorrect location of the fetus in the uterus;
• childbirth in women whose age is less than 19 years;
• childbirth in the fair sex, in whom the pregnancy is the first and who are over 30 years old;
• childbirth in women with a narrow pelvis;
• placenta previa (it partially or completely closes the exit from the reproductive organ);
• premature detachment of the placenta, which is normally located;
• infection at the time of childbirth with microorganisms that are sexually transmitted and cause various diseases.

Women who are at risk for inflammation of the inner lining of the uterus deserve special attention after childbirth. As a rule, after the birth of a child, they are sent for an ultrasound.

The risk group includes those women who have:

• abortions (the more there are, the higher the risk);
• complications from previous pregnancies, childbirth;
• foci of chronic infections in the body.

Complications of endometritis

Inflammation of the lining of the uterus can lead to sepsis. This complication is also called "blood poisoning". There is a risk that if left untreated for a long time, the infection will spread throughout the body through the blood, lymph.

Complications of postpartum endometritis can also be:

• the flow of the disease into a chronic form;
• the formation of pyometra (pus accumulates in the uterine cavity and does not come out due to obstruction of the cervix);
• the occurrence of pelvioperitonitis as a result of pus entering the pelvic cavity;
• the occurrence of salpingitis and oophoritis (inflammation of the fallopian tubes and ovaries).

Severe purulent-septic complications can result from amputation of the uterus and death.

With untimely and improper treatment in the future, the following consequences may be observed:

• violation of the menstrual cycle;
• constant discomfort in the lower abdomen;
• reproductive dysfunction (infertility, spontaneous miscarriages).

All of the above complications, the list of consequences of endometritis is not exhausted. The inflammatory process can cause any pathology. To prevent the occurrence of serious complications, it is necessary to seek help from a specialist in time.

As evidence of the seriousness of the pathologies, it can be noted that from the 17th to the beginning of the 20th century, endometritis (“puerperal fever”) was a serious problem in maternity hospitals, which, due to the lack of suitable treatment, turned into sepsis. The disease claimed the lives of 50% of women in labor.

Diagnosis of endometritis

If the first symptoms of this disease occur, you should immediately consult a gynecologist. He will prescribe the necessary examinations, establish a diagnosis and select the appropriate treatment.

How can a doctor detect endometritis? One of the methods is a gynecological examination. On examination, a gynecologist can detect symptoms of postpartum endometritis - enlarged uterus, pain at the time of palpation, discharge. During the examination, the doctor makes smears on a special flora to identify pathogens. Pathogens are grown under certain conditions on a special medium. Sowing allows you to evaluate the effectiveness of a particular medication.

Endometritis can be detected with a pelvic ultrasound. This research method in the acute form of the disease allows you to see the inner lining of the uterus in an inflamed and thickened form, to detect the presence of complications (inflammation of the uterine appendages). Thanks to ultrasound in chronic endometritis, synechia inside the uterus (adhesions) can be detected, which are often the cause of miscarriage or infertility.

Inflammation of the mucous membrane of the uterus can be detected by the results of a general blood test. An increase in the level of leukocytes (white blood cells) indicates the presence of endometritis.

Doctors to diagnose endometritis can conduct a special polymerase chain reaction. Thanks to it, sexually transmitted infections can be detected.

Another method to diagnose this disease in a woman is an endometrial biopsy. For research, a small piece of the inner uterine membrane is taken. It is examined by specialists under a microscope. In most cases, doctors do not use this method. A biopsy is performed only in cases where there is difficulty in making a diagnosis.

The chronic form of endometritis is much more difficult to diagnose, since the symptoms are similar to other diseases of the female reproductive system. Only a professional doctor can correctly diagnose.

Treatment of endometritis

Inflammation of the inner lining of the uterus is a rather dangerous and serious disease. Treatment of postpartum endometritis should take place in a hospital under medical supervision. As a rule, specialists prescribe antibacterial and antipyretic drugs.

Treatment of acute endometritis

Unfortunately, most women who develop suspicious symptoms turn to the doctor for help too late. This leads to prolonged treatment and hospitalization.

The main principles of treatment of acute endometritis include:

• antibacterial therapy (drugs are administered intramuscularly or intravenously for 5-10 days);
• anti-inflammatory treatment;
• mechanical cleaning of the uterine cavity (curettage in the presence of placental remains in the organ);
• anesthesia;
• detoxification (purification of blood from harmful substances produced by microorganisms);
• the use of immunomodulators and vitamin preparations;
• the use of physiotherapeutic methods of treatment (low-intensity UHF therapy, infrared laser therapy).

Treatment of chronic endometritis

In the chronic form of postpartum endometritis, treatment consists of several stages:

• treatment of sexually transmitted diseases;
• hormonal therapy (taking drugs that normalize hormonal levels);
• removal of synechia in the uterine cavity.

The doctor prescribes antibiotic treatment depending on the type of infection that led to the inflammation of the lining in the uterus. If a virus has become the cause of endometritis, then the specialist will prescribe antiviral drugs and drugs that increase the activity of the immune system.

Hormonal treatment of chronic endometritis refers to the use of oral contraceptives. In most cases, they are taken within 3 months.

Removal of adhesions is performed surgically with the use of painkillers. A hysteroscope is used to examine the uterine cavity. With it, you can detect adhesions in the cavity of the reproductive organ and dissect them.

Additional treatment features

During antibiotic therapy, women should not breastfeed their baby. Breastfeeding should be excluded during the use of antibacterial drugs, as well as for 1-2 weeks after them.

While in the hospital, bed rest and diet must be observed. For the period of treatment of postpartum endometritis, fatty foods and foods that are difficult to digest by the body should be excluded from the diet. The diet should be more fluids and a variety of fruits.

With the timely start of treatment, endometritis does not require special rehabilitation. After going through all the therapeutic procedures, you need to visit a doctor for some time.

Prevention of postpartum endometritis

It is possible to prevent inflammation of the uterine mucosa if we exclude the influence of all factors that predispose to the onset of the disease. The most correct methods of prevention are the following measures: refusal of abortions; timely treatment of sexually transmitted infections. A woman should listen to her doctor and come after giving birth for an appointment for ultrasound, gynecological examinations.

The most important preventive measure of endometritis is the attentive attitude of the fair sex to herself. If suspicious symptoms appear, you should immediately contact a qualified specialist.