Postpartum endometritis treatment. Postpartum endometritis: symptoms and treatment

Frequency postpartum endometritis in the general population of postpartum women it ranges 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 the observations, a severe course of this complication is noted, accompanied by purulent-resorptive fever and the possibility of generalization of the 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. Epithelization and regeneration of the endometrium ends only 5-6 weeks after birth. The process of endometrial restoration postpartum period represents wound healing characterized by a number of histological features.

What causes 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 postpartum women 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 bacteroides and gram-positive cocci: peptococci and peptostreptococci.

Often the cause of this complication is 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. Chills are occasionally observed at the first rise in temperature. The pulse quickens to 80-100 beats/min, and its increase corresponds to a rise in temperature. From the blood picture, leukocytosis is noted in the range of 9.0-12.0-109/l, a slight neutrophil shift, and an increase in ESR to 30-50 mm/h. Content total protein blood and residual nitrogen remain within normal limits. General health does not suffer significantly in postpartum women. Patients experience uterine soreness, which persists for 3-7 days. The size of the uterus is slightly increased, and the lochia long time remain bloody. Assessment of the severity of the patient’s condition and the effectiveness of complex treatment is based on the results of dynamic observation over the next 24 hours. At the same time, indicators of hemodynamics, respiration, urination, the condition of the uterus, the nature of lochia, data laboratory research.

Severe form As a rule, it begins earlier, on the 2-4th day after birth. Moreover, in almost 1/4 of cases this complication develops against the background of chorioamnionitis, after complicated childbirth or surgery.

During dynamic observation in patients with a severe form of postpartum endometritis, there is no improvement within 24 hours, and in a number of observations there is even a negative dynamics of the process. The patient is worried about headaches, weakness, and pain in the lower abdomen. There is a disturbance in sleep, appetite, and tachycardia up to 90-120 beats/min. Body temperature often rises to 39 °C or higher, accompanied by chills. The number of leukocytes increases to 14.0-30.0. 109/l, ESR increases from 15 to 50 mm/h. All patients have a neutrophil shift, anemia and arterial hypotension are often observed.

On examination, pain and slowing of uterine involution are revealed. Lochia becomes brown from 3-4 days and subsequently acquires a purulent character.

After starting treatment, body temperature usually normalizes within 2-4 days.

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

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 operative birth. 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 birth. In most patients, the body temperature initially does not exceed 38 ° C, and chills are rare. In the blood there is leukocytosis 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 neutrophil shift, and in the rest it is weakly expressed. In most patients, lochia is initially brown, turns into sanguineous 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.

During treatment, body temperature normalizes within 5-10 days. However, in some patients low-grade fever can last up to 12-46 days. Involution of the uterus is slowed down. Normalization of the blood picture most often occurs on the 6-15th day of illness.

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 due to underestimation of the severity of the patient and inadequate therapy.

Distinguish abortive form , which appears on the 2-4th day. Distinctive feature This form is that with the start 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 incidence of this complication after cesarean section largely depends on the urgency of the operation. After a planned cesarean section, the incidence of endometritis is 5-6%, and after emergency abdominal delivery - from 22 to 85%.

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

The disease often begins on the 1st-2nd day after surgery, and in some cases on the 4th-5th day. Body temperature rises to 38-39 °C or more, accompanied by chills and tachycardia. Some patients also experience low-grade fever. An increase in heart rate usually corresponds to a rise in body temperature. From 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 neutrophil shift leukocyte formula 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 disturbances, appetite, and pain in the lower abdomen. Involution of the uterus during postpartum endometritis after cesarean section occurs slowly. By the 4-6th day, lochia becomes cloudy, abundant, watery, sometimes has the color of meat slop or takes on a purulent character. Discharge from the uterus becomes normal by 9-11 days. The blood picture normalizes only by 10-24 days after surgery.

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

In patients with endometritis after cesarean 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 disturbances in the sympathetic-adrenal system and changes in the histamine-histaminase system with increased histamine production. At the same time, disturbances of hemodynamics and microcirculation, water and electrolyte balance and hormonal homeostasis develop. There are signs of hypovolemia, hypoproteinemia and hypokalemia. Emerging metabolic disorders can cause clinical syndrome accompanied by intestinal paresis and intoxication. Hypokalemia contributes to the development of micro- and macrocirculation disorders in the gastrointestinal tract. With severe intestinal paresis, impaired microcirculation 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 cases, swelling is noted postoperative suture, which contributes to the delay blood clots, remnants of membranes and placental tissue in the cavity and creates conditions for long-term 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 danger of developing relapses in combination with other complications (adnexitis, parametritis, dehiscence of the postoperative suture, development of peritonitis).

Depending on the severity of the body’s adaptive and compensatory reactions, postpartum endometritis can cause:

• compensated;
• subcompensated;
• decompensated character.

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

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

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

The subcompensated form is characterized by the presence high fever, which does not decrease during therapy, there is pronounced subinvolution of the uterus and 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 and significant disruption of general adaptation mechanisms.

Diagnosis of postpartum endometritis:

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

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

The most typical are the following clinical diagnostic criteria:

• repeated rise in temperature above 37.5 °C from 2 days after delivery;
• soreness and pastiness of the uterus upon palpation;
• purulent lochia.

At echographic examination are revealed:

• disturbances in the processes of uterine involution;
• enlargement and expansion of the uterine cavity;
• inclusions in the uterine cavity of varying size and echogenicity;
• 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 myometrial structure;
• strengthening of the vascular pattern, the appearance of sharply dilated vessels, mainly in the area 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”) due to 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 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 hemorrhage.

A whitish coating (fibrin deposits) is detected on the walls of the uterus 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 zones of yellow-orange regeneration in the area of ​​the tubal angles and the fundus of the uterus. Forming synechiae may be visible.

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

If postpartum endometritis was caused by retained placental tissue, then the examination reveals a stringy structure with a bluish tint, which is sharply contoured and stands out against the background of the walls of the uterus. Blood clots are visualized as oval, round structures of black color.

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

Laboratory diagnostic methods:

Clinical and biochemical analysis blood. Most characteristic changes peripheral blood parameters in postpartum endometritis:

• leukocytosis 12.0 * 109/l or more;
• band 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 isolation of etiologically significant microorganisms in quantities equal to or more than 104 CFU/ml.

There is a direct relationship between the degree of microbial contamination and severity clinical course process. In 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 observed in the range of 105-108 CFU/ml.

Treatment of postpartum endometritis:

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

Integral components of a comprehensive conservative treatment postpartum endometritis are antibacterial, infusion and detoxification therapy, the use of uterine contractions, desensitizing and restorative therapy. To limit inflammation and activate the body's defenses, a therapeutic and protective regimen and sedative therapy are prescribed, which helps to normalize the state of the central nervous system. The patient must be protected from negative emotions and pain. Adequate nutrition is important increased content proteins and vitamins.

Antibacterial therapy. When prescribing antibacterial therapy, it should be taken into account that infection with bacterial associations leads to the development of postpartum endometritis. It is necessary to remember that there is whole line strains of resistant bacteria, and in this regard, prescribe those drugs to 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. At the site 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) when combined with metronidazole or lincomycin group antibiotics (lincomycin or clindamycin).
• Carbapenems.

For 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 not recommended in most cases.

• 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;
  • unasin in a single dose of 1.5 g is administered intramuscularly 4 times a day.
• Second 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;
  • Metrogyl 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, the following is administered intravenously: 1.5 g of cefuroxime and 0.5 g of metrogil.

• First 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, thienam is prescribed intravenously at a dose of 500 mg 3-4 times a day.

To prevent candidiasis and dysbacteriosis, the treatment regimen for postpartum endometritis includes nystatin 500,000 units 4 times a day, levorin 250,000 units 4 times a day.

After the end of antibacterial therapy, it is necessary to correct the biocenosis of the vagina and intestines with therapeutic doses of probiotics (bifidumbacterin, lactobacterin, acylact, 10 doses 3 times a day for 7-10 days), growth stimulants normal microflora intestines (hilak forte 40-60 drops 3 times a day for a week), enzymes (festal 1-2 tablets, mezim forte 1-2 tablets with 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 (furacilin, 1% dioxidine, sodium hypochlorite in a volume of 1200 ml).

Washing the uterine cavity antiseptic solutions are recommended to reduce the absorption of decay products and toxins in case of severe disturbances in the processes of involution, the presence of copious and purulent discharge or when the latter is delayed. The procedure is performed no earlier than 4-5 days after vaginal delivery and 5-6 days after cesarean section.

Contraindications for washing the uterine cavity are:

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

Before the procedure begins, the postpartum woman is placed on a gynecological chair; perform treatment of the external genitalia; the cervix is ​​exposed using speculum and treated with Lugol's solution; the contents of the uterine cavity are sucked out using a Brown syringe for bacteriological examination; carry out careful probing to determine the length of the uterine cavity; drainage and inflow tubes connected together are inserted through the cervical canal into the uterine cavity. It is important that the inflow tube is inserted to the fundus of the uterus, which facilitates complete and uniform irrigation of the endometrial surface. In patients with postpartum endometritis after cesarean section, the tubes should be passed with extreme caution along the anterior wall of the uterus so as not to damage the sutures in the lower segment. After inserting the inflow tube to the fundus of the uterus, the outflow holes on the drainage tube should be located above the area of ​​the internal os. A bottle with a sterile solution of furatsilin diluted 1:5000 is placed in the freezer 2-3 hours before use until the first ice crystals form in it, which indicates a decrease in temperature to +4 °C. The first portion of the cooled solution is injected in a stream over 20 minutes to quick removal liquid contents of the uterine cavity and achieving a hypothermic effect. After the washing liquid has cleared, the solution injection rate is set to 10 ml/min. One procedure requires 2.5-3.5 liters of solution. The total duration of lavage is 1.5-2 hours. During the procedure, the patient’s general condition 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 completing the administration of furatsilin, 20-30 ml of a 1% solution of dioxidine or single dose the antibiotic used in this patient with novocaine (0.25% solution) or 0.9% sodium chloride solution.

The general course ranges from 2-3 to 5 procedures, which can be performed daily or after the 3rd procedure - every other day. Against the background of lavage of the uterine cavity, in a number of observations, the use of only a 3-5-day course of antibacterial therapy with antibiotic-synergists is sufficient. The main criteria for deciding whether to cancel the procedure are improvement of the patient’s well-being, reduction of tachycardia, normalization of body temperature, blood parameters, cessation of pain and progressive contraction of the uterus. After the rinsing is cancelled, the postpartum mother continues to undergo restorative and nonspecific anti-inflammatory therapy for 3-5 days. The absence of relapse of the disease, progressive improvement in the patient’s condition, the disappearance of local signs of the inflammatory process against the background of normalization of laboratory parameters indicate the patient’s recovery.

When parts of the fertilized egg are retained in the uterus and become further infected, there is a danger of toxins entering the patient’s body from the source of infection and biologically active substances, contributing to an increase in intoxication and aggravation of the course of the disease. In this case, measures should be taken to remove them by curettage or vacuum aspiration. The latter is preferred due to the lower risk of intervention. It is advisable to remove parts of the placenta in patients with a limited inflammatory process while the infection is within the uterus. If the process is more widespread and the infection is generalized, instrumental exposure is contraindicated. Removal of parts of the placenta is carried out under general anesthesia, under the control of hysteroscopy, against the background of complex use of antibiotics, infusion, detoxification and desensitizing therapy.

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

Surgical treatment of the uterine cavity for postpartum endometritis after spontaneous birth can reduce bacterial contamination of the uterine cavity. The effectiveness of surgical treatment is practically independent of 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 postpartum women who have suffered preeclampsia, increased blood loss during childbirth or surgery.

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

The following are used as components of infusion therapy:

• crystalloids and electrolyte metabolism correctors (5% and 10% glucose solutions, lactasol, isotonic sodium chloride solution, disol, acesol);
• plasma-substituting colloids (hemodez, rheopolyglucin, 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 a hyperoncotic state, the ratio between colloid 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. When body temperature increases by more than 37 °C for each degree, it is recommended to increase the volume of infusion therapy by 10%.

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 obstruction. A special place among these therapeutic measures is occupied by the restoration of electrolyte balance. Elimination of hypokalemia, improvement of hemocirculation due to moderate hemodilution and the use of vasodilators allows one to avoid a serious outcome. Early and ongoing intervention should be nasogastric intubation. If intestinal paresis has developed, the use of hypertonic solutions in an enema is contraindicated. By replacing potassium ions, sodium aggravates hypokalemia and contributes to the progression of paresis. To restore intestinal function and empty it, the safest thing is to suction its contents through a tube, which is first inserted into the stomach and then passed into the small intestine.

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

Desensitizing and antihistamine therapy. In purulent-inflammatory diseases, the content of free histamine and histamine-like substances increases in the body. In addition, antibacterial therapy may also be accompanied by allergic reactions. In this regard, it is recommended to include antihistamines in the treatment of postpartum endometritis. Diphenhydramine is used 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 facilities. Considering that in the presence of postpartum endometritis, the contractile activity of the myometrium is disrupted, it is necessary to prescribe uterine contractions. This also promotes better outflow of lochia, reduction of the wound surface, and reduces the absorption of decay products during the inflammatory process. For this purpose, it is necessary to administer 1.0 ml (5 units) of oxytocin intramuscularly 2-3 times a day or intravenously drip with 5-10% glucose solution 200.0 ml or with isotonic solution sodium chloride.

Immunocorrective drugs. Prescribe Thimalin or Taktivin 10 mcg daily for 10 days, Viferon rectal suppositories 500,000 units 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 250-300 mg and group B (B6 - 50 mg).

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

Physiotherapeutic methods of treatment.Interference current therapy according to Nemec. 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, quickly-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 physical prevention of uterine subinvolution and postpartum endometritis with interference currents according to Nemec after a cesarean section allows one to achieve the same results as when prescribing uterotonic drug therapy. However, the possibility of reducing the drug load on the body of postpartum women and reducing the overall cost of treatment makes the use of physical methods for the prevention of uterine subinvolution more justified.

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

Acupuncture. Recently, the method has become increasingly widespread. The beneficial effect of acupuncture on the hemostatic system in postpartum women with postpartum endometritis has been proven; a positive effect on the state of activity of factors of nonspecific resistance of the body and an immunostimulating effect have been noted.

External and intracavity irradiation using a low-intensity laser. Laser irradiation has the following beneficial properties: general stimulating, anti-inflammatory, analgesic, immunostimulating, helps normalize 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 sensitivity of microorganisms to antibiotics.

The effectiveness of complex intensive therapy for postpartum endometritis should be assessed no earlier than 7 days after the start of treatment. If the therapy is not effective, even against the background of satisfactory health of the patient, but clinical and laboratory signs of inflammation persist, it is necessary to decide on the removal of the uterus.

Pregnancy and childbirth are important events in the life of every woman. However, sometimes this important point can be overshadowed by the development of various complications afterward, and one of such unpleasant pathologies is postpartum endometritis. This pathological condition in the female body is quite dangerous and requires timely diagnosis and treatment prescriptions.

Postpartum endometritis causes and treatment methods

Childbirth is a complex physiological process, after which the mother is under the close supervision of obstetricians and gynecologists. Special attention Doctors pay attention to body temperature, vaginal discharge and uterine contractions. It is on the basis of such a medical examination of a woman that one can assess her general condition after childbirth and promptly identify the development of various types of complications.

One of the types of complications that a woman faces after the birth of her baby is postpartum endometritis.

Most often, this pathology occurs in a mild form and occurs after a short period of time. full recovery women. However, there are often cases when postpartum endometritis has a complex course, in which the development of purulent-resistent fever and generalization of infection are observed. This pathology occupies a special place among gynecological diseases not only in humans, but also in animals, since postpartum endometritis in cows is one of the main causes of their infertility.

Symptoms of the disease

The endometrium is the tissue that lines the uterine cavity and when any infection penetrates into it, a complex inflammatory process can begin. In a woman’s body, endometritis can occur in two forms:

• acute;
• chronic.

With the acute nature of the disease, signs appear that allow the pathology to be diagnosed in time and effective treatment to begin. Chronic endometritis should be understood as an inflammatory process in which all signs of the disease are blurred or mild.

Postpartum endometritis in female body can occur in several forms, and the signs of the disease in each of them will differ from each other.

Mild endometritis

The symptoms that accompany postpartum endometritis of this form begin to develop 5-8 days after labor. The following signs of such a course of postpartum endometritis can be identified:

• a sharp increase in body temperature;
• rapid pulse;
• upon palpation, a strong increase in the size of the uterus and its pain along the rib, where the large lymph nodes are located, are felt;
• the woman has been experiencing bleeding for a long time;
• in some cases, there is an accumulation of secretions in the uterine cavity.

Severe pathology

Severe postpartum endometritis begins to appear approximately 2-4 days after the birth of the child. Mostly, this form of pathology begins to develop if the birth was complicated or surgical intervention was performed. The following signs of a severe form of pathology can be identified:

• development of purulent-resorptive fever;
• increased soreness of the uterus;
• the presence of pus in the lochia;
• there is a transition of accumulation of secretions from the uterine cavity to pyometra;
• Anemia is considered a characteristic phenomenon.

There is deterioration general condition patient, which manifests itself:

• in general weakness;
• in severe headaches;
• in loss of appetite;
• in problems with sleep;
• in painful sensations in the lower abdomen.

Postpartum endometritis and caesarean section

The frequency of development of such pathology after cesarean section is determined by the urgency of the surgical intervention. If the caesarean section was planned, then the probability of developing postpartum endometritis is only 5-7%. Emergency abdominal delivery significantly increases the likelihood of developing possible complications and postpartum endometritis develops in about half of women.

Typically, endometritis after a cesarean section progresses in a severe form and is explained by the primary infection of the area of ​​the restored incised uterine cavity.

In addition, there is a rapid course of the inflammatory process and its active penetration beyond the boundaries of the mucous membrane, which causes the development of pathologies such as:

• myometritis;
• lymphadenitis;
• metrothrombophlebitis.

The progression of the inflammatory process in the dissected uterine wall leads to disruption of reparative processes, and the material of the applied suture is a factor contributing to the penetration of infection into the pelvic area and myometrium. In addition, the process of postpartum contraction of the uterus is disrupted, which leads to retention of lochia and disruption of their outflow.

Most often, the manifestation of complications after childbirth by cesarean section begins 1-4 days after the operation, and the following signs are observed:

• increased body temperature;
• severe chills;
• tachycardia;
• rapid pulse;
• anemia;
• severe headaches;
• general weakness of the body;
• sleep problems;
• pain in the lower abdomen.

Postpartum endometritis after surgical intervention accompanied by the slow process of uterine involution. At about 4-6 days, significant changes in the lochia are observed, that is, they become:

• cloudy
• abundant
• watery
• the colors of meat slop
• mixed with pus.

Reasons for the development of complications

The main reason for the development of inflammation on the inner lining of the uterine cavity is the penetration of various microorganisms that fall on the wound formed after the separation of the placenta. There are two ways in which infection of the uterine cavity occurs:

• through the vagina;
• from the site of chronic infection.

Most women have accumulations of opportunistic microorganisms in the vagina that can exist in it for a long time and not cause any concern. With a slight violation of their living conditions, a sharp development of severe pathologies is observed, and streptococci and staphylococci are especially active in this case.

One of the reasons for the increased activity of microorganisms that lead to the development of postpartum endometritis is difficult childbirth, as well as diseases that progress in the female body, which are predominantly sexually transmitted.

If a woman suffers from various chronic diseases, microorganisms may enter the uterine cavity with blood or lymph. In addition to the reasons for the development of postpartum endometritis, factors that contribute to the development of such a complication can be identified:

• prolonged labor, premature rupture of amniotic fluid and a prolonged anhydrous period of the fetus;
• childbirth in women with a narrow pelvis;
• various forms of placenta previa
• premature detachment of the placenta in its normal location;
• infection of the uterus during labor;
• young age of the woman giving birth less than 19 years

Women who are at risk for developing an inflammatory process in the uterine cavity after childbirth are necessarily referred for an ultrasound examination.

Diagnosis of pathology

Since the development of postpartum endometritis in a woman’s body can occur in a latent form, a comprehensive assessment of the patient’s general condition is carried out, taking into account clinical data and the results of laboratory tests.

To diagnose postpartum endometritis, the following methods are used:

• carrying out an echographic examination;
• hysteroscopy;
• ultrasonography;
• biochemical and clinical blood tests;
• bacteriological analysis.

Treatment of the disease

Inflammatory process, which accompanies the development of postpartum endometritis in the female body, is a rather dangerous complication. Its progression can lead to an even greater deterioration of a woman’s condition, therefore, when diagnosing this disease, treatment is carried out only in a hospital setting medical institution under the strict supervision of specialists. Postpartum endometritis in a woman’s body can occur in different ways, and the treatment of this complication is determined by its form.

Acute endometritis

Most often, a woman turns to doctors for help when the course of the pathology has already reached a high degree, which significantly increases the duration of treatment and requires emergency hospitalization. When acute postpartum endometritis is diagnosed in a woman’s body, treatment is carried out using the following methods:

• taking antibiotics, with the course of treatment ranging from 5 to 20 days;
• prescription of anti-inflammatory drugs;
• carrying out mechanical cleaning the uterine cavity in the form of curettage;
• use of painkillers;
• carrying out procedures to cleanse the blood of harmful substances that are formed as a result of the vital activity of microorganisms;
• taking vitamin complexes and immunomodulators
• various physiotherapeutic procedures.

Chronic endometritis

If postpartum endometritis becomes chronic, its treatment is carried out in a certain sequence:

• treatment of sexually transmitted pathologies;
• normalization hormonal levels female body;
• cleaning the uterine cavity from synechiae.

The choice of one or another antibacterial drug is determined by the type of infection that caused the development of the inflammatory process in the uterine cavity. The development of postpartum endometritis due to the penetration of the virus into the uterine cavity requires the prescription of antiviral drugs, the action of which is aimed at increasing the protective functions of the body. Prescribing hormonal treatment by a specialist involves taking oral contraceptives and the course of treatment in this case is 3-6 months.

Postpartum endometritis is an inflammation of the uterine mucosa that occurs after childbirth. In some cases, the inflammatory process may spread to the muscular layer of the uterus, which is already defined as endomyometritis.

The incidence of postpartum endometritis among all postpartum women ranges from 2.6% to 7%. This postpartum inflammatory disease most often occurs in a mild form and ends with recovery. However, in approximately 1/4 of the observations, a severe course of this complication is noted, accompanied by purulent-resorptive fever and the possibility of generalization of the infection. Postpartum endometritis is a type of wound infection, since the inner surface of the uterus after separation of the placenta is an extensive wound surface. Epithelization and regeneration of the endometrium ends only 5-6 weeks after birth. The process of endometrial restoration in the postpartum period is wound healing, characterized by a number of histological features. In the development of postpartum inflammatory complications, including endometritis, the activity of the infectious agent, the massiveness of the infection, the condition of the entrance gates of the infection and the condition of the patient’s body itself are important.

Pathogens of endometritis

The leading role in the development of postpartum endometritis belongs to associations of opportunistic microorganisms. Among facultative anaerobes, the most common pathogens are gram-negative bacteria of the family Enterobacteriaceae ( coli, Klebsiella, Proteus). In 25-60% of cases, bacterial cultures of postpartum women with endometritis contain Gardnerella vaginalis. The proportion of gram-positive cocci, such as group D staphylococcus, has increased (37-52%). Often the cause of this complication is associations of microorganisms with mycoplasma, ureaplasma, and chlamydia. An important fact is that all microbes that normally live in the human body are opportunistic to one degree or another and in a certain situation can cause various inflammatory diseases. After childbirth, significant changes occur in the vaginal microflora, which create the prerequisites for the development of an infectious process. However, by the 6th week of the postpartum period, the vaginal microflora is usually restored to normal.

Chronic endometritis

IN last years women have a high incidence of chronic endometritis. At the same time, microorganisms are identified in endometrial cells that can be potential causative agents of postpartum infection. A thorough microbiological examination of pregnant and postpartum women often reveals carriage of virulent group B streptococcus, mycoplasmas, chlamydia, viral infection. As a result of the widespread and, in some cases, unjustified use of antibiotics, microflora sensitive to these drugs is suppressed, which is replaced by antibiotic-resistant strains of microorganisms. In this case, the natural antagonistic relationships within the microbial associations of the human body are disrupted.

Factors contributing to the occurrence of endometritis

A significant role in the pathogenesis of gastrointestinal tract infections in postpartum women is played by the state of immunity. During pregnancy, especially towards the end, and in the early stages of the postpartum period, women experience a decrease in the body's immunological defense, which is a favorable factor for the development of inflammatory complications in the postpartum period. Restoration of immunological protection to a normal level occurs only by the 5-6th day of the postpartum period during vaginal delivery, and after a cesarean section - by the 10th day. In postpartum women after cesarean section, an additional risk factor for the development of postpartum inflammatory complications is surgical trauma, which entails a more significant decrease in immunological reactivity and its slower recovery than after vaginal delivery. There are several factors, the presence of which increases the likelihood of postpartum endometritis, which include: insufficient level of prenatal examination; unsatisfactory social living conditions; malnutrition; bad habits; infectious inflammatory diseases; inflammatory kidney diseases; neuroendocrine diseases (diabetes mellitus); arterial hypertension ; violation fat metabolism; diseases of the bronchopulmonary system of an inflammatory nature; autoimmune diseases; the presence of chronic foci of infection; anemia; immunodeficiency states; inflammatory diseases of the female genital organs; presence of sexually transmitted diseases; long-term use of an intrauterine contraceptive before pregnancy; a large number of instrumental interventions for abortions and spontaneous miscarriages; previous cesarean section.

Features of the course of this pregnancy can also have a negative impact on the possibility of postpartum endometritis. These features include: anemia; gestosis; exacerbation of chronic infectious diseases during pregnancy; spicy infectious diseases suffered during pregnancy; recurrent colpitis and cervicitis; polyhydramnios; threat of miscarriage; surgical correction of isthmic-cervical insufficiency (sutures on the cervix); low position or placenta previa, placental insufficiency; steroid therapy (dexamethasone, metipred) during current pregnancy; invasive diagnostic methods during pregnancy (amniocentesis, chorionic villus biopsy, cordocentesis, intrauterine monitoring during childbirth).

Features of the course of labor can also affect the possibility of postpartum endometritis. The risk of developing complications increases 3 times with duration birth process and a water-free period of more than 12 hours. Other risk factors during childbirth include: abnormal blood loss; chorioamnionitis during childbirth; control examination of the postpartum uterus; manual separation of the placenta and release of the placenta. Caesarean section, in itself, is a serious risk factor for the development of postpartum endometritis. Important from the point of view of the possibility of the occurrence of endometritis is given by the peculiarities of the course of the postpartum period. In this case, factors increased risk are: failure to comply with personal hygiene rules; inadequate management of the postpartum period; inadequate replacement of blood loss; long bed rest; anemia; exacerbation of foci of chronic infection in the body of a postpartum mother; slow involution of the uterus, lochiometer; the birth of a child with clinical manifestations of intrauterine infection (vesiculosis, pneumonia, sepsis); wound infection (presence of infiltrates, hematomas, suppuration of wounds on the perineum and anterior abdominal wall); transient intestinal paresis after cesarean section.

All of these factors, to one degree or another, can contribute to the development of complications, but each of them individually does not have a decisive influence on their occurrence. When several factors are combined, the risk of developing postpartum endometritis increases accordingly.

Symptoms of postpartum endometritis

The classic mild form of postpartum endometritis begins relatively late, on days 5-12 of the postpartum period. Body temperature rises to 38° - 39° C. Sometimes chills occur when the temperature first rises. The pulse increases to 80-100 beats/min. The number of leukocytes in the blood increases and the ESR increases. The general health of postpartum women does not suffer significantly. Patients experience uterine soreness, which persists for 3-7 days. The size of the uterus is slightly increased, and the discharge from the uterus remains bloody for a long time. Severe postpartum endometritis usually begins earlier, 2-4 days after birth. Moreover, in almost 1/4 of cases this complication develops against the background of chorioamnionitis, after complicated childbirth or surgery. During dynamic observation, patients with a severe form do not improve within 24 hours, and in a number of observations there is even a worsening of the complication. The patient is worried about headaches, weakness, pain in the lower abdomen. There is a disturbance in sleep and appetite, the heart rate increases to tachycardia up to 90-120 beats/min. Body temperature often rises to 39° C or higher, accompanied by chills. There is an increase in the number of leukocytes and ESR in the blood. Upon examination, tenderness and increased size of the uterus are revealed. Discharge from the uterus becomes brown from 3-4 days and subsequently becomes purulent in nature.

After starting treatment, body temperature usually normalizes within 2-4 days. The disappearance of pain and normalization of the nature of discharge from the uterus occurs by 5-7 days of treatment. The blood picture improves by 6-9 days. However, most often in practice the clinical picture of the disease does not reflect the severity of the patient’s condition. In this case, postpartum endometritis has an erased character, and its identification presents certain difficulties. The erased form of postpartum endometritis can occur both after spontaneous and after operative childbirth. The disease often begins on days 3-4. In some patients, it may begin to manifest itself both on the 1st day and on the 5-7th day after birth. In most patients, body temperature initially does not exceed 38 ° C, and chills are rare. In most patients, the discharge from the uterus is initially brown, turns into sanguineous and, in some cases, purulent with a specific ichorous odor. Soreness of the uterus persists for 3-8 days, and sometimes continues until 14-16 days of illness. With treatment, the temperature returns to normal within 5-10 days. However, in some patients, low-grade fever can persist for up to 12-16 days. Involution of the uterus is slowed down. Normalization of the blood picture most often occurs on days 6-15 of the disease. Often, after the temperature normalizes and the blood picture improves, the disease recurs with the same clinical manifestations 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 treatment.

Endometritis after cesarean section

Endometritis after cesarean section deserves some attention, the occurrence of which largely depends on the urgency of the operation. After a planned cesarean section, the proportion of endomyometritis is 5-6%, and after emergency abdominal delivery from 22 to 85%. Endometritis after cesarean section most often occurs in a severe form due to the fact that primary infection of the area of ​​​​the reconstructed incision on the uterus occurs and the inflammatory process quickly spreads beyond the mucous membrane with the subsequent development of myometritis, lymphadenitis and metrothrombophlebitis. In conditions of inflammation, the healing processes in the dissected wall of the uterus are disrupted. In addition, the contractile activity of the uterus is also reduced, which complicates the outflow of secretions from the uterus. The disease often begins 1-2 days after surgery, and in some cases on 4-5 days. Body temperature rises to 38°-39° C or more, accompanied by chills and rapid heartbeat. An increase in heart rate usually corresponds to a rise in temperature. Changes in the blood are noted, indicating the presence of a pronounced infectious process. An increase in body temperature in most patients is accompanied by headaches, weakness, sleep disturbances, appetite, and pain in the lower abdomen. By 4-6 days, discharge from the uterus becomes cloudy, profuse, watery, sometimes has the color of meat slop or takes on a purulent character. Discharge from the uterus becomes normal by 9-11 days. The blood picture returns to normal only 10-24 days after surgery.

Postoperative endometritis can be complicated by intestinal paresis, especially in patients who suffered large blood loss during surgery, which was not adequately replenished. With severe intestinal paresis, its barrier function is disrupted, which leads to the penetration of microbial flora into the abdominal cavity and contributes to the development of such severe and dangerous complication like peritonitis. In a number of observations, swelling of the postoperative suture on the uterus is noted, which contributes to the retention of blood clots, remnants of membranes and placental tissue in the cavity and creates conditions for the development of infection. Considering the possibility of developing erased forms of postpartum endometritis, a comprehensive diagnosis of this disease should be carried out based on an assessment of clinical data, as well as the results of laboratory and instrumental studies, including ultrasound and hysteroscopy.

Treatment of postpartum endometritis

Treatment of postpartum endometritis should also be comprehensive and aimed at localizing the inflammatory process, fighting infection, activating the body's defenses, detoxification and correction of homeostasis. Before starting treatment, material from the uterine cavity and vagina is taken for culture to determine the nature of the causative agents of the complication and their sensitivity to antibiotics. Integral components of the complex treatment of postpartum endometritis are antibacterial, infusion and detoxification therapy, the use of uterine contractions, desensitizing and restorative therapy. To limit inflammation and activate the body's defenses, a protective treatment regimen and sedative therapy are prescribed, which helps to normalize 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.

In some cases, as part of the treatment of postpartum endometritis, it is required debridement the uterine cavity, which includes hysteroscopy, vacuum aspiration of the contents of the uterus, and washing its cavity with chilled antiseptic solutions. When parts of the fertilized egg are retained in the uterus and become further infected, there is a danger of toxins and biologically active substances entering the patient’s body from the source of infection, which contribute to an increase in intoxication and aggravation of the course of the disease. In this case, measures should be taken to remove them by curettage or vacuum aspiration. It is advisable to remove parts of the placenta in patients with a limited inflammatory process while the infection is within the uterus. If the process is more widespread and the infection is generalized, instrumental exposure is contraindicated. Removal of parts of the placenta is carried out under general anesthesia, under the control of hysteroscopy, against the background of complex use of antibiotics, infusion, detoxification and desensitizing therapy. In the absence of a significant amount of contents in the uterine cavity, one can limit oneself to only dilating the cervical canal under anesthesia to create a reliable outflow.

In severe forms of postpartum endometritis, plasmapheresis may be used. The main mechanism of its therapeutic action is considered to be the removal of pathological plasma ingredients, cryoglobulins, microbes and their toxins. In addition, there is a pronounced positive effect on the hemostatic system, rheological properties of blood, and the state of the immune system, which significantly improves the course of the postpartum period in women with PEM and accelerates reparative processes in the uterus. Along with the use medicines As part of the treatment of postpartum endometritis, physiotherapeutic treatment methods can also be used: interference current therapy according to Nemec; low frequency pulse currents; constant magnetic field low. It is also possible to use acupuncture. External and intracavitary irradiation using a low-intensity laser is also used. The effectiveness of complex intensive treatment of postpartum endometritis should be assessed no earlier than 7 days after the start of treatment. If the therapy is not effective, even against the background of satisfactory health of the patient, but clinical and laboratory signs of inflammation persist, it is necessary to decide on the removal of the uterus.

Childbirth is an exciting and touching moment for every woman. 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 postpartum mother, most often heat, indicating the development of a particular infection.

The prevalence of infections in the postpartum period is difficult to calculate. It is known that inflammatory processes of the uterus occur in 5-7% of postpartum women after cesarean section, but the real prevalence remains underestimated.

In a Cochrane review (2012), endometritis was found in 1-3% of cases after vaginal delivery. Postpartum endometritis after cesarean section is 5-10 times more common.

Show all

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 the nearby layers of the uterus and tissue.

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

Endomyometritis 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 uterine soreness, bleeding, and an unpleasant odor 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 mucous membrane of the uterus is protected from infection.

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

This most often occurs after childbirth, when bacteria living in the vagina gain access to the upper genital tract.

Postpartum endometritis is characterized by a 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 since low-grade fever, that is, a temperature of 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 24 hours after birth, or 38 C or above for at least 4 consecutive hours after that.

Endometritis can be a component of a postoperative wound infection, but can also be observed after childbirth, which occurred naturally.

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

Instead of cleansing inner surface Epithelization and regeneration of the endometrium occurs through inflammation of the uterus.

2. Predisposing factors

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

What else increases the likelihood of developing endomyometritis?

Of course, the accumulation of blood in the cavity of the postpartum uterus, which is excellent nutrient medium for bacteria. If there were genital tract infections before or during childbirth, endomyometritis will almost always occur, but there is a chance to prevent it with timely treatment with antibacterial drugs.

Progesterone suppresses the immune system, and decreased immunity, which is aggravated by blood loss during childbirth, is a favorable background for endomyometritis. In some cases, voluntarily or by medical recommendations, the postpartum woman has to give up breastfeeding, and this is reflected in a decrease in the contractility of the uterus.

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

The duration of surgery and the use of suture material further increases the risk of infection 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: gestosis, threat of miscarriage, exacerbation of chronic diseases, anemia. The most significant risk factors associated with the moment of delivery are: duration of labor, anhydrous interval, various anomalies of labor, frequent vaginal examinations, increased blood loss, trauma to the birth canal, surgery (caesarean section).

3. Main pathogens

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

Endomyometritis can be caused opportunistic bacteria, various mycoplasmas, occasionally chlamydia, even more rarely viruses, etc.

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

In the vast majority of observations, the causative factor is several microorganisms that are part of 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 a month to a month and a half after birth.

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

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

1. 1 Ascending (through the cervix);
2. 2 Hematogenous (through blood vessels);
3. 3 Lymphogenic (via lymphatic system, which is facilitated by extensive endometrial defects and genital injuries);
4. 4 Intra-amnionic (as a result invasive methods research) ways.

Most authors identify 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 necrosis of decidual tissue, endomyometritis with retained placental tissue.

4. Symptoms of postpartum endometritis

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

More severe symptoms of intoxication and more severe course The disease is observed in endometritis without ultrasound signs of tissue residues (“pure” endometritis).

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

Treatment of wound complications includes antibacterial therapy and debridement primary focus. Localized infection can be treated empirically with gram-positive antibacterial drugs such as cefazolin and vancomycin.

Diagnostic criteria for various clinical forms of postpartum endometritis have not yet been fully 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 disease. In severe and moderate forms, the first symptoms of the disease appear on the 2nd–3rd day.

In postpartum women diagnosed with mild postpartum endometritis, typical manifestations of the disease can be seen on the 3rd to 5th day.

The diagnosis of endometritis is established clinically, since 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, surgical birth, all postpartum women are advised 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, with abnormal bowel movements (diarrhea) and/or abdominal pain raise suspicion of an infection caused by group A streptococcus, which requires urgent treatment with antibiotics.

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

Outbreaks of streptococcal infection in the postpartum period in women may be associated with infection themselves medical workers, That's why medical staff regularly undergoes appropriate screenings.

Late postpartum endomyometritis (after 7 days after birth) should raise suspicion. should be carried out for endomyometritis that occurs 7 days after birth, as well as in patients with high risk infections, for example in adolescents.

5. Treatment of the disease

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

Treatment of endomyometritis in the postpartum period begins with 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). Also held antimicrobial treatment drugs wide range, detoxification therapy is also important.

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

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

A Cochrane review (2015) on antibacterial therapy for the treatment of endometritis after childbirth analyzed 42 studies (experience of treating more than 4,000 patients).

Fewer cases detected unsuccessful treatment in patients receiving clindamycin with aminoglycosides compared with patients receiving cephalosporins (RR 0.69, 95% CI 0.49 to 0.99) or penicillins (RR 0.65, 95% CI 0.46 to 0.90).

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

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

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

The combination of clindamycin and aminoglycosides (most often gentamicin) is an effective regimen for the treatment of postpartum endomyometritis, but treatment is always prescribed taking into account multiple factors, thereby eliminating the possibility of self-medication.

Other possible antibacterial therapy regimens include a combination of amoxicillin with clavulanic acid; 2-3 generation cephalosporins can also be prescribed, but always in combination with metronidazole.

Alternatively, other broad-spectrum drugs such as imipenem may be chosen. Treatment can only be prescribed individually, there is no universal treatment.

Parenteral treatment with one or another antibacterial drug should be continued until the temperature responds, pain decreases, and the white blood cell count normalizes.

Failure to improve within 72 hours of starting antibiotic therapy or a recurrence of symptoms and signs usually indicates problems in the abdominal cavity, about 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 drug if enterococcal infection is suspected.

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

6. When can antibacterial drugs be stopped?

After sanitizing the source of infection, as well as returning 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, the following regimens are quite effective: oral clindamycin + intramuscular gentamicin, oral amoxicillin-clavulanate, intramuscular cefotetan, intramuscular meropenem or imipenem-cilastatin, oral amoxicillin in combination with metronidazole.

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

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 mother's body, infusion therapy, and sedatives.

It is important to remember that with endomyometritis, the contractility of the uterus is impaired, so contractile drugs must be prescribed.

Proteolytic drugs can also be prescribed to increase the effectiveness of the action. antibacterial drugs.

If placenta remains are found (with ultrasound examination), membranes, blood, pus, it is very important to perform surgical sanitation of the uterus (vacuum aspiration is optimal, 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 prevent wound infection and the development of endomyometritis.

A meta-analysis of randomized controlled trials that compared 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 case of prophylaxis with antibacterial drugs.

8. What is important to remember?

If any changes occur in the mother's condition, consultation with an obstetrician-gynecologist is necessary. But what should be especially alarming regarding endomyometritis?

Appearance in the postpartum period elevated temperature body, unpleasant odor of lochia (vaginal discharge in the postpartum period), abdominal pain (lower, in the stomach area, anywhere) all this requires immediate consultation with an obstetrician-gynecologist!!! And not a moment of hesitation!

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

The internal 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 its form, inflammation is divided into 2 types: acute and chronic. Their symptoms are the same, but in form 2 they are a little blurry. 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;
• ailments (weakness, weakness, headache).

Particular attention should be paid to such symptoms of postpartum endometritis as discharge. Normally, after the birth of a child, heavy discharge with blood occurs within a couple of days. Then they become scanty and acquire brownish and yellowish shades.

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

Symptoms of chronic endometritis

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 with an unpleasant (putrefactive) odor;
• pain during bowel movements.

Causes of endometritis

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

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

Opportunistic microbes can live in a woman’s vagina. For a long time they can live on mucous membranes and not bother their owner. However, when living conditions change, they can cause various diseases. This is especially true for streptococci and staphylococci. Microorganisms may become active due to difficult labor. The cause of postpartum endometritis can also be those infections that are sexually transmitted.

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

Predisposing factors for the development of inflammation and risk groups

Predisposing factors for postpartum endometritis include:

• gestosis (complication of the 2nd half " interesting situation» women, manifested by increased blood pressure, the appearance of protein in the urine, edema);
• prolonged labor, premature rupture of amniotic fluid and a long anhydrous period;
• incorrect placement of the fetus in the uterus;
• childbirth in women under 19 years of age;
• childbirth among representatives of the fair sex, whose pregnancy is their first and who are over 30 years old;
• childbirth in women with a narrow pelvis;
• placenta previa (it partially or completely blocks the exit from the genital organ);
• premature detachment of the placenta, which is normally located;
• infection at the time of birth 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. Typically, after the baby is born, 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 blood and lymph.

Complications of postpartum endometritis can also include:

• progression of the disease into a chronic form;
• 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 fallopian tubes and ovaries).

Severe purulent-septic complications can result in uterine amputation and death.

If untimely and incorrect treatment is used, the following consequences may occur in the future:

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

The list of consequences of endometritis is not exhausted by all of the above complications. The inflammatory process can cause any pathology. To prevent the occurrence of severe 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 giving birth.

Diagnosis of endometritis

When the first symptoms occur of this disease 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 gynecological examination. Upon examination, a gynecologist may detect symptoms of postpartum endometritis - increased size of the uterus, pain when palpated, 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. Culture allows you to evaluate the effectiveness of a particular medication.

Endometritis can be detected using 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, and to detect the presence of complications (inflammation of the uterine appendages). Thanks to ultrasound in case of chronic endometritis, it is possible to detect synechiae inside the uterus (adhesions), which are often the cause of miscarriage or infertility.

Inflammation of the uterine mucosa can be identified by the results general analysis blood. An increase in the level of leukocytes (white blood cells) indicates the presence of endometritis.

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

Another method that allows you to diagnose this disease in a woman is an endometrial biopsy. For research it is taken small piece inner uterine lining. 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 it is difficult to make 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 make a correct diagnosis.

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 detect suspicious symptoms turn to a doctor for help too late. It leads to long-term treatment and hospitalization.

The basic 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 (scraping if there are remains of the placenta in the organ);
• anesthesia;
• detoxification (cleansing the blood of harmful substances produced by microorganisms);
• use of immunomodulators and vitamin preparations;
• the use of physiotherapeutic methods of treatment (low-intensity UHF therapy, infrared laser therapy).

Treatment of chronic endometritis

At chronic form Postpartum endometritis treatment consists of several stages:

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

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

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

Adhesions are removed surgically with the use of painkillers. A hyteroscope is used to examine the uterine cavity. With its help, you can detect adhesions in the cavity of the reproductive organ and dissect them.

Additional treatment features

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

While in the hospital you need to follow bed rest and diet. During 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 include more liquids and various fruits.

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

Prevention of postpartum endometritis

Inflammation of the uterine mucosa can be prevented by excluding the influence of all factors that predispose to the occurrence of the disease. Most in the right ways prevention measures are the following: refusal of abortion; timely treatment sexually transmitted infections. A woman should listen to her doctor and come after childbirth as prescribed for ultrasound and gynecological examinations.

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