19.04.2019

Pelvic inflammation treatment. Treatment of inflammatory process in the vagina. Folk remedies for the treatment of inflammatory diseases of the pelvic organs

Pelvic inflammatory diseases (PID) are characterized by various manifestations depending on the level of damage and the strength of the inflammatory response. The disease develops as a result of penetration of a pathogen (enterococci, bacteroids, chlamydia, mycoplasmas, ureaplasmas, trichomonas) into the genital tract and in the presence of favorable conditions for its development and reproduction. Such conditions are created in the postpartum or post-abortion period, during menstruation, during various intrauterine manipulations (insertion of an IUD, hysteroscopy, hysterosalpingography, diagnostic curettage).

Existing natural defense mechanisms, such as anatomical features, local immunity, acidic environment of vaginal contents, lack of endocrine disorders or serious extragenital diseases, are able in the vast majority of cases to prevent the development of genital infection. An inflammatory response occurs to the invasion of a particular microorganism, which, based on the latest concepts of the development of the septic process, is usually called a systemic inflammatory response.

Acute salpingoophoritis

It is one of the most common diseases of inflammatory etiology in women. Every fifth woman who has suffered salpingo-oophoritis is at risk of infertility. Adnexitis may be the cause high risk ectopic pregnancy And pathological course pregnancy and childbirth. The fallopian tubes are the first to be affected, and the inflammatory process can involve all layers of the mucous membrane of one or both tubes, but more often only the mucous membrane of the tube is affected, and catarrhal inflammation of the mucous membrane of the tube occurs - endosalpingitis. Inflammatory exudate, accumulating in the tube, often flows through the ampullary opening into the abdominal cavity, adhesions form around the tube, and the abdominal opening of the tube closes. A saccular tumor develops in the form of a hydrosalpinx with transparent serous contents or a pyosalpinx with purulent contents. Subsequently, the serous exudate of the hydrosalpinx resolves as a result of treatment, and the purulent pyosalpinx can perforate into the abdominal cavity. The purulent process can capture and melt all large areas of the pelvis, spreading to all internal genitalia and nearby organs.

Inflammation of the ovaries (oophoritis) as a primary disease is rare; infection occurs in the area of the ruptured follicle, since the rest of the ovarian tissue is well protected by the covering germinal epithelium. In the acute stage, edema and small cell infiltration are observed. Sometimes in the follicle cavity corpus luteum or small follicular cysts, ulcers, microabscesses are formed, which, merging, form an ovarian abscess, or pyovarium. It is almost impossible to diagnose an isolated inflammatory process in the ovary, and this is not necessary. Currently, only 25-30% of patients with acute adnexitis have a pronounced picture of inflammation, the rest experience a transition to chronic form, when therapy is stopped after the clinic quickly subsides.

Acute salpingoophoritis is treated with antibiotics (preferably fluoroquinolones III generation- ciprofloxacin, tarivid, abactal), since it is often accompanied by pelvioperitonitis - inflammation of the pelvic peritoneum.

Endometritis

Acute endometritis always requires antibacterial therapy. The basal layer of the endometrium is affected by the inflammatory process due to the invasion of specific or nonspecific pathogens. Defense Mechanisms endometrium, congenital or acquired, such as T-lymphocyte aggregates and other elements of cellular immunity, are directly related to the action of sex hormones, especially estradiol. These mechanisms act in conjunction with the macrophage population and protect the body from damaging factors. With the onset of menstruation, this barrier on a large surface of the mucous membrane disappears, which makes it possible to become infected. Another source of protection in the uterus is the infiltration of the underlying tissues with polymorphonuclear leukocytes and the rich blood supply of the uterus, which promotes adequate perfusion of the organ with blood and nonspecific humoral protective elements contained in its serum: transferrin, lysozyme, opsonins.

The inflammatory process can spread to the muscle layer, resulting in metroendometritis and metrothrombophlebitis with a severe clinical course. The inflammatory reaction is characterized by a disorder of microcirculation in the affected tissues, expressed by exudation; with the addition of anaerobic flora, necrotic destruction of the myometrium can occur.

Clinical manifestations of acute endometritis: already on the 3-4th day after infection, an increase in body temperature, tachycardia, leukocytosis and a shift in the blood, an increase in ESR are observed. Moderate enlargement of the uterus is accompanied by pain, especially along its ribs (along the blood and lymphatic vessels). Purulent-bloody discharge appears. The acute stage of endometritis lasts 8-10 days and requires quite serious treatment. With proper treatment, the process ends, less often it turns into a subacute and chronic form, and even less often, with self-administered indiscriminate antibiotic therapy, endometritis can take a milder abortive course.

Treatment of acute endometritis, regardless of the severity of its manifestations, begins with antibacterial infusion, desensitizing and restorative therapy.

Antibiotics are best prescribed taking into account the sensitivity of the pathogen to them; doses and duration of antibiotic use are determined by the severity of the disease. Due to the frequency of anaerobic infections, metronidazole is additionally recommended. Considering the very rapid course of endometritis, cephalosporins with aminoglycosides and metronidazole are preferred among antibiotics. For example, cefamandole (or cefuroxime, claforan) 1-2 g 3-4 times a day IM or IV drip + gentamicin 80 mg 3 times a day IM + Metrogyl 100 ml IV drip.

Instead of cephalosporins, semisynthetic penicillins can be used (if abortive course), for example ampicillin 1 g 6 times a day. The duration of such combined antibacterial therapy depends on the clinic and laboratory response, but not less than 7-10 days. To prevent dysbiosis from the first days of antibiotic treatment, use nystatin 250,000 units 4 times a day or diflucan 50 mg per day for 1-2 weeks orally or intravenously.

Detoxification infusion therapy may include a number of infusion agents, for example, Ringer-Locke solution - 500 ml, polyionic solution - 400 ml, hemodez (or polydesis) - 400 ml, 5% glucose solution - 500 ml, 1% solution calcium chloride— 200 ml, unithiol with 5% solution ascorbic acid 5 ml 3 times a day. In the presence of hypoproteinemia, it is advisable to carry out infusions of protein solutions (albumin, protein), blood replacement solutions, plasma, red blood cells or whole blood, amino acid preparations.

Physiotherapeutic treatment occupies one of the leading places in the treatment of acute endometritis. It not only reduces the inflammatory process in the endometrium, but also stimulates ovarian function. When normalizing the temperature reaction, it is advisable to prescribe low-intensity ultrasound, inductothermy electromagnetic field HF or UHF, magnetic therapy, laser therapy.

Pelvioperitonitis

Inflammation of the pelvic peritoneum most often occurs secondary to the penetration of infection into the abdominal cavity from an infected uterus (with endometritis, infected abortion, ascending gonorrhea), fallopian tubes, ovaries, intestines, with appendicitis, especially with a pelvic location. In this case, an inflammatory reaction of the peritoneum is observed with the formation of serous, serous-purulent or purulent effusion. The condition of patients with pelvioperitonitis remains satisfactory or moderate severity. The temperature rises, the pulse quickens, but the function of cardio-vascular system is almost not disturbed. With pelvioperitonitis, or local peritonitis, the intestine remains unbloated, palpation of the upper half of the organs abdominal cavity painless, and symptoms of peritoneal irritation are determined only above the pubis and in the iliac regions. However, patients report severe pain in the lower parts abdomen, there may be retention of stool and gas, and sometimes vomiting. The level of leukocytes is increased, the formula shifts to the left, the ESR is accelerated. Gradually increasing intoxication worsens the condition of patients.

Treatment of salpingoophoritis with or without pelvioperitonitis begins with a mandatory examination of the patient for flora and sensitivity to antibiotics. Most importantly, the etiology of inflammation should be determined. Today, benzylpenicillin is widely used for the treatment of specific gonorrheal process, although preference should be given to drugs such as Rocephin, Cephobid, Fortum.

The “gold standard” of antibacterial therapy for salpingoophoritis is the prescription of claforan (cefotaxime) at a dose of 1-2 g 2-4 times a day intramuscularly or one dose of 2 g intravenously in combination with gentamicin 80 mg 3 times a day (can Gentamicin is administered once at a dose of 160 mg IM). It is imperative to combine these drugs with Metrazdil, which is administered intravenously at a dose of 100 ml 1-3 times a day. The course of antibiotic treatment should be carried out for at least 5-7 days, you can vary mainly basic drugs by prescribing cephalosporins of the second and third generation (mandol, zinacef, rocephin, cephobid, fortum and others at a dose of 2-4 g per day).

In case of acute inflammation of the uterine appendages, complicated by pelvioperitonitis, oral administration of antibiotics is possible only after the main course of therapy and only if necessary. As a rule, such a need does not arise, and maintaining the previous clinical symptoms may indicate that inflammation is progressing and, possibly, a suppurative process is occurring.

Detoxification therapy is mainly carried out with crystalloid and detoxification solutions in an amount of 2-2.5 liters with the inclusion of solutions of hemodez, rheopolyglucin, Ringer-Locke, polyionic solutions - acessol, etc. Antioxidant therapy is carried out with a solution of unithiol 5 ml with a 5% solution of ascorbic acid 3 times a day i.v.

In order to normalize the rheological and coagulation properties of blood and improve microcirculation, aspirin 0.25 g/day is used for 7-10 days, as well as intravenous administration of rheopolyglucin 200 ml (2-3 times per course). Subsequently, a complex of resorption therapy and physiotherapeutic treatment is used (calcium gluconate, autohemotherapy, sodium thiosulfate, humizol, plasmol, aloe, FIBS). Of the physiotherapeutic procedures for acute processes, ultrasound is appropriate, which causes analgesic, desensitizing and fibrolytic effects, as well as strengthening metabolic processes and tissue trophism, inductothermy, UHF therapy, magnetic therapy, laser therapy, and later - sanatorium-resort treatment.

Purulent tubo-ovarian formations

Among 20-25% of patients suffering from inflammatory diseases of the uterine appendages, 5-9% experience purulent complications requiring surgical interventions.

You can select the following provisions concerning the formation of purulent tubo-ovarian abscesses:

chronic salpingitis in patients with tubo-ovarian abscesses is observed in 100% of cases and precedes them;
the spread of infection occurs predominantly through the intracanalicular route from endometritis (with IUD, abortion, intrauterine interventions) to purulent salpingitis and oophoritis;
there is often a combination of cystic transformations in the ovaries and chronic salpingitis;
there is a mandatory combination of ovarian abscesses with exacerbation of purulent salpingitis;
ovarian abscesses (pyovarium) are formed mainly from cystic formations, often microabscesses merge.

Morphological forms of purulent tubo-ovarian formations:

pyosalpinx - predominant defeat fallopian tube;
pyovarium - predominant damage to the ovary;
tubo-ovarian tumor.

All other combinations are complications of these processes and can occur:

without perforation;
with perforation of ulcers;
with pelvioperitonitis;
with peritonitis (limited, diffuse, serous, purulent);
with pelvic abscess;
with parametritis (posterior, anterior, lateral);
with secondary lesions of adjacent organs (sigmoiditis, secondary appendicitis, omentitis, interintestinal abscesses with the formation of fistulas).

Clinically differentiating each localization is almost impossible and impractical, since the treatment is fundamentally the same: antibacterial therapy in this case takes the leading place both in the use of the most active antibiotics and in the duration of their use. At the core purulent processes lies the irreversible nature of the inflammatory process. Its irreversibility is due to morphological changes, their depth and severity caused by impaired renal function.

Conservative treatment irreversible changes in the uterine appendages are unpromising, since it creates the preconditions for the occurrence of new relapses and aggravation of metabolic disorders in patients, increases the risk of the upcoming operation in terms of damage to adjacent organs and the inability to perform the required volume of the operation.

Purulent tubo-ovarian formations are associated with great difficulties both in diagnostic and clinically. Nevertheless, a number of characteristic syndromes can be identified:

intoxication;
painful;
infectious;
early renal;
hemodynamic disorders;
inflammation of adjacent organs;
metabolic disorders.

Clinically, intoxication syndrome is manifested by the phenomena of intoxication encephalopathy: headaches, heaviness in the head and severe general condition. Dyspeptic disorders (dry mouth, nausea, vomiting), tachycardia, and sometimes hypertension (or hypotension when the septic shock, which is one of its early symptoms along with cyanosis and facial flushing against the background of severe pallor).

Pain syndrome, present in almost all patients, is of an increasing nature, accompanied by deterioration general condition and well-being; pain during a special examination and symptoms of irritation of the peritoneum around the palpable formation are noted. Pulsating increasing pain, persistent fever with body temperature above 38°C, tenesmus, loose stool, absence of clear contours of the tumor, lack of effect from treatment - all this indicates the threat of perforation or its presence, which is an absolute indication for urgent surgical treatment. The infectious syndrome is present in all patients and is accompanied in most of them by high body temperature (38°C and above). Tachycardia corresponds to fever, as well as an increase in leukocytosis, the ESR and leukocyte index of intoxication increase, the number of lymphocytes decreases, the shift to the left increases, the number of molecules of average mass increases, reflecting ever-increasing intoxication. Often, due to impaired urine passage, renal dysfunction occurs. Metabolic disorders manifest themselves in the form of dysproteinemia, acidosis, electrolyte disturbances, and changes in the antioxidant system.

The treatment strategy for this group of patients is based on the principles of organ-preserving operations, which nevertheless provide for radical removal of the main source of infection. Therefore, for each specific patient, the time and scope of the operation must be selected individually. Clarifying the diagnosis sometimes takes several days, especially in cases where there is a borderline variant between suppuration and acute inflammatory process or when differential diagnosis oncological process. Antibacterial therapy is required at each stage of treatment.

Preoperative therapy and preparation for surgery include:

antibiotics (cephobid 2 g/day, fortum 2-4 g/day, reflin 2 g/day, augmentin 1.2 g intravenously once a day, clindamycin 2-4 g/day, etc.); they must be combined with gentamicin 80 mg IM 3 times a day and an infusion of Metragil 100 ml IV 3 times;
detoxification therapy with infusion correction of volemic and metabolic disorders;
mandatory assessment of the effectiveness of treatment based on the dynamics of body temperature, peritoneal symptoms, general condition and blood counts.

At the surgical stage, it is necessary to continue antibacterial therapy. It is especially important to administer one daily dose of antibiotics on the operating table, immediately after the end of the operation. This concentration is necessary because it creates a barrier to further dissemination infections: penetration into the area of inflammation is no longer prevented by dense purulent capsules of tubo-ovarian abscesses. Betalactam antibiotics (cephobid, rocephin, fortum, claforan, tienam, augmentin) overcome these barriers well.

Postoperative therapy involves continuing antibacterial therapy with the same antibiotics in combination with antiprotozoal, antimycotic drugs and uroseptics. The duration of treatment depends on the clinical picture and laboratory data (at least 7-10 days). The discontinuation of antibiotics is carried out in accordance with their toxic properties, therefore gentamicin is often discontinued first after 5-7 days of therapy or replaced with amikacin.

Infusion therapy should be aimed at combating hypovolemia, intoxication and metabolic disorders. Normalization of gastrointestinal motility is very important (intestinal stimulation, HBOT, hemosorption or plasmapheresis, enzymes, epidural blockade, gastric lavage, etc.). Hepatotropic, restorative and antianemic therapy is combined with immunostimulating treatment (UVR, laser blood irradiation, immunocorrectors).

All patients who have undergone surgery for purulent tubo-ovarian abscesses require post-hospital rehabilitation in order to prevent relapses and restore specific body functions.

Literature

Abramchenko V.V., Kostyuchek D.F., Perfileva G.N. Purulent-septic infection in obstetric and gynecological practice. St. Petersburg, 1994. 137 p.
Bashmakova M. A., Korkhov V. V. Antibiotics in obstetrics and perinatology. M., 1996. P. 6.
Bondarev N. E. Optimization of diagnosis and treatment of mixed sexually transmitted diseases in gynecological practice: Abstract of thesis. dis. ...cand. honey. Sci. St. Petersburg, 1997. 20 p.
Ventsela R. P. Nosocomial infections. M., 1990. 656 p.
Gurtovoy B. L., Serov V. N., Makatsaria A. D. Purulent-septic diseases in obstetrics. M., 1981. 256 p.
Keith L.G., Berger G.S., Edelman D.A. Reproductive health. T. 2. Rare infections. M., 1988. 416 p.
Krasnopolsky V. I., Kulakov V. I. Surgery inflammatory diseases of the uterine appendages. M., 1984. 234 p.
Korkhov V.V., Safronova M.M. Modern approaches for the treatment of inflammatory diseases of the vulva and vagina. M., 1995. P. 7-8.
Kumerle X. P., Brendel K. Clinical pharmacology during pregnancy / Ed. X. P. Kumerle, K. Brendel: Trans. from English In 2 volumes. T. 2. M., 1987. 352 p.
Serov V.N., Strizhakov A.N., Markin S.A. Practical obstetrics: A guide for doctors. M., 1989. 512 p.
Serov V.N., Zharov E.V., Makatsaria A.D. Obstetric peritonitis: Diagnostics, clinic, treatment. M., 1997. 250 p.
Strizhakov A. N., Podzolkova N. M. Purulent inflammatory diseases of the uterine appendages. M., 1996. 245 p.
Khadzhieva E. D. Peritonitis after caesarean section: Tutorial. St. Petersburg, 1997. 28 p.
Sahm D. E. The role of automation and molecular technology in antimicrobial susceptibility testing // Clin. Microb. And Inf. 1997. Vol. 3. No. 2. P. 37-56.
Snuth C. B., Noble V., Bensch R. et al. Bacterial flora of the vagina during the mensternal cycle // Ann. Intern. Med. 1982. P. 48-951.
Tenover F. Norel and emerging mechanisms of antimicrobial resistance in nosocomial pathogens // Am. J. Med. 1991. 91. P. 76-81.

According to statistics, pelvic inflammatory diseases (PID), as well as inflammation of the female genital organs in general, occupy first place in gynecological pathology. In terms of requests for help from a doctor, infections and diseases of the pelvic organs account for 65% of all cases. In 60% of cases, PID is caused by sexually transmitted infections or sexually transmitted infections (STIs). According to WHO, chlamydia and gonorrhea are noted in 65–70% of all cases of PID

Accepted in gynecology classification according to the location of the inflammatory process in the pelvic regions.

Diseases of the lower genital organs:

vulvitis (inflammation in the external female genitalia);
bartholinitis (inflammation of the gland of the vaginal vestibule);
colpitis (inflammatory process of the vaginal mucosa);
endocervicitis and cervicitis, chronic and acute (inflammation of the uterus and its cervical canal);

Inflammation of the pelvic organs located in the upper sections:

Pelvioperitonitis (pelvic inflammation in the peritoneum);
Unilateral and bilateral salpingoophoritis (a combination of an inflammatory process in the tubes and ovaries);
Endomyometritis (inflammation covers the mucous and muscular layers of the uterus);
Parametritis (periuterine tissue is affected).

Another dividing sign of inflammatory processes is the course of the disease. There are acute forms of the disease, subacute and chronic.

The criterion that determines the treatment tactics for such diseases is the type of pathogen that caused infections of the pelvic organs.

Cause of inflammation of the uterus and appendages There are various microorganisms that penetrate the genital tract: viruses, fungi, protozoa and bacteria.

As a rule, inflammation of the uterus and appendages occurs in at a young age, taking a severe course in 60-80% of cases. Often the onset of the disease coincides with the onset of sexual activity.

Risk factors for inflammation of the uterus and appendages:

A woman has a large number of sexual partners;

The presence of a large number of sexual partners with a sexual partner;

Use of intrauterine contraceptives (spirals);

Douching (helps to “wash out” normal microflora from the vagina and replace it with conditionally pathogenic);

Previous history of inflammation of the uterus and appendages or sexually transmitted diseases;

Violation of the protective mechanisms caused by the mucous plug of the cervical canal (contains antibacterial substances), in particular, with endocervicitis;

Ectropion (eversion of the mucous membrane) of the cervix is a condition that occurs as a result of undetected ruptures of the cervix during childbirth.

Besides, contribute to the development of inflammation of the uterus and appendages general diseases; big exercise stress and mental stress, stressful situations; endocrine disorders; allergic factors; the presence of a dormant (latent) infection in the body.

Symptoms of inflammation of the uterus and appendages:

Redness, swelling, itching of the mucous membrane of the vulva and vagina;
Pressure and pain in the lower abdomen, pelvic area;
Pain during sexual intercourse (dyspareunia);
Pain in the lower back;
Copious mucous or mucopurulent vaginal discharge with unpleasant smell and a yellowish tint;
Discharge with an unpleasant odor, yellowish, cloudy with gas bubbles;
Curd-like discharge accompanied by itching or burning;
Bloody discharge, mucopurulent discharge with pain in the lower abdomen;
Irregular menstruation;
high fever, fatigue, diarrhea, or vomiting;
Painful or difficult urination.

When to see a doctor?

You need emergency medical care if you:

Intense pain in the lower abdomen;
Vomit;
Signs of shock such as fainting;
Fever, temperature above 38.3°C

What are the complications of PID?

Early diagnosis and adequate treatment can prevent complications of PID. If left untreated, PID can cause damage reproductive organs women:

Tubal infertility occurs in 15-20% of women with PID;
Ectopic pregnancy develops in 12-15% of women with PID;
Chronic pelvic pain occurs in 18% of women with PID;
Tubo-ovarian abscess is one of the causes of death in women from PID;
Pelvioperitonitis is inflammation of the pelvic peritoneum. It is a serious complication of PID, often leading to sepsis. It develops secondary to damage to the uterus, fallopian tubes and ovaries when pathogenic microorganisms penetrate from them through contact, hematogenous and lymphogenous routes.

Repeated episodes of PID increase the chances of developing these complications.

Diagnosis of inflammatory diseases of the pelvic organs

PID is often difficult to diagnose because symptoms may be subtle. However, the diagnosis is made based on clinical examination. For an accurate diagnosis, it is necessary to examine a cervical smear (smear from the cervix) for infection using PCR and bacteriological culture. If an infection is detected (for example, chlamydia or gonorrhea), it is necessary specific treatment. However, a negative result for infection does not mean the absence of PID.

Ultrasound examination of the pelvic organs is a very informative procedure. Ultrasound allows you to see the enlargement of the fallopian tubes, as well as determine the presence of purulent cavities.

In some cases, laparoscopy becomes necessary. Laparoscopy is a minor surgical procedure in which a thin, flexible tube (laparoscope) is inserted through a small incision in the lower abdomen. The doctor has the opportunity to examine the pelvic organs and even take sections of tissue for examination, if necessary. Laparoscopy is considered the most reliable diagnostic method, but it is rarely used when other studies are unsuccessful.

Treatment of the disease

The main components of the treatment of pelvic inflammation:

antibiotics (ORCIPOL - a combined antibacterial drug consisting of 2 components: ciprofloxacin - a broad-spectrum antibiotic of the 2nd generation fluoroquinolone group and ornidazole - an antibacterial drug that affects anaerobic microflora and protozoa. Used only as prescribed by a doctor. Available in tablets of 10 pieces , is used 2 times a day, i.e. the package is enough for a course of treatment of 5 days. The drug is a combination drug, so there is no need to use ciprofloxacin and/or ornidazole separately, SECNIDOX is the only secnidazole on the Ukrainian market, is available in tablets and is used as directed doctor, when it is necessary to influence anaerobic, atypical microflora and protozoa);
anti-inflammatory drugs;
antihistamines and antifungal drugs(FLUZAMED - fluconazole, a systemic antifungal drug in the form of a 150 mg capsule. Dispensed from the pharmacy without a prescription. With for preventive purposes A single dose of the drug is sufficient);
painkillers;
local procedures - washing, douching, drugs with intravaginal release forms (LIMENDA - vaginal suppositories, which contain 2 components: metronidazole + miconazole. Used in complex therapy bacterial vaginosis with tablet forms of metronidazole, tinidazole, ornidazole, secnidazole and used as prescribed by a doctor, BIOSELAC - vaginal capsules containing a standardized strain of Lactobacillus, which is normal microflora woman's vagina. There are 10 capsules in a package, use 1-2 capsules per day for 7-10 days. First ones are better Take 2 capsules per day for 2-3 days, and then switch to a single dose, 1 capsule at night);
general strengthening agents (GOLD RAY – natural preparation based on royal jelly, wheat germ oil, garlic powder.

GOLD RAY is intended to strengthen the body after a course of antibiotic therapy, as well as in complex treatment diseases of the genital area in women (algodismenorrhea, menopausal syndrome, premenstrual syndrome, inflammatory diseases of the female genital organs, infertility).

The duration and effectiveness of treatment depends on the stage of the disease and the advanced stage of the process.

Hospitalization is indicated:

severe signs of disease (pain, nausea, vomiting, high fever);
PID during pregnancy;
lack of effect from taking antibiotics orally or the need for intravenous administration;

purulent inflammation of the tubes or ovaries; if the inflammation continues or the ulcers do not go away, treatment is carried out surgically.

V. N. Kuzmin

Doctor of Medical Sciences, Professor, MGMSU, Moscow

Existing natural protective mechanisms, such as anatomical features, local immunity, the acidic environment of the vaginal contents, the absence of endocrine disorders or serious extragenital diseases, can in the vast majority of cases prevent the development of genital infection. An inflammatory response occurs to the invasion of a particular microorganism, which, based on the latest concepts of the development of the septic process, is usually called a systemic inflammatory response.

Acute salpingoophoritis

It is one of the most common diseases of inflammatory etiology in women. Every fifth woman who has suffered salpingo-oophoritis is at risk of infertility. Adnexitis can cause a high risk of ectopic pregnancy and pathological course of pregnancy and childbirth. The fallopian tubes are the first to be affected, and the inflammatory process can involve all layers of the mucous membrane of one or both tubes, but more often only the mucous membrane of the tube is affected, and catarrhal inflammation of the mucous membrane of the tube occurs - endosalpingitis. Inflammatory exudate, accumulating in the tube, often flows through the ampullary opening into the abdominal cavity, adhesions form around the tube, and the abdominal opening of the tube closes. A saccular tumor develops in the form of a hydrosalpinx with transparent serous contents or a pyosalpinx with purulent contents. Subsequently, the serous exudate of the hydrosalpinx resolves as a result of treatment, and the purulent pyosalpinx can perforate into the abdominal cavity. The purulent process can capture and melt all large areas of the pelvis, spreading to all internal genitalia and nearby organs.

Inflammation of the ovaries (oophoritis) as a primary disease is rare; infection occurs in the area of the ruptured follicle, since the rest of the ovarian tissue is well protected by the covering germinal epithelium. In the acute stage, edema and small cell infiltration are observed. Sometimes, in the cavity of the follicle of the corpus luteum or small follicular cysts, ulcers and microabscesses form, which, merging, form an ovarian abscess, or pyovarium. It is almost impossible to diagnose an isolated inflammatory process in the ovary, and this is not necessary. Currently, only 25-30% of patients with acute adnexitis have a pronounced picture of inflammation, while the rest experience a transition to a chronic form, when therapy is stopped after the clinic quickly subsides.

Acute salpingoophoritis is treated with antibiotics (preferably third generation fluoroquinolones - ciprofloxacin, tarivid, abactal), since it is often accompanied by pelvioperitonitis - inflammation of the pelvic peritoneum.

Endometritis

Acute endometritis always requires antibacterial therapy. The basal layer of the endometrium is affected by the inflammatory process due to the invasion of specific or nonspecific pathogens. Endometrial protective mechanisms, congenital or acquired, such as T-lymphocyte aggregates and other elements of cellular immunity, are directly related to the action of sex hormones, especially estradiol. These mechanisms act in conjunction with the macrophage population and protect the body from damaging factors. With the onset of menstruation, this barrier on a large surface of the mucous membrane disappears, which makes it possible to become infected. Another source of protection in the uterus is the infiltration of the underlying tissues with polymorphonuclear leukocytes and the rich blood supply of the uterus, which promotes adequate perfusion of the organ with blood and nonspecific humoral protective elements contained in its serum: transferrin, lysozyme, opsonins.

Treatment of acute endometritis, regardless of the severity of its manifestations, begins with antibacterial infusion, desensitizing and restorative therapy.

Instead of cephalosporins, you can use semi-synthetic penicillins (for abortive cases), for example, ampicillin 1 g 6 times a day. The duration of such combined antibacterial therapy depends on the clinic and laboratory response, but not less than 7-10 days. To prevent dysbiosis from the first days of antibiotic treatment, use nystatin 250,000 units 4 times a day or diflucan 50 mg per day for 1-2 weeks orally or intravenously.

Detoxification infusion therapy may include a number of infusion agents, for example, Ringer-Locke solution - 500 ml, polyionic solution - 400 ml, hemodez (or polydesis) - 400 ml, 5% glucose solution - 500 ml, 1% calcium chloride solution - 200 ml, unithiol with a 5% solution of ascorbic acid, 5 ml 3 times a day. In the presence of hypoproteinemia, it is advisable to carry out infusions of protein solutions (albumin, protein), blood replacement solutions, plasma, red blood cells or whole blood, amino acid preparations.

Physiotherapeutic treatment occupies one of the leading places in the treatment of acute endometritis. It not only reduces the inflammatory process in the endometrium, but also stimulates ovarian function. When normalizing the temperature reaction, it is advisable to prescribe low-intensity ultrasound, inductothermy with an HF or UHF electromagnetic field, magnetic therapy, and laser therapy.

Pelvioperitonitis

Inflammation of the pelvic peritoneum most often occurs secondary to the penetration of infection into the abdominal cavity from an infected uterus (with endometritis, infected abortion, ascending gonorrhea), fallopian tubes, ovaries, intestines, with appendicitis, especially with a pelvic location. In this case, an inflammatory reaction of the peritoneum is observed with the formation of serous, serous-purulent or purulent effusion. The condition of patients with pelvioperitonitis remains satisfactory or moderate. The temperature rises, the pulse quickens, but the function of the cardiovascular system is almost not impaired. With pelvioperitonitis, or local peritonitis, the intestine remains unbloated, palpation of the upper half of the abdominal organs is painless, and symptoms of peritoneal irritation are determined only above the pubis and in the iliac regions. However, patients note severe pain in the lower abdomen, there may be retention of stool and gas, and sometimes vomiting. The level of leukocytes is increased, the formula shifts to the left, the ESR is accelerated. Gradually increasing intoxication worsens the condition of patients.

In case of acute inflammation of the uterine appendages, complicated by pelvioperitonitis, oral administration of antibiotics is possible only after the main course of therapy and only if necessary. As a rule, such a need does not arise, and the persistence of previous clinical symptoms may indicate that the inflammation is progressing and, possibly, a suppurative process is occurring.

In order to normalize the rheological and coagulation properties of blood and improve microcirculation, aspirin 0.25 g/day is used for 7-10 days, as well as intravenous administration of rheopolyglucin 200 ml (2-3 times per course). Subsequently, a complex of resorption therapy and physiotherapeutic treatment is used (calcium gluconate, autohemotherapy, sodium thiosulfate, humizol, plasmol, aloe, FIBS). Of the physiotherapeutic procedures for acute processes, ultrasound is appropriate, which causes analgesic, desensitizing and fibrolytic effects, as well as enhancing metabolic processes and tissue trophism, inductothermy, UHF therapy, magnetic therapy, laser therapy, and later - sanatorium treatment.

Purulent tubo-ovarian formations

Among 20-25% of patients suffering from inflammatory diseases of the uterine appendages, 5-9% experience purulent complications requiring surgical interventions.

The following provisions regarding the formation of purulent tubo-ovarian abscesses can be highlighted:

chronic salpingitis in patients with tubo-ovarian abscesses is observed in 100% of cases and precedes them;

the spread of infection occurs predominantly through the intracanalicular route from endometritis (with IUD, abortion, intrauterine interventions) to purulent salpingitis and oophoritis;

there is often a combination of cystic transformations in the ovaries and chronic salpingitis;

there is a mandatory combination of ovarian abscesses with exacerbation of purulent salpingitis;

Ovarian abscesses (pyovarium) are formed mainly from cystic formations, often microabscesses merge.

Morphological forms of purulent tubo-ovarian formations:

pyosalpinx - predominant damage to the fallopian tube;

pyovarium - predominant damage to the ovary;

tubo-ovarian tumor.

All other combinations are complications of these processes and can occur:

without perforation;

with perforation of ulcers;

with pelvioperitonitis;

with peritonitis (limited, diffuse, serous, purulent);

with pelvic abscess;

with parametritis (posterior, anterior, lateral);

with secondary lesions of adjacent organs (sigmoiditis, secondary appendicitis, omentitis, interintestinal abscesses with the formation of fistulas).

Clinically differentiating each localization is almost impossible and impractical, since the treatment is fundamentally the same: antibacterial therapy in this case takes the leading place both in the use of the most active antibiotics and in the duration of their use. The basis of purulent processes is the irreversible nature of the inflammatory process. Its irreversibility is due to morphological changes, their depth and severity caused by impaired renal function.

Conservative treatment of irreversible changes in the uterine appendages is unpromising, since it creates the preconditions for the occurrence of new relapses and aggravation of metabolic disorders in patients, increases the risk of upcoming surgery in terms of damage to adjacent organs and the inability to perform the required volume of surgery.

Purulent tubo-ovarian formations are associated with great difficulties both diagnostically and clinically. Nevertheless, a number of characteristic syndromes can be identified:

intoxication;

infectious;

early renal;

hemodynamic disorders;

inflammation of adjacent organs;

metabolic disorders.

Clinically, intoxication syndrome is manifested by the phenomena of intoxication encephalopathy: headaches, heaviness in the head and severe general condition. Dyspeptic disorders (dry mouth, nausea, vomiting), tachycardia, and sometimes hypertension (or hypotension during the onset of septic shock, which is one of its early symptoms along with cyanosis and facial hyperemia against the background of severe pallor) are noted.

The pain syndrome, present in almost all patients, is of an increasing nature, accompanied by a deterioration in general condition and well-being; pain during a special examination and symptoms of irritation of the peritoneum around the palpable formation are noted. Pulsating increasing pain, persistent fever with a body temperature above 38°C, tenesmus, loose stools, lack of clear contours of the tumor, lack of effect from treatment - all this indicates the threat of perforation or its presence, which is an absolute indication for urgent surgical treatment. The infectious syndrome is present in all patients and is accompanied in most of them by high body temperature (38°C and above). Tachycardia corresponds to fever, as well as an increase in leukocytosis, the ESR and leukocyte index of intoxication increase, the number of lymphocytes decreases, the shift to the left increases, the number of molecules of average mass increases, reflecting ever-increasing intoxication. Often, due to impaired urine passage, renal dysfunction occurs. Metabolic disorders manifest themselves in the form of dysproteinemia, acidosis, electrolyte disturbances, and changes in the antioxidant system.

The treatment strategy for this group of patients is based on the principles of organ-preserving operations, which nevertheless provide for radical removal of the main source of infection. Therefore, for each specific patient, the time and scope of the operation must be selected individually. Clarifying the diagnosis sometimes takes several days, especially in cases where there is a borderline variant between suppuration and acute inflammatory process or in the differential diagnosis of an oncological process. Antibacterial therapy is required at each stage of treatment.

Preoperative therapy and preparation for surgery include:

antibiotics (cephobid 2 g/day, fortum 2-4 g/day, reflin 2 g/day, augmentin 1.2 g intravenously once a day, clindamycin 2-4 g/day, etc.); they must be combined with gentamicin 80 mg IM 3 times a day and an infusion of Metragil 100 ml IV 3 times;

detoxification therapy with infusion correction of volemic and metabolic disorders;

mandatory assessment of the effectiveness of treatment based on the dynamics of body temperature, peritoneal symptoms, general condition and blood counts.

At the surgical stage, it is necessary to continue antibacterial therapy. It is especially important to administer one daily dose of antibiotics on the operating table, immediately after the end of the operation. This concentration is necessary because it creates a barrier to the further spread of infection: penetration into the area of inflammation is no longer prevented by dense purulent capsules of tubo-ovarian abscesses. Betalactam antibiotics (cephobid, rocephin, fortum, claforan, tienam, augmentin) overcome these barriers well.

All patients who have undergone surgery for purulent tubo-ovarian abscesses require post-hospital rehabilitation in order to prevent relapses and restore specific body functions.

Literature

Abramchenko V.V., Kostyuchek D.F., Perfileva G.N. Purulent-septic infection in obstetric and gynecological practice. St. Petersburg, 1994. 137 p.

Bashmakova M. A., Korkhov V. V. Antibiotics in obstetrics and perinatology. M., 1996. P. 6.

Bondarev N. E. Optimization of diagnosis and treatment of mixed sexually transmitted diseases in gynecological practice: Abstract of thesis. dis. ...cand. honey. Sci. St. Petersburg, 1997. 20 p.

Ventsela R.P. Nosocomial infections. M., 1990. 656 p.

Gurtovoy B. L., Serov V. N., Makatsaria A. D. Purulent-septic diseases in obstetrics. M., 1981. 256 p.

Khadzhieva E. D. Peritonitis after cesarean section: Textbook. St. Petersburg, 1997. 28 p.

Sahm D. E. The role of automation and molecular technology in antimicrobial susceptibility testing // Clin. Microb. And Inf. 1997. Vol. 3. No. 2. P. 37-56.

Snuth C. B., Noble V., Bensch R. et al. Bacterial flora of the vagina during the mensternal cycle // Ann. Intern. Med. 1982. P. 48-951.

Tenover F. Norel and emerging mechanisms of antimicrobial resistance in nosocomial pathogens // Am. J. Med. 1991. 91. P. 76-81.

Pelvic inflammatory diseases (PID) include inflammation of the uterus, its tubes, ovaries, parametrium and pelvic peritoneum. Isolated inflammation of these formations is extremely rare in clinical practice due to their anatomical proximity and functional unity.

SYNONYMS

In the English-language literature, these diseases are referred to as pelvic inflammatory disease. In the domestic literature, the most used term in relation to PID is “salpingitis” or “salpingoophoritis”.

ICD-10 CODE
N70 Salpingitis and oophoritis (including abscess of the fallopian tube, tubo-ovarian, ovarian, pyosalpinx, salpingoophoritis, tubo-ovarian inflammatory disease).
N71 Inflammatory diseases uterus, except the cervix (including uterine abscess, metritis, myometritis, pyometra, endo(myo-)metritis).
N72 Inflammatory diseases of the cervix (erosion and ectropion of the cervix without cervicitis are excluded).
N73 Other inflammatory diseases of the female pelvic organs.
N74 Inflammatory diseases of the female pelvic organs in diseases classified in other headings.

EPIDEMIOLOGY

Inflammatory diseases are the most common pathology of the internal genitalia in childhood. They make up from 1 to 5% of all acute surgical diseases abdominal organs in children, ranking third in frequency after acute appendicitis And intestinal obstruction. There are several age peaks in the incidence of PID:
at 3–5, 11–13 and 18–20 years old. The first two coincide with the age maximums of the disease of appendicitis, the last - with the debut of sexual activity. Due to the frequent combination of inflammation of the appendix and OVID, appendicular-genital syndrome is distinguished.

According to domestic and foreign scientists, girls aged 15–19 years are most at risk of inflammation. At this age, the immature multilayered epithelium of the cervix is more susceptible to the action of infectious, cocarcinogenic and carcinogenic agents. The current situation is due to freedom of sexual behavior, frequent changes sexual partners, ignorance or unwillingness to use barrier contraception, drug addiction.

Every year, 4% of women aged 15 to 44 undergo a medical abortion worldwide. 12.25–56% of patients develop endometritis after artificial termination of pregnancy.

In Russia in 2002, 1,782 million abortions were registered. Of these, 10.3% were teenagers and girls aged 15–19 years.

SCREENING

Conducted when visiting gynecologists and pediatricians, during preventive examinations.

CLASSIFICATION

Based on the topography of the damage to the macroorganism, inflammatory diseases of the lower part of the urogenital tract and ascending infection can be distinguished. Lesions of the lower part of the urogenital tract include urethritis, paraurethritis, bartholinitis, colpitis and endocervicitis.

Inflammatory processes are divided by duration into acute and chronic. Inflammatory processes lasting up to 4–6 weeks are considered acute; in most cases, acute inflammation ends within 1.5–2 weeks. In clinical practice, it is customary to distinguish between acute, subacute and chronic PID. By acute inflammation we mean a disease that has arisen for the first time and has a clear clinical picture.

Currently, according to the proposal of G. Monif (1983), four stages of the acute inflammatory process are distinguished:

Stage I - acute endometritis and salpingitis without signs of inflammation of the pelvic peritoneum;
Stage II - acute endometritis and salpingitis with signs of peritoneal irritation;
Stage III - acute salpingoophoritis with occlusion of the fallopian tubes and the development of tubo-ovarian formation;
Stage IV - rupture of the tubo-ovarian formation.

IN AND. Krasnopolsky (2002) identifies the following forms of PID:

uncomplicated forms (salpingitis, oophoritis, salpingoophoritis);
complicated forms (pyosalpinx, ovarian abscess (pyovar), purulent tubo-ovarian formation);
severe purulent-septic diseases (panmetritis, parametritis, interintestinal, subphrenic abscesses,
genital fistulas, purulent infiltrative omentitis, diffuse peritonitis, sepsis).

ETIOLOGY

As a rule, PID is characterized by polymicrobial etiology. Almost all microorganisms present in the vagina (with the exception of lactobacteria and bifidobacteria) can take part in the inflammatory process. However, the leading role belongs to the most virulent microorganisms: representatives of the Enterobacteriaceae family (primarily Escherichia coli) and staphylococcus. The role of anaerobes as copathogens is generally recognized, but it should not be overestimated.

In PID, staphylococci, streptococci, enterococci, anaerobes, chlamydia, mycoplasma, and ureaplasma are most often found. Great value in last years give to an opportunistic infection, which means predominantly endogenous microorganisms that exhibit pathogenic properties mainly against the background of a violation of the body's anti-infective defense mechanisms. The development of opportunistic infections is facilitated by: irrational use of broad-spectrum antibiotics and hormonal drugs; surgical interventions; various invasive medical procedures; violation of the integrity of tissues and local immunity of the vagina as a result of primary infection, etc.

PATHOGENESIS

Infection of the internal genital organs can occur:

lymphogenous with appendicitis, cholecystitis, perihepatitis, pleurisy, with the development of pelvioperitonitis and further lymphogenous spread to the peritoneum of the subdiaphragmatic region ( abdominal syndrome Fitz-Hugh-Curtis);
hematogenous, as evidenced by extragenital complications (for example, damage to the joint capsules due to chlamydia);
canalicularly (through the cervical canal, uterine cavity, fallopian tubes to the peritoneum and abdominal organs).

CLINICAL PICTURE

Clinical manifestations of acute inflammation of the internal genital organs: high body temperature, pain in the lower abdomen, there may be nausea, vomiting, a disturbance in the general condition, severe intoxication, changes in the blood (leukocytosis, increased ESR, the appearance of Reactive protein).

Subacute inflammation is a first-time process with less pronounced symptoms than in acute inflammation of the internal genital organs: low-grade fever body, absence of severe intoxication, slight pain reaction, low leukocytosis and moderate increased ESR in blood. This process is characterized by a protracted course. Obviously, this division is arbitrary, since the assessment of the manifestations of the inflammatory process is very subjective.

Chronic PID can be a consequence of acute inflammation that is not completely cured, and also have a primarily chronic nature. Chronic PID often occurs in waves with alternating periods of exacerbation and remission.

It is customary to distinguish between chronic salpingoophoritis in the acute stage, primary chronic salpingoophoritis and residual effects (cicatricial adhesions) of chronic salpingoophoritis.

The infection can spread upward or downward. It is necessary to distinguish between primary and secondary salpingitis. In primary salpingitis, the infection rises from the lower genital tract by spreading cervical or perianal flora on the fallopian tubes (diagnostic and therapeutic procedures). With secondary salpingitis, inflammation develops due to the penetration of the pathogen from nearby organs, in particular from the affected appendix.

DIAGNOSTICS

ANAMNESIS

When studying the anamnesis, it is necessary to pay attention to the presence of extragenital diseases (appendicitis, cholecystitis, perihepatitis, tonsillitis, etc.) and genital (vulvitis) foci of chronic infection.

PHYSICAL EXAMINATION

During bimanual rectoabdominal examination in the area of the location of the uterine appendages, soreness, slight increase. During the formation of a tubo-ovarian tumor of inflammatory origin formation is determined in the area of the uterine appendages, which can reach large sizes. If there is a pelvic ganglioneuritis, pain in the area of exit of the pelvic nerves and the absence of anatomical changes are noted internal genital organs.

LABORATORY RESEARCH

If PID is suspected, a clinical blood test is performed (pay attention to leukocytosis, changes leukocyte formula, increase in ESR, appearance of Reactive protein in the blood), microscopic and microbiological examination of discharged contents from the genital tract, urethra. Also conducting research using the PCR method for the presence of chlamydial and gonococcal infections.

When viewing the results of an ultrasound of the pelvic organs, in some cases free fluid is found in the pelvic cavity pelvis Sensitivity this method- 32–42%, specificity - 58–97%, which allows it to be classified as auxiliary diagnostic methods for PID. Ultrasound should be performed if there is suspicion of tubo-ovarian formations. In the same situation, it is advisable to perform an MRI of the pelvic organs.

DIFFERENTIAL DIAGNOSTICS

Inflammatory diseases of the internal genitalia often occur under the guise of ARVI, acute abdominal pathology (most often acute appendicitis), which often requires diagnostic laparoscopy to be sure condition of the appendix and uterine appendages. PID must be differentiated from uterine and ectopic pregnancy in sexually active adolescents or suspected sexual abuse. In this case, carry out Ultrasound determines the level of hCGβ in the blood serum. In addition, PID has a similar clinical and laboratory picture. ovulatory syndrome, ovarian apoplexy and uterine torsion.

In case of PID in children, it is necessary to consult with specialists in a therapeutic profile if there is a suspicion of infection or inflammatory diseases of the urinary tract, by a surgeon - to exclude acute surgical pathology of the abdominal organs, a phthisiatrician - to exclude the inflammatory process of tuberculosis etiology.

EXAMPLE OF FORMULATION OF DIAGNOSIS

Acute right-sided salpingoophoritis.

TREATMENT OF INFLAMMATION OF THE PELVIC ORGANS IN GIRLS

TREATMENT GOALS

Prevention of further development of the inflammatory process, prevention of reproductive disorders.

INDICATIONS FOR HOSPITALIZATION.

1. Body temperature is above 38 °C.
2. Severe intoxication.
3. Complicated forms of PID (presence of an inflammatory conglomerate - tubo-ovarian formation).
4. Pregnancy.
5. Availability of an IUD.
6. Unidentified or questionable diagnosis, presence of symptoms of peritoneal irritation.
7. Intolerance to oral medications.
8. No improvement during therapy after 48 hours.

NON-DRUG TREATMENT

In case of acute salpingo-oophoritis, physiotherapy is carried out only in combination with adequate antibacterial, detoxification and other drug therapy. Treatment can begin immediately after diagnosis.

Contraindications for use physical factors consist of general ones for physiotherapy and special ones for pathology genitals. In case of acute salpingitis, oophoritis, low-frequency magnetic therapy is indicated, therapy with constant magnetic field; in case of subacute inflammation of the appendages, microwave therapy with decimeter waves is performed, magnetic laser therapy, laser therapy, electrophoresis of drugs with pulsed currents.

During the period of stable remission, it is possible to use preformed physical factors: FNC and ultrasound therapy, low-frequency electrostatic field therapy, electropulse therapy using hardware and software complex "AndroGyn", laser therapy, nonspecific electrothermotherapy, interference therapy, electrophoresis of drugs pulse currents. Optimal time start of physiotherapy - 5–7 days menstrual cycle.

In case of chronic inflammatory process in the uterine appendages, especially in combination with chronic extragenital inflammatory diseases, plasmapheresis is pathogenetically justified, because During the procedure, not only elimination of toxic substances, Ag, AT, immune complexes, immunocompetent cells, but also deblocking own detoxification systems, immune system. Maximum efficiency Plasmapheresis can be achieved with carrying it out in the first phase of the menstrual cycle (immediately after the cessation of menstrual bleeding).

DRUG TREATMENT

TREATMENT OF ACUTE PIDID

The dosage of drugs is selected taking into account the age, body weight of the child and the severity of the clinical picture. diseases.

Antibacterial drugs or their combination are selected taking into account the pathogen and its sensitivity to antimicrobial drugs.

At mild form diseases, basic therapy consists of antibacterial drugs, derivatives nitroimidazole, antifungal and antihistamines. Additionally, NSAIDs are used immunomodulators.

For chlamydial and mycoplasma etiologies of PID, it is preferable to use antibiotics capable of accumulation in affected cells and blocking intracellular protein synthesis. Such drugs include tetracyclines (doxycycline, tetracycline), macrolides (azithromycin, josamycin, clarithromycin, midecamycin, oleandomycin, roxithromycin, spiramycin, erythromycin) and fluoroquinolones (lomefloxacin, norfloxacin, ofloxacin, pefloxacin, ciprofloxacin, sparfloxacin).

In modern treatment of acute uncomplicated chlamydial or mycoplasma salpingo-oophoritis, the following antibiotics:

azithromycin;
doxycycline.

For salpingoophoritis caused by gonococci, “protected” penicillins are used - a combination of an antibiotic with substances that destroy β-lactamase, considering that 80% of gonococcal strains due to the production of β-lactamase resistant to penicillin drugs. No less effective are drugs from the cephalosporin group, especially III–IV generation (ceftriaxone, cefotaxime, etc.), and fluoroquinolones.

In modern treatment of acute uncomplicated gonococcal salpingoophoritis, the following antibiotics are used:

ceftriaxone;
amoxicillin + clavulanic acid;
cefotaxime;
fluoroquinolones (lomefloxacin, norfloxacin, ofloxacin, pefloxacin, ciprofloxacin, sparfloxacin);
Spectinomycin.

In the acute stage of the inflammatory process, in the absence of technical or clinical possibility of collecting material and To determine the type of pathogen ex juvantibus, a combination of several antibacterial broad-spectrum drugs for 7–10 days.

Schemes of possible combinations of antimicrobial drugs:

amoxicillin + clavulanic acid and doxycycline;
doxycycline and metronidazole;
fluoroquinolone and lincosamide;
fluoroquinolone and metronidazole;
macrolide and metronidazole.

In severe cases, the presence of pelvioperitonitis and septic condition, purulent formations in girls The following antibacterial therapy regimens are recommended:

III–IV generation cephalosporin + doxycycline;
ticarcillin + clavulanic acid (or piperacillin + tazobactam) and doxycycline (or macrolide);
fluoroquinolone and metronidazole (or lincosamide);
carbapenem and doxycycline (or macrolide);
gentamicin and lincosamide.

If therapeutic and diagnostic laparoscopy is necessary, antibiotic therapy can be started 30 minutes before or during during induction of anesthesia or immediately after surgical treatment. In severe cases of the disease it is preferable parenteral route of drug administration.

It is mandatory to include synthetic (azoles) or natural (polyenes) antifungal drugs in treatment regimens for systemic and, if necessary, local use. Of the systemic azoles, fluconazole and Itraconazole and ketoconazole are practically not used due to their high toxicity. Antifungal agents follows with Use with caution in patients with severe liver dysfunction. No usage observations itraconazole in children under 14 years of age. Prophylactic use polyene antimycotics nystatin and levorin ineffective, currently natamycin is most often used among polyene drugs. For candidiasis For salpingoophoritis, the same antifungal drugs are used, combining local and general therapy.

Of the antimycotics, fluconazole is most often used (for children under 12 years of age and weighing less than 50 kg, the dose of the drug is is 3–12 mg/kg body weight, for children over 12 years old and weighing more than 50 kg - 150 mg once in the 2nd and last day of taking antibacterial drugs); itraconazole (for children over 14 years old, 100 mg or 5 mg/kg body weight (with weight less than 50 kg) 2 times a day for 3 days 5 days before the end of antibiotic use) or natamycin (according to 100 mg 2–4 times a day while taking antibiotics).

Antibacterial therapy can be carried out in combination with plasmapheresis with a small volume of plasma exfusion. It is also possible to conduct a course of plasmapheresis sequentially after the end of antibacterial therapy. For extracorporeal detoxification, in addition to plasmapheresis, autologous blood is also irradiated with ultraviolet light, laser, ozone therapy.

The use of PG synthesis blockers - nimesulide is indicated (for children over 12 years of age, a single dose of 1.5 mg/kg is prescribed body weight, but not more than 100 mg, 2 times a day, maximum daily dose 5 mg/kg) or diclofenac (for children 6–15 years old use only enteric-coated tablets at a dose of 0.5–2 mg/kg body weight, divided by 2–3 reception; Adolescents over 16 years of age can be prescribed 50 mg 2 times a day orally or rectally in suppositories for 7 days).

Other NSAIDs may also be used. Diclofenac should be used orally with caution in patients with diseases of the liver, kidneys and gastrointestinal tract, and indomethacin - for patients with diseases of the liver, kidneys and erosive ulcers gastrointestinal lesions.

Among antihistamines, it is preferable to prescribe clemastine, quifenadine, mebhydrolin, chloropyramine, loratadine, ketotifen.

It is advisable to include IFN drugs, IFN inducers, as well as immunoactivators in the therapeutic complex. Viferon © prescribed rectally (for children under 7 years old, Viferon1 suppositories are used ©, over 7 years old and adults - Viferon2© - 2 times a day for 10 days), cycloferon © orally or intramuscularly (0.25 g each on the 1st, 2nd, 4th, 6th, 11th, 14th, 17th, 20th, 23rd, 26th th, 29th day of treatment). It is possible to use Kipferon© rectally, 1 suppository 2–3 times a day for 5–7 days.

To normalize the intestinal microflora (especially after treatment with antibiotics), the following can be used: drugs like bactisubtil © (children over 3 years old, 3–6 capsules per day for 7–10 days, over 3 years old, including adults, 4–8 capsules per day orally, an hour before meals), Hilak Forte © (children infancy 15–30 drops 3 times a day day, for children of the older age group, 20–40 drops 3 times a day orally in a small amount of liquid).

Along with this, it is advisable to use antioxidants, vitamin preparations, adaptogens (saparal©, extract eleutherococcus, aralia tincture, pantocrine©, lemongrass tincture, ginseng tincture, etc.) and eubiotics. From eubiotics pre-pubertal girls should be prescribed bifid drugs (bifidumbacterin©, bifiform ©, etc.). For girls older adults are prescribed biological products containing both bifidobacteria and lactobacilli.

Alternative method

Antihomotoxic therapy drugs are used as additional therapy. To prevent side effects effects of antibiotics, as well as to achieve anti-inflammatory, desensitizing, immunocorrective effect while taking antibacterial drugs, the following may be recommended drug complex:

hepel
gynecohel

The use of the complex is discontinued along with the use of antibacterial drugs.

Then take gynecohel for 20 days © 10 drops 2 times a day (preferably at 8 and 16 hours), mucosa compositum © 2.2 ml 1 time every 5 days IM - 5 injections per course, hepel © 1 tablet 3 times a day except days taking mucosa compositum ©. To prevent development adhesive process and exacerbations of the inflammatory process It is recommended to carry out a course of antihomotoxic therapy for 3 months:

TREATMENT OF CHRONIC PIDID

During chronic salpingoophoritis, phases of exacerbation and remission are distinguished. The disease in the acute stage may proceed in two different ways: in one case, a true exacerbation of inflammation develops, i.e. ESR increases, pain in the appendage area, leukocytosis, hyperthermia, and exudative process in the uterine appendages predominate.

In another, more common variant, acute phase shifts in clinical picture and the blood formula are not expressed, there is a deterioration in health, unstable mood is observed, neurotic reactions, note symptoms neuralgia of the pelvic nerves.

Treatment of exacerbation occurring according to the first option is carried out similarly to the treatment of acute salpingoophoritis (classes and dosages medicines see section “Treatment of acute PID”).

Enzyme preparations (Wobenzym©, phlogenzyme ©, trypsin ©, chymotrypsin ©, etc.) play important role in pathogenetic therapy for PID. Wobenzym © prescribe 3 tablets 3 times a day for children under 12 years of age and 5 tablets 3 times a day for children over 12 years old orally 40 minutes before meals with plenty of liquid (250 ml). Use this drug with caution prescribed to patients with a high risk of bleeding and severe renal impairment and liver.

In case of exacerbation of salpingoophoritis, which occurs according to the second option, antibacterial drugs are rarely used, only when signs of the inflammatory process intensify. In complex therapy, physical factors are used effects, drugs that activate blood circulation, enzyme and vitamin preparations.

Alternative method

Antihomotoxic therapy in the complex of treatment of subacute and first, infectious-toxic variants exacerbation of chronic salpingoophoritis includes:

Antihomotoxic therapy in the complex of rehabilitation measures for PID on menstrual days for 3 cycles includes:

To prevent adhesions for 3 cycles (except for menstruation), use:

Antihomotoxic therapy in complex therapy for the second variant of exacerbation of chronic salpingoophoritis includes the following drugs:

For menstrual irregularities (scanty bleeding), in combination with atrophic endometrium according to Based on ultrasound and/or histological examination data, sequential estrogen progestogen drugs are prescribed (fixed combination):

in phase I, estrogen (estradiol) is taken;
in phase II - estrogen in combination with gestagen:

Estradiol + estradiol and dydrogesterone (femoston 1/5©);
- conjugated estrogens + medroxyprogesterone (premella cycle©) 1 tablet daily without a break for 3–6 months;
-estradiol + medroxyprogesterone (divin©);
-estradiol / estradiol + levonorgestrel (klimonorm©);
-estradiol / estradiol + cyproterone (clymene©);
-estradiol / estradiol + norgestrel (cycloproginova©) 1 tablet daily for 21 days, then a break of 7 days and a new cycle for 3–6 cycles.

In these cases, estrogens are also used for 21 days:

estradiol (in transdermal form: gels estrogel© 0.06% and divigel© 0.1% - 0.5–1.0 g/day, climar patches© 1 time
per week, in the form of octodiol© nasal spray, in tablet form estrimax©, estrofem© 1 tablet per day,
proginova© 1 tablet per day);
conjugated estrogens (K.E.S.©, Premarin© 1 tablet per day);
in combination with gestagens in phase II of the cycle from the 12th to the 21st day:
dydrogesterone (1 tablet 2-3 times a day);
progesterone (1 tablet 2-3 times a day, in transdermal form - the gel is applied to the skin 1 time a day).

Alternative method

Antihomotoxic therapy drugs:

During remission for prevention unwanted pregnancy sexually active adolescents are prescribed monophasic COCs.

SURGERY

Surgical treatment is performed when conservative therapy is ineffective, as a rule, in the case of formation tubo-ovarian purulent formations.

Acute salpingoophoritis, accompanied by peritonitis, is also an indication for surgical treatment, Laparoscopic access is preferable, and one should strive for organ-preserving operations.

INDICATIONS FOR CONSULTATION WITH OTHER SPECIALISTS

In case of PID in children, it is necessary to consult with specialists in a therapeutic profile if there is a suspicion of infection or inflammatory diseases of the urinary tract, consultation with a surgeon - to exclude acute surgical pathology of the abdominal organs (most often appendicitis), a phthisiatrician - to exclude inflammatory process of tuberculosis etiology.

APPROXIMATE DURATION OF DISABILITY

Period of incapacity for work in acute PID or during an exacerbation of a chronic inflammatory process is 7–14 days.

FOLLOW-UP

After completion of therapy in an outpatient or inpatient setting, the underlying disease is corrected biocenosis of the intestines and genitals, restoration of the menstrual cycle. In sexually active adolescents carry out correction of sexual behavior (use of COCs in combination with barrier methods for a period of at least 3 months). In the absence of signs of an inflammatory process, examination and study of clinical and biochemical blood counts are carried out after 1, 3, 6, 9, 12 months in the first year, then once every 6 months for 2 years.

INFORMATION FOR THE PATIENT

Girls with PID (and their parents) should be informed that if it worsens general well-being, appearance pain in the lower abdomen, increased body temperature, the appearance of discharge from the genital tract with an unpleasant odor you need to consult a doctor. In the presence of foci of chronic infection (chronic inflammatory diseases oropharynx, urinary system, gastrointestinal tract) requires observation by specialists of the appropriate profile. After suffered acute PID or with formed chronic inflammation internal genitalia are necessary regular preventive examinations by a pediatric gynecologist.

FORECAST

With adequate treatment and rehabilitation, the prognosis is favorable.

PREVENTION

Prevention of PID in girls younger age is nonspecific and involves the sanitation of foci of chronic infection. In addition, it is possible to reduce the incidence of illness in sexually active adolescents through the use of mechanical means contraception, reducing the number of sexual partners, combating drug addiction, reducing the intake of alcoholic beverages. Regular testing for STIs is also necessary.

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Pelvic inflammatory diseases (PID) are characterized by various manifestations depending on the level of damage and the strength of the inflammatory response. The disease develops when a pathogen (enterococci, bacteroides, chlamydia, mycoplasma, ureaplasma, trichomonas) penetrates into the genital tract and in the presence of favorable conditions for its development and reproduction. These conditions occur during the postpartum or post-abortion period, during menstruation, during various intrauterine manipulations (insertion of an IUD, hysteroscopy, hysterosalpingography, diagnostic curettage).

Existing natural protective mechanisms, such as anatomical features, local immunity, the acidic environment of the vaginal contents, the absence of endocrine disorders or serious extragenital diseases, can in the vast majority of cases prevent the development of genital infection. In response to the invasion of a particular microorganism, an inflammatory response occurs, which, based on the latest concepts of the development of the septic process, is usually called a “systemic inflammatory response.”

Acute endometritis always requires antibacterial therapy. The basal layer of the endometrium is affected by the inflammatory process due to the invasion of specific or nonspecific pathogens. Endometrial protective mechanisms, congenital or acquired, such as T-lymphocyte aggregates and other elements of cellular immunity, are directly related to the action of sex hormones, especially estradiol, act in conjunction with the macrophage population and protect the body from damaging factors. With the onset of menstruation, this barrier on a large surface of the mucous membrane disappears, which makes it possible to become infected. Another source of protection in the uterus is the infiltration of the underlying tissues with polymorphonuclear leukocytes and the rich blood supply of the uterus, which promotes adequate perfusion of the organ with blood and nonspecific humoral protective elements contained in its serum: transferrin, lysozyme, opsonins.

The inflammatory process can spread to the muscle layer: then metroendometritis and metrothrombophlebitis occur with a severe clinical course. The inflammatory reaction is characterized by a disorder of microcirculation in the affected tissues, expressed by exudation; with the addition of anaerobic flora, necrotic destruction of the myometrium can occur.

Clinical manifestations of acute endometritis are characterized already on the 3-4th day after infection by an increase in body temperature, tachycardia, leukocytosis and an increase in ESR. Moderate enlargement of the uterus is accompanied by pain, especially along its ribs (along the blood and lymphatic vessels). Purulent-bloody discharge appears. The acute stage of endometritis lasts 8-10 days and requires quite serious treatment. With proper treatment, the process is completed, less often it turns into subacute and chronic forms, and even less often, with independent and indiscriminate antibiotic therapy, endometritis can take a milder abortive course.

Treatment of acute endometritis, regardless of the severity of its manifestations, begins with antibacterial infusion, desensitizing and restorative therapy.

Antibiotics are best prescribed taking into account the sensitivity of the pathogen to them. The dosage and duration of antibiotic use are determined by the severity of the disease. Due to the frequency of anaerobic infections, additional use of metronidazole is recommended. Considering the very rapid course of endometritis, cephalosporins with aminoglycosides and metronidazole are preferable among antibiotics. For example, cefamandole (or cefuroxime, cefotaxime) 1.0-2.0 g 3-4 times a day IM or IV drip + gentamicin 80 mg 3 times a day IM + Metrogyl 100 ml IV / in drip.

Instead of cephalosporins, you can use semi-synthetic penicillins (for abortive cases), for example, ampicillin 1.0 g 6 times a day. The duration of such combined antibacterial therapy depends on the clinic and laboratory response, but should not be less than 7-10 days. To prevent dysbiosis from the first days of antibiotic treatment, use nystatin 250,000 units 4 times a day or Diflucan 50 mg/day for 1-2 weeks orally or intravenously.

Detoxification infusion therapy may include a number of infusion agents, for example, Ringer-Locke solution - 500 ml, polyionic solution - 400 ml, hemodez (or polydesis) - 400 ml, 5% glucose solution - 500 ml, 1% calcium chloride solution - 200 ml, Unithiol with a 5% solution of ascorbic acid, 5 ml 3 times a day. In the presence of hypoproteinemia, it is advisable to carry out infusions of protein solutions (albumin, protein), blood replacement solutions, plasma, red blood cells or whole blood, amino acid preparations.

Physiotherapeutic treatment occupies one of the leading places in the treatment of acute endometritis. It not only reduces the inflammatory process in the endometrium, but also stimulates ovarian function. When normalizing the temperature reaction, it is advisable to prescribe low-intensity ultrasound, inductothermy with an HF or UHF electromagnetic field, magnetic therapy, and laser therapy.

Every fifth woman who has suffered salpingo-oophoritis is at risk of infertility. Adnexitis can cause a high risk of ectopic pregnancy and pathological course of pregnancy and childbirth. The fallopian tubes are the first to be affected, and the inflammatory process can involve all layers of the mucous membrane of one or both tubes, but more often only the mucous membrane of the tube is affected, and catarrhal inflammation of the mucous membrane of the tube occurs - endosalpingitis. Inflammatory exudate, accumulating in the tube, often flows through the ampullary opening into the abdominal cavity, adhesions form around the tube and the abdominal opening of the tube closes. A saccular tumor develops in the form of a hydrosalpinx with transparent serous contents or in the form of a pyosalpinx with purulent contents. Subsequently, the serous exudate of the hydrosalpinx resolves as a result of treatment, and the purulent pyosalpinx can perforate into the abdominal cavity. The purulent process can capture and melt all large areas of the pelvis, spreading to all internal genitalia and nearby organs.

Inflammation of the ovaries (oophoritis) As a primary disease, it is rare; infection occurs in the area of the ruptured follicle, since the rest of the ovarian tissue is well protected by the covering germinal epithelium. In the acute stage, swelling and small cell infiltration are observed. Sometimes, in the cavity of the follicle of the corpus luteum or small follicular cysts, ulcers and microabscesses form, which, merging, form an ovarian abscess or pyovarium. In practice, it is impossible to diagnose an isolated inflammatory process in the ovary, and this is not necessary. Currently, only 25-30% of patients with acute adnexitis have a pronounced picture of inflammation; the remaining patients experience a transition to a chronic form, when therapy is stopped after a rapid subsidence of the clinic.

Acute salpingoophoritis It is also treated with antibiotics (preferably third generation fluoroquinolones - Ciprofloxacin, Tarivid, Abaktal), since it is often accompanied by pelvioperitonitis - inflammation of the pelvic peritoneum.

Inflammation of the pelvic peritoneum most often occurs secondary to the penetration of infection into the abdominal cavity from an infected uterus (with endometritis, infected abortion, ascending gonorrhea), from the fallopian tubes, ovaries, from the intestines, with appendicitis, especially with its pelvic location. In this case, an inflammatory reaction of the peritoneum is observed with the formation of serous, serous-purulent or purulent effusion. The condition of patients with pelvioperitonitis remains either satisfactory or moderate. The temperature rises, the pulse quickens, but the function of the cardiovascular system is slightly impaired. With pelvioperitonitis, or local peritonitis, the intestine remains unbloated, palpation of the upper half of the abdominal organs is painless, and symptoms of peritoneal irritation are determined only above the pubis and in the iliac regions. However, patients note severe pain in the lower abdomen, there may be retention of stool and gas, and sometimes vomiting. The level of leukocytes is increased, the formula shifts to the left, the ESR is accelerated. Gradually increasing intoxication worsens the condition of patients.

Treatment of salpingoophoritis with or without pelvioperitonitis begins with a mandatory examination of the patient for flora and sensitivity to antibiotics. The most important thing is to determine the etiology of inflammation. Today, benzylpenicillin is widely used for the treatment of specific gonorrheal process, although drugs such as Rocephin, Cephobid, Fortum are preferable.

The “gold standard” in the treatment of salpingoophoritis from antibacterial therapy is the prescription of Claforan (cefotaxime) at a dose of 1.0-2.0 g 2-4 times a day intramuscularly or one dose of 2.0 g intravenous in combination with gentamicin 80 mg 3 times/day (gentamicin can be administered once at a dose of 160 mg IM). It is imperative to combine these drugs with the administration of Metrogyl IV 100 ml 1-3 times a day. A course of antibiotic treatment should be carried out for at least 5-7 days, prescribing cephalosporins of the second and third generations (Mandol, Zinacef, Rocephin, Cephobid, Fortum and others at a dose of 2-4 g/day).

In case of acute inflammation of the uterine appendages, complicated by pelvioperitonitis, oral administration of antibiotics is possible only after the main course, and only if the need arises. As a rule, there is no such need, and the persistence of previous clinical symptoms may indicate the progression of inflammation and a possible suppurative process.

Detoxification therapy is mainly carried out with crystalloid and detoxification solutions in an amount of 2-2.5 liters with the inclusion of solutions of hemodez, Reopoliglyukin, Ringer-Locke, polyionic solutions - acessol, etc. Antioxidant therapy is carried out with a solution of Unithiol 5.0 ml with a 5% solution of ascorbic acid 3 times/day i.v.

In order to normalize the rheological and coagulation properties of blood and improve microcirculation, they use acetylsalicylic acid(Aspirin) 0.25 g/day for 7-10 days, as well as intravenous administration of Reopoliglucin 200 ml (2-3 times per course). Subsequently, a whole complex of resorption therapy and physiotherapeutic treatment is used (calcium gluconate, autohemotherapy, sodium thiosulfate, Humisol, Plazmol, Aloe, FiBS). Among the physiotherapeutic procedures for acute processes, ultrasound is appropriate, providing analgesic, desensitizing, fibrolytic effects, enhancing metabolic processes and tissue trophism, inductothermy, UHF therapy, magnetic therapy, laser therapy, and later - sanatorium-resort treatment.

Among 20-25% of inpatients with inflammatory diseases of the uterine appendages, 5-9% develop purulent complications requiring surgical interventions.

The following provisions regarding the formation of purulent tubo-ovarian abscesses can be highlighted:

chronic salpingitis in patients with tubo-ovarian abscesses is observed in 100% of cases and precedes them;
the spread of infection occurs predominantly through the intracanalicular route from endometritis (with IUD, abortion, intrauterine interventions) to purulent salpingitis and oophoritis;
frequent combination of cystic transformations in the ovaries with chronic salpingitis;
there is a mandatory combination of ovarian abscesses with exacerbation of purulent salpingitis;
Ovarian abscesses (pyovarium) are formed mainly from cystic formations, often microabscesses merge with each other.

Morphological forms of purulent tubo-ovarian formations:

pyosalpinx - predominant lesion of the fallopian tube;
pyovarium - predominant damage to the ovary;
tubo-ovarian tumor.

All other combinations are complications of these processes and can occur:

without perforation;
with perforation of ulcers;
with pelvioperitonitis;
with peritonitis (limited, diffuse, serous, purulent);
with pelvic abscess;
with parametritis (posterior, anterior, lateral);
with secondary lesions of adjacent organs (sigmoiditis, secondary appendicitis, omentitis, interintestinal abscesses with the formation of fistulas).

Clinically differentiating each of these localizations is almost impossible and impractical, since the treatment is fundamentally the same; antibacterial therapy takes a leading place both in the use of the most active antibiotics and in the duration of their use. The basis of purulent processes is the irreversible nature of the inflammatory process. Irreversibility is due to morphological changes, their depth and severity, often accompanying severe renal dysfunction.

Conservative treatment of irreversible changes in the uterine appendages is unpromising, since if it is carried out, it creates the preconditions for the occurrence of new relapses and aggravation of impaired metabolic processes in patients, increases the risk of upcoming surgery in terms of damage to adjacent organs and the inability to perform the required volume of surgery.

Purulent tubo-ovarian formations represent a difficult diagnostic and clinical process. Nevertheless, a number of characteristic syndromes can be identified:

intoxication;
painful;
infectious;
early renal;
hemodynamic disorders;
inflammation of adjacent organs;
metabolic disorders.

Clinically, intoxication syndrome manifests itself in intoxication encephalopathy, headaches, heaviness in the head and severity of the general condition. Dyspeptic disorders (dry mouth, nausea, vomiting), tachycardia, and sometimes hypertension (or hypotension during the onset of septic shock, which is one of its early symptoms along with cyanosis and facial hyperemia against the background of severe pallor) are noted.

Pain syndrome is present in almost all patients and is of an increasing nature, accompanied by a deterioration in general condition and well-being, there is pain during a special examination, displacement behind the cervix and symptoms of irritation of the peritoneum around the palpable formation. Pulsating increasing pain, persistent fever with a body temperature above 38°C, tenesmus, loose stools, absence of clear contours of the tumor, lack of effect from treatment - all this indicates the threat of perforation or its presence, which is an absolute indication for urgent surgical treatment . The infectious syndrome is present in all patients, manifested in the majority by high body temperature (38°C and above), tachycardia corresponds to fever, as well as an increase in leukocytosis, ESR and leukocyte index of intoxication increase, the number of lymphocytes decreases, the shift of white blood to the left and the number of molecules of average mass, reflecting increasing intoxication. Often there is a change in kidney function due to impaired urine passage. Metabolic disorders manifest themselves in dysproteinemia, acidosis, electrolyte imbalance, etc.

The treatment strategy for this group of patients is based on organ-preserving principles of operations, but with radical removal main site of infection. Therefore, for each specific patient, the volume of the operation and the time of its implementation should be optimal. Clarifying the diagnosis sometimes takes several days - especially in cases where there is a borderline variant between suppuration and an acute inflammatory process or in differential diagnosis from an oncological process. Antibacterial therapy is required at each stage of treatment.

Preoperative therapy and preparation for surgery include:

antibiotics (use Cefobid 2.0 g/day, Fortum 2.0-4.0 g/day, Reflin 2.0 g/day, Augmentin 1.2 g IV drip 1 time/day, Clindamycin 2.0- 4.0 g/day, etc.). They must be combined with gentamicin 80 mg IM 3 times a day and Metrogyl infusion 100 ml IV 3 times;
detoxification therapy with infusion correction of volemic and metabolic disorders;
mandatory assessment of the effectiveness of treatment based on the dynamics of body temperature, peritoneal symptoms, general condition and blood counts.

The surgical stage also includes ongoing antibacterial therapy. It is especially valuable to administer one daily dose of antibiotics on the operating table immediately after the end of the operation. This concentration is necessary as a barrier to further spread of infection, since penetration into the area of inflammation is no longer prevented by dense purulent capsules of tubo-ovarian abscesses. Betalactam antibiotics (Cephobid, Rocephin, Fortum, Claforan, Tienam, Augmentin) pass these barriers well.

Postoperative therapy includes the continuation of antibacterial therapy with the same antibiotics in combination with antiprotozoal, antimycotic drugs and uroseptics in the future (according to sensitivity). The course of treatment is based on the clinical picture and laboratory data, but should not be less than 7-10 days. Antibiotics are discontinued based on their toxic properties, so gentamicin is often discontinued first, after 5-7 days, or replaced with amikacin.

Infusion therapy should be aimed at combating hypovolemia, intoxication and metabolic disorders. Normalization of gastrointestinal motility is very important (intestinal stimulation, HBOT, hemosorption or plasmapheresis, enzymes, epidural blockade, gastric lavage, etc.). Hepatotropic, restorative, antianemic therapy is combined with immunostimulating therapy (UVR, laser blood irradiation, immunocorrectors).

All patients who have undergone surgery for purulent tubo-ovarian abscesses require post-hospital rehabilitation in order to prevent relapses and restore specific body functions.

Literature

Abramchenko V.V., Kostyuchek D.F., Perfilyeva G.N. Purulent-septic infection in obstetric and gynecological practice. St. Petersburg, 1994. 137 p.
Bashmakova M. A., Korkhov V. V. Antibiotics in obstetrics and perinatology. M., 1996. No. 9. P. 6.
Bondarev N. E. Optimization of diagnosis and treatment of mixed sexually transmitted diseases in gynecological practice: abstract. dis. ...cand. honey. Sci. St. Petersburg, 1997. 20 p.
Ventsela R. P. Nosocomial infections // M., 1990. 656 p.
Gurtovoy B. L., Serov V. N., Makatsaria A. D. Purulent-septic diseases in obstetrics. M., 1981. 256 p.
Keith L.G., Berger G.S., Edelman D.A. Reproductive health: T. 2 // Rare infections. M., 1988. 416 p.
Krasnopolsky V. I., Kulakov V. I. Surgical treatment of inflammatory diseases of the uterine appendages. M., 1984. 234 p.
Korkhov V.V., Safronova M.M. Modern approaches to the treatment of inflammatory diseases of the vulva and vagina. M., 1995. No. 12. P. 7-8.
Kumerle X. P., Brendel K. Clinical pharmacology during pregnancy / ed. X. P. Kumerle, K. Brendel: trans. from English T. 2. M., 1987. 352 p.
Serov V. N., Strizhakov A. N., Markin S. A. Practical obstetrics: a guide for doctors. M., 1989. 512 p.
Serov V.N., Zharov E.V., Makatsaria A.D. Obstetric peritonitis: diagnosis, clinic, treatment. M., 1997. 250 p.
Strizhakov A. N., Podzolkova N. M. Purulent inflammatory diseases of the uterine appendages. M., 1996. 245 p.
Khadzhieva E. D. Peritonitis after cesarean section: a textbook. St. Petersburg, 1997. 28 p.
Sahm D. E. The role of automation and molecular technology in antimicrobial susceptibility testing // Clin. Microb. And Inf. 1997; 3: 2(37-56).
Snuth C. B., Noble V., Bensch R. et al. Bacterial flora of the vagina during the mensternal cycle // Ann. Intern. Med. 1982; p. 948-951.
Tenover F.C. Norel and emerging mechanisms of antimicrobial resistance in nosocomial pathogens // Am. J. Med. 1991; 91, p. 76-81.

V. N. Kuzmin, Doctor of Medical Sciences, Professor
MGMSU, Moscow

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Acute salpingoophoritis

Endometritis

Pelvioperitonitis

Purulent tubo-ovarian formations

Literature

What are the complications of PID?

SYNONYMS

EPIDEMIOLOGY

SCREENING

CLASSIFICATION

ETIOLOGY

PATHOGENESIS

CLINICAL PICTURE

DIAGNOSTICS

ANAMNESIS

PHYSICAL EXAMINATION

LABORATORY RESEARCH

DIFFERENTIAL DIAGNOSTICS

EXAMPLE OF FORMULATION OF DIAGNOSIS

TREATMENT OF INFLAMMATION OF THE PELVIC ORGANS IN GIRLS

TREATMENT GOALS

INDICATIONS FOR HOSPITALIZATION.

NON-DRUG TREATMENT

DRUG TREATMENT

SURGERY

INDICATIONS FOR CONSULTATION WITH OTHER SPECIALISTS

APPROXIMATE DURATION OF DISABILITY

FOLLOW-UP

INFORMATION FOR THE PATIENT

FORECAST

PREVENTION

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