Postpartum thrombophlebitis

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					Postparum septic deseases




           Prepared by Stelmakh O.Y
                   Definition
   Postpartum infectious diseases - diseases
    observed in parturients directly related to
    pregnancy and childbirth and due to bacterial
    infection. Infectious diseases identified in the
    postpartum period, but the pathogenesis is not
    related to pregnancy and childbirth (flu,
    dizentireya, etc.), a group of postpartum illness
    is not expected
         Etiology and pathogenesis

   Pyo-inflammatory diseases remain one of their
    pressing problems of modern obstetrics. The
    introduction of midwifery practice for over fifty
    years ago, antibiotics contributed to a sharp
    reduction in the frequency of postpartum
    infectious diseases. However, in the last decade
    around the world celebrate the growth of post-
    natal infections. The frequency of postpartum
    infections ranges from 2% to 10%.
   A few more infectious complications
    after caesarean section. From septic
    obstetric complications worldwide die
    every year about 150,000 women.
    Septic complications in the postpartum
    period, as a cause of maternal mortality
    continue to keep the sad lead, ranking
    2-3 place, sharing it with obstetric
    hemorrhage.
      BACTERIA COMMONLY RESPONSIBLE FOR FEMALE
                 GENITAL INFECTIONS


   Aerobes
     Group A, B, and D streptococci
     Enterococcus
     Gram-negative bacteria—Escherichia coli, Klebsiella, and Proteus species

     Staphylococcus aureus
   Anaerobes
     Peptococcus species
     Peptostreptococcus species
     Bacteroides bivius, B. fragilis, B. disiens
     Clostridium species
     Fusobacterium species
   Other
     Mycoplasma hominis
     Chlamydia trachomatis
   This is facilitated by a number of factors that
    make up the features of modern medicine.
    Change contingent pregnant and postpartum
    women, many of whom are women with severe
    extragenital pathology, with an induced
    pregnancy, with hormonal and surgical correction
    of premature births, etc. This is also due to the
    changing nature of the microflora. In connection
    with a broad and not always sufficiently justified
    the use of broad-spectrum antibiotics, and
    disinfectants emerged strains of bacteria that
    have multiple resistance to antibiotics and
    disinfectants.
   In the postpartum period in the genital tract
    puerperal there is not one antiinfectious barrier.
    The inner surface of the uterus postpartum is a
    wound surface, and the contents of the uterus
    (blood clots, epithelial cells, sections of decidua)
    is a favorable environment for microbial growth.
    The uterus is easily infected by the ascent of
    pathogenic and conditionally pathogenic flora of
    the vagina. As mentioned above, some
    parturients postnatal infection is an extension of
    chorioamnionitis.
   Activators of inflammatory diseases can be
    pathogenic and opportunistic
    microorganisms. Among the pathogens
    most frequently - gonococcus, chlamydia,
    mycoplasmas, Trichomonas. Opportunistic
    microorganisms inhabit the human body,
    being a factor of nonspecific anti-
    infectious protection. However, in certain
    circumstances they can become agents of
    puerperal infections
   As agents of puerperal infections can be
    aerobes: enterococci, E. coli, Proteus,
    Klebsiella, group B streptococci,
    staphylococci. The flora is represented by
    anaerobes: bacteroids, fuzobakterii,
    peptokokki, peptostreptokokki. In modern
    obstetrics has increased the role of
    chlamydia, mycoplasma infections, fungal.
    Nature of the pathogen determines the
    clinical course of postpartum infection.
    Anaerobic gram-negative cocci are not
    very virulent. Anaerobic gram-negative
    bacillus contribute to the development of
    severe infection.
     Widening
  of postpartum
   infection by
lymphatic vessels
   Transmission
    In 9 out of 10 cases of postpartum
    infection such as the route of infection
    does not exist, since the activation of its
    own opportunistic flora (autoinfection). In
    other cases, a persistent infection outside
    hospital strains in violation of the rules of
    aseptic and antiseptic. It should also
    highlight a relatively new way of infection
    - intraamnialny associated with the
    introduction of obstetric practice invasive
    methods (amniocentesis, fetoskopiya,
    cordocentesis).
         Pathway of infection

   In cases of massive infection with highly
    virulent microflora and / or significant
    reduction of the protective forces of
    puerperal infection of the primary lesion
    extends beyond it. Allocate the following
    pathway of infection from the primary
    tumor: hematogenous, lymphogenous by
    extension, perineural
CLASSIFICATION

   Currently, widespread classification of
    postpartum infectious diseases Sazonov-
    Bartels. According to this classification,
    various forms of puerperal infection are
    considered as separate stages of a single
    dynamically passing the infection process.
    The first phase - an infection limited to the
    domain generic wounds: postpartum
    endometritis, postpartum ulcer (on the
    perineum, the wall of the vagina, cervix).
   The second stage - the infection has
    spread beyond the postpartum wounds,
    but remained localized within the pelvis: a
    metritis, parametritis, salpingoophoritis,
    pelvioperitonitis, limited thrombophlebitis
    (metrotromboflebit, pelvic vein
    thrombophlebitis).
    The third stage of infection is outside the
    pelvis and has a tendency to generalize:
    diffuse peritonitis, septic shock, anaerobic
    gas infection, progressive
    thrombophlebitis.
    The fourth stage - a generalized infection:
    sepsis (septicemia, pyosepticemia )
                             Clinic
   The clinical picture of postpartum infectious diseases is
    very variable, which is associated with poly etiology of
     postpartum infection, stages and different ways of its
      distribution, non-uniform response of the organism
     puerperal. With considerable variability in the clinical
       course of both localized and generalized forms of
         postnatal diseases, a number of characteristic
     symptoms: fever, chills, tachycardia, sweating, sleep
        disturbance, headache, euphoria, lack or loss of
      appetite, dysuric and dyspeptic symptoms, lowering
                          blood pressure
               FIRST STAGE
   Postpartum ulcer occurs after an injury the
    skin, mucous membrane of the vagina,
    cervix, as a result of operative birth
    vaginally, prolonged labor large fetus.
    Mostly local symptoms: pain, burning,
    redness, swelling of tissues, purulent
    discharge, the wound bleeds easily. When
    large areas of destruction, and inadequate
    treatment can occur generalization of
    infection.
   Postpartum endometritis is one of the
    most frequent complications of the
    postpartum period and 40-50% of all
    complications. Most often, the
    endometrium is the result of
    chorioamnionitis. One-third of parturients
    with postpartum endometritis were
    diagnosed during pregnancy bacterial
    vaginosis. There are four forms of
    puerperal endometritis (classical, abortive,
    erased and endometritis after cesarean
    section).
                        Endometritis
 The classical form of endometritis occurs for 1-5 days. The
body temperature rises to 38-39 ° C, there is tachycardia 80-
 100 bpm. per minute. Note the general state of depression,
       chills, dryness, and flushing of the skin, topically -
 subinvolution and soreness of the body of the uterus, with
  the smell of pus discharge. Changed the clinical picture of
blood: leukocytosis 10-15 * 109 / l with neutrophilic shift to
    the left, ESR 45 mm / h. Erased form occurs at 5-7 day,
  develops slowly. Temperature does not exceed 38 ° C, no
    chills. The majority of women in childbirth there are no
    changes of leukocyte formula. Local symptoms is weak
   (slight tenderness to palpation of the uterus). In 20% of
cases becomes undulating course, the relapse occurs at 12.3
                     days after the "healing".
                Endometritis

   Endometritis after cesarean section always
    occurs in severe type of classical forms of
    endometritis with pronounced signs of
    intoxication and paresis of the bowel,
    accompanied by dry mouth, flatulence,
    decreased urine output. The development
    of endometritis possible in patients in
    whom the operation was accompanied by
    profuse bleeding, loss of fluid and
    electrolytes.
                   Second stage

   Metritis - is deeper than endometritis, failure
    of the uterus that develops when
    "breakthrough" leukocyte shaft of the
    placental site and spread of infection through
    the lymphatic and blood vessels into the
    muscular layer of the uterus. Metritis may
    develop along with endometritis or go to a
    continuation. In the latter case, it does not
    develop before the 7 days after birth. The
    disease begins with fever, the temperature
    rises to 39-40 ° C. In the heavily disturbed
    general condition. On palpation of the uterus
    body - enlarged, painful, particularly in the
    ribs. Allocation of scarce dark red color
    mixed with pus, with the smell.
  Pelvic cellulitis (parametritis) from extension of puerperal infection. Bacteria may enter
the parametrial tissue between the leaves of the broad ligament by direct extension or by
    lymphatic transmission from cervical lacerations or foci of trauma within the uterus,
  including placental implantation site or cesarean section incision. Bacterial spread may
  also develop across the wall of an infected vein. Lacerations of the perineum or vagina
         usually cause only localized cellulitis, but may extend to pelvic lymphatics.
                    Salpingoophoritis
   Postpartum salpingoophoritis develops on 7-10 day after birth. The
    temperature rises to 40 ° C, there are fever, pain in lower abdomen,
    lower back, symptoms of irritation of the peritoneum, flatulence. The
    uterus is enlarged, pasty, rejected in one way or another. In the
    appendages define painful infiltration without clear contours.
    Sometimes impossible to palpate infiltration due to severe pain.
    Postpartum parametritis - an inflammation of the parauterine cellular.
    Pathways are traditional, but infection can occur as a result of deep
    ruptures of the cervix or perforation of the uterus. Develops on 10-12
    days after birth. There is a chill, the temperature rises to 39 ° C. The
    general condition of puerperal almost unchanged. There may be
    complaints about the nagging pains in the abdomen. At vaginal
    examination in the broad ligament of the uterus define moderately
    painful without clear contours of infiltration, flattening of the vaginal
    fornix on the affected side.
   Postpartum pelvioperitonitis - an inflammation of the peritoneum, a
    limited pelvic cavity. Secrete serous, purulent pelvioperitonit
    seroznofibrinozny and that it becomes a 3-4 day illness.
    Pelvioperitonit most characteristic of gonorrhea infection, which
    predominates fibrinous exudate. When septic puerperal infection
    often develops during the first week after birth. Start
    pelvioperitonitis resembles the clinical picture of peritonitis. The
    disease occurs acutely, accompanied by high fever, chills, sharp
    pains in the abdomen, nausea, vomiting, bloating and abdominal
    tension, determine the symptoms of irritation of the peritoneum.
    Uterine body is enlarged, painful. In the pelvic cavity determine
    infiltration without clear contours. Movement of the body of the
    uterus painful and limited. Posterior fornix is flattened. After 1-2
    days the general condition improved, the local symptoms localized
    in the lower abdomen.
         Postpartum thrombophlebitis
   Postpartum thrombophlebitis (limited) - is one of
    the serious complications postpartum. According
    to modern concepts in the pathogenesis of
    thrombotic events leading role played by the
    following factors: changes in hemodynamic
    changes in the vascular wall, infectious factors,
    changes in blood coagulation. Localization
    thrombophlebitis divided into extrapelvic and
    intrapelvic (central). Extrapelvic thrombo-
    phlebitis include superficial and deep veins of
    the lower extremities. Intrapelvic (central) are
    divided into metrotromboflebitis and
    thrombophlebitis of veins of the pelvis.
    Thrombophlebitis leg deep vein
   Thrombophlebitis leg deep vein often develops in 2 to 3
    weeks after birth. The clinical picture is scarce: fever,
    pain in the calf muscles, aggravated by movements in the
    ankle with the statute on the affected side (Homans
    sign), moderate swelling of the ankle on the affected
    side. Sometimes it helps in the diagnosis of deep vein
    thrombophlebitis of leg a symptom of "cuff" (on the shin
    impose a cuff of the device for determining blood
    pressure and pump air into the norm of pain occur at a
    pressure of 170-180mm Hg. Art. And above, with
    thrombophlebitis - less than 140) .
             Metrotrombophlebitis
   Metrotromboflebitis difficult to recognize. Emphasis is placed on
    rapid pulse, subinvolution uterus, prolonged, heavy bleeding from
    the genital tract. At vaginal examination - enlarged and painful,
    especially in the field edges, rounded shape of the uterus, on its
    surface determine the twisted veins.
    Thrombophlebitis of the veins of the pelvis reveal, usually before
    the end of 2 weeks. The most difficult flowing and life-threatening
    form of postpartum thrombophlebitis is the ilio-femoral (ilio-femoral)
    venous thrombosis.
                        Diagnosis
   Postnatal diagnosis of infectious diseases is carried out
    taking into account the complaints of the patient,
    anamnesis, evaluation of clinical manifestations,
    laboratory results, as well as hardware and instrumental
    methods.
    Produce a thorough examination of mammary glands,
    external genitalia, perineum, vagina, cervix, as well as
    vaginal examination.
    Clinical analysis of blood from these patients
    predominantly reveals decrease in the number of red
    blood cells and hemoglobin, increased WBC count, ESR,
    reduced hematocrit. In the leucocyte count is a shift to
    the left with increasing number of sticks-nuclear
    neutrophils. Sometimes report significant
    thrombocytopenia (with septic shock). Changes in
    clinical severity of blood, usually correspond to the
    severity of the disease.
       MAIN COMPONENTS OF
           TREATMENT
   Treatment should be etiotropic,
    comprehensive, systematic and active. It
    should start as early as possible in
    identifying the initial manifestation of
    post-natal infection, which contributes
    significantly to the prevention of severe
    generalized forms.
    Anti-infective treatment is a major
    component in the complex treatment of
    septic puerperal diseases.
                     Antibiotics
    For antibiotic therapy at the same time
    prescribe a combination of at least two
    antibiotics in the highest dose. The intensity of
    the antibiotic determined by the clinical form
    and severity of the disease. In severe infection,
    use a combination of three antibiotics: penicillin
    aminoglycosides, metronidazole or
    aminoglycosides, cephalosporins metronidazole,
    penicillins inhibitors of b-lactamases. At
    moderate infection is most frequently used
    combinations: oksicillin + ceporin, ampicillin+
    gentamicin, penicillin +metronidazole,
    aminoglycosides +metronidazole.
       Anti-inflammatory therapy

   To include steroidal anti-inflammatory drugs
    (corticosteroids and their analogues) and
    nonsteroidal anti-inflammatory drugs. For the
    first universal characteristic, rapidly manifesting
    anti-inflammatory and immunosuppressive
    effects. Almost all non-steroidal anti-
    inflammatory drugs inhibit the formation of
    prostaglandins, acting synergistically with other
    mediators of inflammation, which reduces the
    effects of bradykinin, histamine, serotonin
Remediation of the primary hearth
    Task - to remove inflammatory debris and
     deliver of drug treatment. In identifying the
     contents of the uterus (about 70% of
     parturients) is preferable to perform vacuum
     aspiration, which relate to a safer intervention
     than curettage curette. A more effective method
     of influence on the primary focus for
     endometritis consider the method of aspiration-
     irrigation drainage of the uterine cavity cooled
     solution (+4 ° C), antiseptics and antibiotics with
     the addition of glucocorticoid hormones. Good
     clinical results obtained with the local use of
     diuretic agents (urea, mannitol).
      Immunostimulatory therapy
   By reducing the immune protection of the use of
    even the most active antibiotics may prove to be
    inconclusive. Therefore, use tools that increase the
    specific immunologic reactivity and nonspecific host
    defense parturients - antistaphylococcal gamma
    globulin, antistaphylococcal plasma adsorbed
    staphylococcal toxoid, gamma globulin, human
    immunoglobulin in a concentrated form
    (intraglobin, Pentaglobin, citotek).
          Infusion and detoxification
                    therapy
   In order to eliminate hypovolemia, implementing detoxification
    and correction of underlying colloid-osmotic state conduct a
    multi-component fluid therapy. Maintenance Mode
    gemodelyution contributes to the normalization of
    microcirculation and rheological characteristics of blood
    coagulation. Most often use Plasma (reopoliklyukin,
    poliglyukin), synthetic colloidal substances, protein preparations
    (albumin, aminopeptide, gidrolizin, zhelatinol),solutions.
   Desensibilization therapy - suprastin,
    diphenhydramine, Promethazine, tavegil.
    Prevention koagulyation violations -
    reopoliglyukin, trental, heparin.
    Antihypoxic therapy. To increase the blood
    oxygen capacity, elimination of hypoxia in the
    inflammation used normo-and hyperbaric
    oxygenation, transfusion of hemoglobin with a
    full functional frash blood.
    Symptomatic treatment - uterotonic, analgesics,
    sedatives, etc.
                        Prevention
   Prevention of septic puerperal diseases must begin
    with the first weeks of pregnancy. In the women's
    consultations should identify pregnant women who are
    at high risk of bacterial infection and its
    manifestations, and carry out preventive and curative
    interventions.
    In obstetric hospitals should strictly observe the rules
    of aseptic and antiseptic, widely introduce new
    technologies childbirth. These include: early
    attachment of the newborn to the breast, a system of
    isolated joint stay of mother and child, followed by an
    early discharge from the hospital, limiting the use of
    healthy women means and methods of
    decontamination, violating biocaenosis body.

				
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posted:1/26/2013
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