Maternal sepsis is a systemic complication of infections of the female genitourinary system and breast that developed during pregnancy, expulsion of the fetus and in the postpartum (post–abortion) period. It is manifested by a severe general condition, increasing weakness, fever, palpitations, shortness of breath, and a decrease in blood pressure. As the progression progresses, clouding of consciousness, pronounced difficulty in breathing, a sharp decrease in the volume of urine excreted are added. The diagnosis is established on the basis of physical examination, ultrasound, laboratory blood tests. Complex treatment: surgical rehabilitation of ulcers, antibiotic therapy, intensive therapy.
O75.3 Other infections during childbirth
Maternal sepsis (puerperal fever) is a life–threatening condition characterized by disorders of hemodynamics, metabolism, blood clotting, multiple organ failure and arising in response to infectious inflammation in the genital and urinary organs, as well as in the mammary gland in the gestational, labor and postpartum periods. The outdated synonym for sepsis “blood poisoning” is now irrelevant: the penetration of an infectious agent into the blood is not a prerequisite for the development of the septic process – bacteremia is registered only in 50% of patients. Sepsis develops in one out of 5,000 pregnant and giving birth and is accompanied by septic shock in 10% of cases, the share of the disease in the structure of maternal mortality is 12%. In 44% of cases, sepsis is registered at the stage of pregnancy (with a uniform distribution by gestation periods), in 10% – during childbirth, in 46% – in the postpartum period.
Maternal sepsis is always secondary, its source is a local infection. The main pathogens of purulent-inflammatory diseases are representatives of opportunistic flora (pyogenic streptococcus, group B Streptococcus, Staphylococcus aureus, E. coli, Klebsiella, proteus, peptococcus, peptostreptococcus, bacteroid, candida fungus), most often inhabit the lower parts of the genitourinary sphere and intestines and lead to pathology only under the influence of certain factors. The main causes and sources of infection include:
- Surgical operations and tissue injuries. The wound surface serves as a gateway to infection and contributes to a significant decrease in local immunity. The purulent process can be the outcome of cesarean section, early discharge of amniotic fluid (with incorrect fetal position, multiple pregnancy), ruptures received in childbirth and surgical interventions on the perineum.
- Therapeutic and diagnostic manipulations. The pathogen is transmitted by contact with a contaminated instrument, in addition, the microtrauma obtained during the study creates favorable conditions for lympho- and hematogenic infection. Risk factors include cervical cerclage, amniocentesis, cordocentesis, urethral catheterization, in vitro fertilization, multiple vaginal examinations during childbirth.
- Physiological changes caused by pregnancy. The growing uterus squeezes and displaces the surrounding anatomical structures, and progesterone reduces the tone of smooth muscles. These factors lead to urodynamic disorders and create prerequisites for the development of gestational pyelonephritis and urosepsis.
- Stagnation of breast milk. As a result of lactostasis, there is an active growth of staphylococci that cause mastitis. Violation of milk outflow is the main cause of postpartum abscesses and phlegmon.
On the other hand, purulent processes can be complicated by sepsis only if the immune response is hypo- or hyperreactive. Functional disorders of the immune system lead to increased activity of opportunistic microorganisms and the formation of a pathological reaction to purulent inflammation. Risk factors include obesity, diabetes mellitus, anemia, acute and chronic inflammation (genital and extragenital), lack of nutrition, age over 35 years.
Massive tissue damage by infection is accompanied by permanent or periodic release of inflammatory response mediators into the bloodstream, which depletes the regulatory function of the immune system and triggers a number of uncontrolled reactions in distant organs and tissues. As a result, the endothelium is damaged, microcirculation (perfusion) worsens, oxygen transport decreases. These changes lead to violations of homeostatic regulation, the development of acute multiple organ failure syndrome (AMOFS) and DIC syndrome.
The ventricles of the heart expand, there is a decrease in cardiac output, vascular tone is disturbed. Atelectasis forms in the lungs, respiratory distress syndrome develops. As a result of a decrease in the volume of circulating blood (VCB) and hemostatic disorders, the microcirculation of the renal tissue and blood supply to the cortical layer deteriorates, followed by acute functional insufficiency. Metabolic processes are disrupted in the liver, and lack of blood supply leads to the formation of necrotic areas. Hypoperfusion leads to pathological permeability of the intestinal mucosa with the release of toxins and microorganisms into the lymphatic system, as a result of ischemia, stress ulcers form on the walls of the gastrointestinal tract. Violation of metabolic processes and microcirculation of the brain causes neurological disorders.
Maternal sepsis is classified according to different criteria: by pathogen, by metastatic spread (septicemia, characterized by the presence of only a primary focus, and septicopyemia – the presence of purulent dropouts in other tissues and organs) or by clinical course. In modern obstetrics, a classification has been adopted that reflects the successive stages of the formation of a systemic inflammatory reaction:
- Systemic inflammatory response syndrome (SIRS). A harbinger of a septic condition is a systemic reaction to an inflammatory process of any etiology. It is established in the presence of an inflammatory disease and on the basis of at least two clinical manifestations of SIRS: tachycardia, tachypnea or hyperventilation, hypo- or hyperthermia, leukocytosis (leukopenia) or an increase in the proportion of immature neutrophils. In 12% of patients with sepsis, there are no signs of SIRS.
- Sepsis. Pathological systemic response to primary or associated infection. The diagnosis is made in the presence of an infectious focus or on the basis of verified bacteremia and acutely developed signs of functional insufficiency of two or more organs (AMOFS).
- Septic shock. An extreme form of a pathological reaction. It is accompanied by pronounced, persistent, poorly amenable to drug correction hypotension and perfusion disorders.
Postpartum sepsis manifests on the second or third day after the expulsion of the fetus with purulent secretions, phenomena of general intoxication (tachycardia, shortness of breath, weakness, loss of appetite, sometimes vomiting and diarrhea) and an increase in temperature to 39-40 ° C with chills. Hyperthermia is usually stable, but there may be forms with a gradual increase or a large variation in daily temperature and rare attacks of chills. Abdominal or mammary pains are noted, generalized rashes may be registered. The severity of symptoms and duration of the disease vary depending on the form of the clinical course.
For lightning-fast obstetric sepsis, the increase in symptoms is characteristic during the day, with an acute form, the clinical picture unfolds within a few days. In the subacute form, the signs are less pronounced, the process develops for weeks. Chroniosepsis is characterized by mild changes (subfebrility, increased sweating, headache and dizziness, drowsiness, diarrhea) and a sluggish course for many months. The recurrent form is a series of attenuations (periods of remission without noticeable manifestations) and exacerbations (periods with vivid symptoms) and is characteristic of septicopiemia, when the deterioration is caused by repeated episodes of secondary abscess formation.
In the absence of treatment, intoxication of the body increases and a severe form with shock syndrome develops. In the early (“warm”) phase, weakness progresses, dizziness is noted. At the same time, the temperature decreases to normal or subfebrile values, tachycardia increases. The mucous membranes and nail beds acquire a bluish hue, the skin is hyperemic. There is excitement, consciousness can be clear or confused, psychoses and hallucinations are not uncommon. The average duration of the early stage is 5-8 hours, less often – up to two days. In the case of gram-negative infection, this phase may last several minutes.
Late (“cold”) the stage is marked by an increase or weakening of the heartbeat with the transition to bradycardia, a drop in temperature below normal, significant difficulty breathing. Anxiety and excitement increases, then is replaced by adynamia, consciousness is darkened. The skin acquires an earthy hue, is covered with a sticky cold sweat, a cyanotic marble pattern appears on the legs, especially pronounced in the knee area. Oliguria develops, sometimes jaundice appears.
Anaerobic sepsis associated with uterine gangrene is characterized by a particularly severe course and a number of specific signs. The disease proceeds with lightning speed or acutely, accompanied by intense uncupable pain in the lower abdomen, crepitation and increased pain during palpation of the uterus, the release of gas and fetid liquid from the vagina with air bubbles, bronze skin color, brown urine. The phenomena of septic shock manifest themselves already at the very beginning of the disease.
Patients who have survived the acute period may develop a severe, often fatal complication – superinfection. A significant deterioration in the quality of life or death of the patient often entails other consequences of sepsis: irreversible organ changes of the kidneys, liver, lungs, heart, brain associated with ischemia or purulent metastasis, perforation and bleeding from gastroenteric stress ulcers, arterial thromboembolism and phlebothrombosis. Sepsis in pregnant women can cause premature birth, fetal death, encephalopathy and cerebral palsy of the born child.
Obstetrician-gynecologist, therapist, resuscitator, microbiologist participate in the diagnosis of maternal sepsis, complicated forms require the involvement of a nephrologist, cardiologist, neurologist, hepatologist. During gynecological examination and general examination, septic condition can be suspected by the presence of a focus of purulent inflammation in the pelvic organs or mammary gland, as well as signs of SIRS. The following studies are being conducted:
- Determination of the pathogen. A cultural analysis of blood and a vaginal smear can identify an infectious agent and select an effective drug for the treatment of infection. Bacteremia confirms the presence of a septic process. In the absence of bacteremia, a procalcitonin test is performed to differentiate local and generalized infection.
- Instrumental research. Ultrasound of the pelvis and kidneys confirms (reveals) the presence of a primary purulent focus in the genitourinary organs. Ultrasound of the abdominal cavity, chest X-ray, echocardiography can detect secondary abscesses in the liver, lungs, and heart.
- Clinical and biochemical blood tests. A general blood test detects leukocytosis, leukopenia, a shift of the leukocyte formula to the left – values that indirectly confirm the septic condition. The data of the biochemical study indicate violations of the water-electrolyte balance and kidney and liver functions. Blood gas analysis reveals ABS disorders and respiratory failure. According to the results of the coagulogram, blood clotting disorders are determined. Testing the level of lactate in plasma allows you to detect tissue hypoperfusion and assess the severity of shock. The immunogram indicates disorders of immune activity.
Maternal sepsis should be differentiated with gestosis, amniotic embolism and pulmonary embolism, acute infections (severe influenza, brucellosis, typhus, malaria, miliary tuberculosis), acute pancreatitis, leukemia, lymphogranulomatosis. For differential diagnosis, a consultation of a cardiac surgeon, an infectious disease specialist, a phthisiologist, an oncohematologist may be required.
Treatment of maternal sepsis
Therapeutic measures are carried out in the conditions of a gynecological or observational obstetric department, patients with severe forms of sepsis are transferred to the intensive care unit. The treatment is complex, includes surgical and conservative methods and is aimed at fighting infection and correcting vital functions:
- Infusion therapy. Treatment includes correction of homeostatic disorders (hypotension, coagulopathy, acid-base and water-salt metabolism disorders, VCB deficiency), restoration of tissue perfusion, detoxification. For these purposes, salt and colloidal solutions, albumin, cryoplasm, inotropes and vasopressors are introduced.
- Antibacterial therapy. It is aimed at destroying the infectious agent in order to block the inflammatory cascade. Initial treatment includes intravenous administration of a combination of broad-spectrum drugs. After isolation of the pathogen, etiotropic antibiotic therapy is started.
- Surgical treatment. Elimination of purulent foci increases the effectiveness of intensive therapy and improves the prognosis. Treatment involves the rehabilitation of primary and secondary foci – opening and emptying of abscesses, curettage, vacuum aspiration or removal of the uterus (hysterectomy).
If necessary, artificial ventilation of the lungs, enteral nutrition of the patient is carried out. Additional methods of intensive therapy include the use of corticosteroids, surgical detoxification (plasmapheresis, hemosorption, hemofiltration) after surgical treatment of suppuration, immunotherapy.
Prognosis and prevention
In the early stages, when pronounced signs of AMOFS, stable hypotension and DIC syndrome have not developed, the prognosis is favorable. With the development of septic shock, mortality can reach 65% (on average – 45%). Preventive measures consist in the timely treatment of inflammatory diseases (both at the planning stage and during pregnancy), the fight against community-acquired interventions (intrauterine and vaginal manipulations, criminal abortions, home births), rational preventive antibiotic therapy during surgical interventions, proper nutrition, stabilization of blood glucose levels in diabetes mellitus