Metroendometritis is an inflammation of the muscular and mucous membrane of the uterine wall, combining signs of myometritis and endometritis. The clinic of acute metroendometritis is determined by hyperthermia, intoxication, pain in the lower abdomen, purulent whiteness. Chronic metroendometritis is accompanied by serous discharge from the genital tract, menstrual dysfunction and intermenstrual bleeding. Pathology is diagnosed according to the results of gynecological examination, echography, bacteriological seeding of the discharge. Treatment of acute form – antibiotic therapy, detoxification, adequate anesthesia; with chronic metroendometritis, physiotherapy and hormone therapy are indicated.
General information
Metroendometritis is a combined inflammatory process in the uterus, covering the basal layer of the endometrium and the adjacent myometrium. In this case, endometritis, as a rule, precedes the development of metritis. The general population frequency of various forms of metroendometritis has not been determined, however, it is known that in the postpartum period, this infectious complication develops in 3-8% of maternity patients, and in pathological childbirth its frequency increases to 20%. Delayed diagnosis and irrational therapy of metroendometritis can lead to the development of generalized purulent-septic complications, and in the long term – uterine infertility. The severity of the prognosis puts metroendometritis among the most important problems of modern obstetrics and gynecology.
Causes
Taking into account causally significant factors, two etiological forms of metroendometritis are distinguished – infectious and aseptic. Most cases of the disease are caused by opportunistic flora or aerobic-anaerobic complexes, which often act synergistically. The most relevant pathogens, according to microbiological studies, are Staphylococcus, Streptococcus, proteus, intestinal and Pseudomonas aeruginosa, anaerobic bacteria (bacteroids, peptostreptococci, peptococci). Many patients with metroendometritis have polymicrobial associations: Staphylococcus aureus in combination with hemolytic streptococcus, E. coli or Enterobacteria. Along with non-specific microflora, gonococci, mycoplasmas, Koch bacilli, Diphtheria bacillus can be detected in crops.
Infection in most cases is realized in an ascending way: from the vagina and cervical canal into the uterine cavity. This is facilitated by various gynecological manipulations – expansion of the cervical canal, abortion, childbirth, IUD installation, hysteroscopy, hysterosalpingography, SDC. The source of the downward spread of infection can be the fallopian tubes, contact – an inflammatory-altered appendix, hematogenic introduction of pathogens – distant purulent foci in the ENT organs.
The development of metroendometritis of infectious etiology is favored by conditions that facilitate the penetration of pathogens into the uterus: menstruation, uterine bleeding, venous stagnation in the pelvic cavity, nonspecific and specific colpitis and endocervicitis. Postabortem metroendometritis, as a rule, occurs against the background of incomplete removal of the fetal egg. Risk factors for puerperal (postpartum) metroendometritis are weakness of labor, a long anhydrous period, retention of placental tissue residues in the uterus, postpartum bleeding. The origin of aseptic metroendometritis is closely related to injuries and bruises of the uterus, the effects of physical and chemical factors (cryotherapy, endometrial ablation, douching). Infectious inflammation in these cases joins already a second time.
The infectious process in metroendometritis begins in the basal layer of the endometrium. The absence of a clear anatomical boundary between it and the myometrium causes the rapid spread of infection to the muscle membrane. The endometrium thickens, loosens, becomes edematous and hyperemic, covered with a purulent plaque. Microscopically visualized leukocyte infiltration, dystrophy and peeling of the glandular epithelium. The myometrium is also swollen, infiltrated by lymphocytes and segmented neutrophils. In severe cases, involvement in inflammatory changes of the serous lining of the uterus is noted, leading to the development of perimetritis.
In chronic metroendometritis, edema and hyperemia are less pronounced, lymphocytes and plasmocytes predominate in the inflammatory infiltrate. The myometrium is thickened due to the proliferation of connective tissue. Due to sclerotic processes in the vessels and fibrous transformations of the stroma, the endometrium acquires an uneven thickness, areas of hyperplasia and polypous growths appear on it. Dystrophic changes in the glands lead to disruption of the secretory transformation of the endometrium and disorders of menstrual function (anovulation, cycle failures).
Symptoms
Acute metroendometritis
Signs of acute inflammation usually appear on 3-4 days after artificial termination of pregnancy, childbirth, therapeutic and diagnostic manipulations on the uterus. The condition deteriorates rapidly: body temperature reaches 38.0—39.0 ° C, there is cognition, pronounced malaise, tachycardia, intoxication syndrome. There are painful sensations in the lower abdomen and in the sacrum, with palpation, the uterus is enlarged and painful. There are abundant cloudy whites – serous-purulent, purulent, sometimes with a putrid odor.
The presence of obstacles to the outflow of purulent secretions from the uterine cavity (submucous fibroids, uterine polyps, scarring of the cervix, etc.) may cause the occurrence of pyometra. In this case, the patient’s condition becomes heavier, cramping pains appear in the lower abdomen. With postpartum metroendometritis, against the background of lochia retention due to poor uterine contraction, its inflection or blockage of the cervical canal by blood clots, the development of lochiometra is possible.
Acute metroendometritis lasts on average from 5-7 to 8-10 days. Erased forms (for example, against the background of antibiotic therapy) proceed with a subfebrile temperature. In aggravated cases, the inflammatory process with metroendometritis can spread to the peritoneum of the pelvis or the serous covering of the abdominal cavity (pelvioperitonitis, peritonitis). Uterine gangrene and sepsis are considered to be the most prognostically unfavorable complications.
Chronic metroendometritis
It may be a continuation of the acute form with improper or not sufficiently intensive treatment, or it may immediately arise as a primary chronic disease. With chronic metroendometritis, vaginal discharge is serous, light, sometimes with a purulent admixture. Periodically, pulling pains may occur over the womb, in the lumbar region and sacrum. Palpationally, the uterus is painless, compacted and somewhat enlarged.
Pathomorphological changes in the endometrium cause the predominance of menstrual dysfunction in the clinical picture of chronic metroendometritis: menorrhagia, metrorragia, anovulatory cycles. The companions of this form of metroendometritis are often Nabothian cysts, chronic adnexitis, adhesions in the pelvis, chronic pelvic pain, intrauterine synechiae. These pathological conditions, in turn, cause a violation of childbearing function (spontaneous termination of pregnancy, habitual miscarriages, infertility).
Diagnostics
Acute metroendometritis in a patient who turned to a gynecologist with characteristic complaints allows us to think about the connection of the disease with recent childbirth, intrauterine therapeutic and diagnostic interventions, STDs. Examination on a chair helps to make an objective picture of the disease: the outflow of purulent whites from the cervical canal, soreness and enlargement of the uterus (or its subinvolution). In the general blood test, inflammatory changes are determined: leukocytosis, leucoformula shift to the left, acceleration of ESR. Verification of pathogens of metroendometritis is carried out by smear microscopy, bacteriological examination of the discharge, PCR diagnostics.
Chronic metroendometritis is indicated by liquid white, an enlarged uterus of dense consistency, various disorders of menstrual function. Ultrasound of the pelvic organs visualizes thickened myometrium, hyperplastic endometrium of heterogeneous echostructure. Histological analysis of scrapings of the uterine mucosa obtained as a result of diagnostic curettage makes it possible to identify changes characteristic of chronic metroendometritis.
Treatment
Therapy of acute metroendometritis should be started as early as possible and carried out in full. It shows rest, bed rest, applying a hot water bottle with ice to the lower abdomen. In order to influence the widest possible range of microbial pathogens, semi-synthetic penicillins (ampicillin, carbenicillin), cephalosporins in combination with metronidazole are prescribed. After receiving the results of microbiological analysis, correction of antibiotic therapy is carried out.
With severe intoxication syndrome, infusion of colloidal and crystalloid solutions is prescribed. The complex of general drug therapy includes desensitizing, analgesics, uterotonic agents, antispasmodics, vitamins, immunomodulators. A tangible positive effect in the treatment of acute metroendometritis is observed during intrauterine lavage – drip irrigation of the uterus with antiseptic solutions and antibiotics. If there is a delay in the uterine cavity of parts of the fetal egg or placenta remnants, their removal is carried out by vacuum aspiration or curettage. With the development of septic complications, surgical intervention may be required – supravaginal amputation of the uterus or hysterectomy (removal of the uterus together with the cervix).
In chronic metroendometritis, along with intramuscular antimicrobial therapy, targeted administration of antibiotics into the uterine mucosa is practiced. Therapeutic douching, physiotherapy treatment (UHF therapy, laser therapy, intracavitary electrophoresis, paraffin therapy, mud therapy, etc.), therapeutic baths (hydrogen sulfide, radon) are used. Correction of ovarian hypofunction is carried out by prescribing hormonal drugs (COCs). In the case of the formation of intrauterine splices, their separation is performed under hysteroscopic control.
Prognosis and prevention
The course and prognosis of metroendometritis depend on the virulence of pathogens and the resistance of the patient’s body. The outcome of acute endometritis can be both recovery and chronization of the disease. The septic complications that have arisen threaten not only further reproductive plans, but also life. The consequences of chronic metroendometritis inevitably affect the reproductive function, becoming the cause of ectopic pregnancy, miscarriages, premature birth, anomalies of the placenta, weakness of labor, postpartum bleeding, etc.
The metroenometritis warning system consists of measures of personal prevention and medical control. Prevention and timely therapy of inflammatory diseases of the genitals, refusal of abortions, rational management of childbirth, compliance with sterility during intrauterine interventions, gynecological examinations and ultrasound control will help to avoid metroendometritis and its accompanying complications.
