Obstetric peritonitis is an acute inflammation of the peritoneum resulting from its bacterial contamination during childbirth or the postpartum period. It is manifested by diffuse abdominal pain, abdominal wall tension, flatulence, stool retention, fever and an increase in general intoxication. To make a diagnosis, physical examination methods, ultrasound, abdominal radiography, laboratory diagnostic methods are used. Treatment is usually surgical with extirpation of the uterus and its tubes. After surgery, the patient is shown active antibacterial and infusion therapy.
O86.8 Other specified postpartum infections
Currently, inflammation of the peritoneum in maternity patients occurs relatively rarely – the frequency of pathology usually does not exceed 0.05-0.3%. At the same time, due to the high mortality rate, obstetric peritonitis is one of the most severe complications of childbirth and the most common causes of maternal mortality. In more than 98% of cases, the disease develops after surgical delivery by caesarean section, much less often (in 1-2% of patients) – against the background of purulent salpingoophoritis or septicopiemia. The prevalence of pathology directly depends on the contingent of pregnant women and the level of medical care in obstetric hospitals.
Inflammation of the peritoneum after cesarean section or childbirth is a consequence of an imbalance between the virulence of pathogenic microorganisms and the level of immune resistance of a woman. The causative agents of obstetric peritonitis are usually gram-negative bacteria (proteus, Pseudomonas aeruginosa and E. coli) and non-spore-forming anaerobes (Clostridia, fusobacteria, peptococci and especially bacteroids). In a third of cases, gram-positive staphylococci and enterococci are detected in the peritoneal exudate. The most severe forms of the disease are caused by anaerobic-aerobic associations.
The risk of postpartum peritonitis increases with a prolonged anhydrous period (over 12 hours), bacterial contamination of the vagina, chorionamnionitis, postpartum endometritis, chronic cervicitis, salpingitis, adnexitis and prolonged intestinal paresis. Specialists in the field of obstetrics and gynecology distinguish three ways of infection of the peritoneum:
- Infection in childbirth. Microorganisms enter the abdominal cavity together with the contents of the uterus during operative delivery of a pregnant woman with chorioamnionitis.
- Penetration through the intestinal wall. After childbirth, against the background of prolonged paresis, the intestinal wall becomes permeable to pathogenic microflora.
- Seeding due to seam divergence. In more than half of cases, the cause of peritonitis is the failure of postoperative sutures on the uterus.
When microorganisms enter, inflammation does not always occur, a significant role in the development of peritonitis is played by a decrease in resistance. Even during normal pregnancy and uncomplicated childbirth, there is an immunodeficiency due to the depressing effect of estrogens, progesterone and placental proteins. The probability of obstetric peritonitis increases significantly with massive blood loss, anemia, severe gestosis, prolonged labor, stress due to insufficient anesthesia, irrational intake of antibacterial and corticosteroid drugs, traumatization of soft tissues during childbirth, medical manipulations, surgical interventions.
The key link in the development of the disease is the release of a significant amount of tissue and bacterial toxins with massive contamination of the uterine cavity, and then the peritoneum with pathological microorganisms. Toxins entering the blood stimulate the release of histamine, serotonin and a number of other bioactive substances. As a result, vascular permeability and blood microcirculation are disrupted, which leads to its deposition and sequestration, primarily in the vessels of the peritoneum and abdominal organs.
Due to the increasing swelling of the intestine, its motility and absorption processes are disrupted, which provokes the accumulation of gases and fluids in the intestinal loops. Further overgrowth of the intestinal wall aggravates microcirculation disorders, increases dehydration and hydroionic disorders. Against the background of general intoxication, deficiency of intra- and extracellular fluid, acidosis, hypokalemia, hypovolemia increases, which is accompanied by blood thickening, oliguria, cardiovascular and respiratory disorders. In the terminal phase of obstetric peritonitis, the main vital functions are decompensated.
When classifying peritoneal inflammations that occur in obstetric practice, the mechanism of infection, the degree of prevalence of the pathological process, the nature of the exudate and the clinical course are taken into account. Taking into account the possible ways of spreading pathogens, there are:
- Primary peritonitis, in which microorganisms enter the peritoneum during cesarean section from the uterus (early peritonitis) or from the intestine after surgery.
- Secondary peritonitis caused by the divergence of failed sutures on the operated uterus in the presence of postpartum endometritis.
According to obstetricians and gynecologists, primary infection is observed in approximately 45% of cases of the disease, symptoms of inflammation occur on 1-2 days with peritoneal contamination during surgery and on 3-4 days with intestinal paresis. Secondary peritonitis develops on 4-9 days after placement in 55% of patients. Depending on the degree of peritoneal lesion, inflammation can be general, widespread (diffuse or diffuse), locally limited (abscess) or unlimited (pelvioperitonitis). By the nature of the exudate, the inflammatory process can be serous, fibrinous and purulent. Taking into account the severity of clinical manifestations, there are reactive, toxic and terminal stages of the disease.
Symptoms of obstetric peritonitis
In almost 40% of maternity patients, the symptoms of postpartum peritonitis are erased. In the classic course, on 1-9 days after childbirth, a woman notes bloating. In the first (reactive) phase, which lasts up to a day, there is no stool, the discharge of gases is difficult or impossible. There is a local soreness in the lower abdomen, which subsequently acquires a diffuse character, accompanied by tension of the muscles of the anterior abdominal wall. Lochia become pus-like with an unpleasant odor. The maternity patient complains of nausea, vomiting, dry mouth, pronounced chills. The temperature rises to 38-39 ° C and above.
The transition of the disease to the second (toxic) phase is indicated by a pronounced intoxication syndrome. The patient feels weakness, lethargy, weakness, dizziness. The amount of urine decreases, flatulence increases, there is no intestinal peristalsis. The temperature remains high. Breathing and heart rate increase. Pain and muscle tension are somewhat reduced. With inadequate treatment, the disease passes into the terminal stage after 1-3 days. The maternity hospital continues to complain of pronounced weakness, dizziness, a feeling of bloating and its spilled soreness. The temperature often falls below 36 ° C.
With untimely diagnosis and improper treatment, obstetric peritonitis is complicated by abdominal abscesses, dynamic intestinal obstruction, acute portal vein thrombophlebitis, upper and lower respiratory tract infections (tracheobronchitis, nosocomial pneumonia), uroinfection, DIC syndrome, bleeding, sepsis and septic shock. In the terminal stage, patients develop multiple organ failure with disorders of cardiovascular and respiratory activity, impaired kidney and liver function, confusion, passing into coma and death. The long-term consequences of cured peritonitis are impaired intestinal motility, postoperative hernias and adhesive disease, which in 20% of cases leads to infertility. In women who have suffered peritoneal inflammation, the risk of developing strangulation intestinal obstruction increases.
Timely detection of obstetric peritonitis is a key condition for choosing the right treatment tactics and preventing possible complications. In diagnostics, such physical, instrumental and laboratory methods of examination are used as:
- Palpation of the abdomen. With inflammation of the peritoneum, diffuse soreness, flatulence, positive symptoms of Shchetkin-Blumberg, Kullenkampf, Razdolsky are determined.
- Percussion of the abdominal cavity. In the lateral flanks and lower abdomen, there is a blunting, indicating the presence of fluid.
- Auscultation of the intestine. When listening, there are no characteristic intestinal noises.
- Microbiological examination. The causative agent of the disease is determined in the discharge of the uterus, blood, peritoneal exudate. Its sensitivity to antibiotics is evaluated.
- A general blood test. Moderate or pronounced leukocytosis, rod-shaped shift of the formula, toxic granularity of neutrophils, high ESR are detected.
- Biochemical blood testing. There are signs of metabolic acidosis, disorders of protein and lipid metabolism, respiratory alkalosis, increased content of nitrogenous slags.
- Assessment of the hemostasis system. Hypercoagulation and consumption coagulopathy are characteristic.
- General urinalysis. In the composition of urine, leukocytes, hyaline cylinders, protein are determined.
- Ultrasound of the abdominal cavity. Fluid is detected behind the uterus, in the intestine and between its loops, the intestinal wall is hyperechogenic, the suture on the uterus has an uneven thickness and structure.
- Overview radiography of the abdomen. The presence of peritonitis is indicated by hyperpneumatosis of the intestine and the Cloiber bowl.
According to the indications, CT of the abdominal cavity and diagnostic laparoscopy may be recommended. To assess the state of the cardiovascular system, an ECG is prescribed, blood pressure and pulse are monitored in dynamics.
Differential diagnosis is carried out with severe postpartum endometritis, acute purulent pyelonephritis, surgical diseases (appendicitis, acute cholecystitis, pancreatitis, perforation of stomach ulcers, etc.). A surgeon, anesthesiologist-resuscitator, therapist, infectious disease specialist, clinical pharmacologist are involved in the management of the patient.
The choice of therapeutic tactics depends on the type, stage and severity of the disease. Conservative therapy is effective only in the reactive phase of early peritonitis. The treatment regimen includes:
- Antibacterial drugs. Before determining the sensitivity of the pathogen, antibiotics are prescribed from groups of semi-synthetic penicillins, cephalosporins, aminoglycosides. Subsequently, the treatment is corrected taking into account the results of a microbiological study.
- Infusion-transfusion therapy. Controlled hemodilution is carried out using rheocorrectors, detoxification solutions, protein preparations, electrolytes, anabolic hormones. If necessary, freshly frozen blood plasma is injected.
The duration of conservative therapy is usually 12-24 hours. With the ineffectiveness of drug treatment, the increase in signs of intestinal obstruction and general intoxication, surgical intervention is indicated. Relaparotomy is also performed for obstetric peritonitis caused by intestinal paresis or divergence of the suture on the uterus. At the short stage of preoperative preparation, the patient is injected with a nasogastric tube for decompression of the stomach, active infusion therapy and antibiotics are prescribed. During the operation, the uterus with tubes is extirpated, with purulent oophoritis, an oophorectomy is performed (the ovaries are removed). The abdominal cavity is sanitized after a thorough revision, drained through the anterior abdominal wall and vagina. Intestinal probes of Abbott-Miller are used for intestinal decompression according to indications.
In the postoperative period, infusion and antibiotic therapy continues, hemostasis is corrected. The appointment of general tonic agents, immunocorrectors, hormonal and desensitizing drugs is shown. Symptomatic therapy is aimed at correcting respiratory, cardiovascular disorders, neurological disorders, and the resumption of full functioning of the liver and kidneys. Drugs that stimulate and restore the evacuation function of the gastrointestinal tract are used. Various types of eubiotics are used to prevent dysbiosis.
Prognosis and prevention
Obstetric peritonitis belongs to the category of severe infectious diseases. With its widespread form, mortality ranges from 15 to 30%. Prevention provides for the timely diagnosis of inflammatory diseases of the female genital area, the reasoned appointment of invasive procedures during pregnancy, the choice of the correct obstetric tactics in case of premature discharge or leakage of amniotic fluid. Since postpartum inflammation of the peritoneum often becomes a consequence of cesarean section, an important role is played by an informed choice in favor of operative delivery. For preventive purposes, thermometry and screening are shown to all maternity women in the postpartum period for timely detection of signs of intoxication and symptoms of peritoneal irritation.