Postpartum endometritis is a purulent–inflammatory disease of the uterine mucosa that develops in the early period after childbirth. With postpartum endometritis, fever, intoxication syndrome, tenderness in the lower abdomen, abundant pus-like lochia, subinvolution of the uterus are noted. The diagnosis of postpartum endometritis is based on clinical data confirmed by the results of ultrasound of the pelvis, hysteroscopy, back-seeding of the separated uterus. Postpartum endometritis requires the appointment of antibacterial, detoxification therapy; performing gentle curettage, vacuum aspiration and washing of the uterine cavity.
Postpartum endometritis is a form of postpartum infection characterized by infectious inflammation of the inner lining of the uterus (endometrium). After the separation of the afterbirth, a significant wound surface is formed inside the uterus, during delivery by caesarean section, an additional surgical injury of the uterus occurs. Regeneration of the endometrium occurs only by the end of 5-6 weeks after delivery. Activation of conditionally pathogenic microflora and penetration of infection through the damaged endometrium during this period leads to the emergence of an inflammatory process in the uterus. Endometritis develops in about 7% of maternity patients, but among postpartum purulent-inflammatory pathology, its frequency is 36-59%. Postpartum endometritis can be acute and chronic. In most cases, there is a mild course, about 25% of cases of the disease are severe with the potential for generalization of infection. The inflammatory process usually extends to the muscular layer of the uterus – the myometrium, therefore, in most cases, postpartum metroendometritis is diagnosed in gynecology.
The cause of postpartum endometritis is a bacterial infection, most often entering the uterine cavity ascending from the lower genital tract or gastrointestinal tract. Facultative pathogenic microorganisms, often in the form of polymicrobial associations, act as infectious agents in 90% of cases: Enterobacteria (E.coli, Klebsiella pneumoniae, Proteus spp., Enterococcus spp.), epidermal staphylococcus, group A and B streptococci, non-spore-forming anaerobes (Bacteroides fragilis, Peptococcus sp., Peptostreptococcus sp., Fusobacterium sp.), gardnerella. Mycoplasmas, chlamydia, gonococci are less often detected.
A prerequisite for the development of postpartum endometritis is considered to be a decrease in the immune resistance of the body. In the late stages of pregnancy and in the early postpartum period, significant qualitative shifts in the genital microflora occur. The natural antagonism within the associations of microorganisms living in the vagina is disrupted. The risk of postpartum endometritis increases if a pregnant woman has infectious and inflammatory diseases of the urogenital and bronchopulmonary tract, foci of chronic infection, endocrine disorders, immunodeficiency, autoimmune conditions and anemia. The background for reducing the immunity of a pregnant woman can be a low social level, insufficient nutrition, bad habits.
The development of postpartum infectious complications is facilitated by previously performed instrumental interventions on the uterine cavity (curettage, abortions), long-term intrauterine contraception; features of the course of pregnancy and childbirth (threat of termination, placenta previa, surgical correction of cervical insufficiency), invasive diagnostic manipulations (amnio- and cordocentesis, chorion biopsy), late rupture of fetal membranes, prolonged anhydrous interval and prolonged labor, chorioamnionitis, pathological blood loss, perineal trauma, manual separation of the placenta, cesarean section. Moreover, after childbirth through the natural birth canal, the frequency of endometritis is 1-3% of cases, after planned operative delivery – 5-15%, after emergency – more than 20%.
Inadequate management of the postpartum period, uncompensated replenishment of blood loss, prolonged bed rest, slowing of uterine involution, intrauterine infection of the newborn (vesiculosis, pneumonia, sepsis), poor personal hygiene of the genitals also form the conditions for the development of infectious complications after childbirth.
Postpartum endometritis can occur in mild, moderate and severe forms, be compensated, subcompensated and decompensated. With a mild course, manifestations of acute postpartum endometritis develop on 5-12 days after delivery. There is chills, a rise in temperature to subfebrile (up to 38 ° C), an increase in pulse rate to 80-100 beats / min., abdominal wall soreness, moderate blood lochia. The contractility of the uterus is slightly reduced. The condition of the maternity hospitals remains satisfactory and does not deteriorate significantly within 24 hours.
The severe course of the disease is often preceded by chorioamnionitis, complications of childbirth or operative delivery. Severe postpartum endometritis occurs immediately 2-3 days after delivery. Characterized by weakness, headache, febrile temperature rise (39 ° C and above) with chills, tachycardia (100-110 beats / min.), pain in the lower abdomen and lower back, impaired appetite and sleep. Lochia become profuse cloudy, bloody-purulent with an ichorous odor. Negative dynamics of the general condition is possible within 24 hours. The involution of the uterus is slow. Postpartum endometritis can be complicated by endomyometritis, lymphadenitis and metrothrombophlebitis, intestinal paresis, peritonitis, pelvic abscess, generalization of infection.
Compensated type of endometritis occurs with short-term (up to 3 days) resorptive fever and absence of uterine subinvolution; subcompensated – against the background of high fever and pronounced uterine subinvolution, decompensated turns into severe purulent-inflammatory complications – peritonitis, sepsis, septic shock. Postpartum endometritis may occur in an erased form with a relatively late onset (5-7 days), an unclear clinic, a prolonged course, relapses and the risk of generalization of infection.
The diagnostic complex of postpartum endometritis includes an analysis of the course of labor, clinical picture data, bimanual examination, general blood and urine analysis, back-seeding of the discharge from the uterine cavity, pelvic ultrasound with dopplerography, hysteroscopy.
Ultrasound of the pelvis in postpartum endometritis shows an increase in the volume of the uterus and the expansion of its cavity due to pathological inclusions and gas, the failure of sutures after cesarean section (infiltration of tissues, the appearance of defects in the form of a “niche”) Hysteroscopy is performed to visualize changes in the endometrium (swelling, cyanosis, hemorrhagic foci), to clarify the nature of uterine inclusions (remnants of placental tissue, necrotic decidual tissue, blood clots, fibrin deposits, pus) and the condition of the postoperative suture. With postpartum endometritis, remnants of a delayed placenta are often found. Histological examination of the afterbirth shows the presence of inflammatory changes in it.
In the general blood test for postpartum endometritis, leukocytosis is detected (in mild form – 9-12 × 109 / l, severe – 10-30 × 109 / l); neutrophilic shift of the blood formula to the left, an increase in ESR (up to 30-55 mm / h and even 55-65 mm / h). Back-seeding of the separated uterus is carried out to determine the sensitivity of the microflora to antibacterial drugs. The acid-base state of the lochiae is being investigated (with endometritis pH <7), if sepsis is suspected, blood is pumped. Differential diagnosis of postpartum endometritis is carried out with postpartum parametritis, pelvioperitonitis, metrothrombophlebitis, thrombophlebitis of the pelvic veins.
Treatment of postpartum endometritis is complex and includes medication and non-drug tactics. Patients with acute postpartum endometritis are shown hospitalization in a hospital, bed rest, cold on the lower abdomen, diet. The main focus is on antibacterial therapy. Broad–spectrum antibiotics are immediately prescribed intravenously (cephalosporins of the third generation), if the sensitivity of the pathogen to certain drugs is detected – treatment. In mild and moderate forms of endometritis, monotherapy with antibiotics is sufficient, in severe cases, various combinations of them are used (clindamycin + gentamicin, metronidazole + gentamicin). With severe intoxication, it is necessary to prescribe detoxification infusion therapy, hemosorption, lymphosorption, plasmapheresis.
To improve the outflow of lochiae, a combination of uterine contractors (oxytocin) and antispasmodics (drotaverine) is used. It is advisable to use anticoagulants (heparin), antihistamines, immunostimulants, vitamins (A, C, K, troupe B). After the acute phase is stopped, physiotherapy – medicinal electrophoresis or ultraphonophoresis, magnetotherapy, laser therapy, diadynamic currents, darsonvalization and UFO (locally), acupuncture – give a good therapeutic effect.
In the presence of remnants of infected and necrotized fetal membranes or afterbirth, careful curettage or vacuum aspiration of the contents of the uterine cavity, intrauterine lavage with disinfectant solutions, and flushing drainage is necessary. In the absence of the effect of intensive therapy (after 7 days from the start of treatment of postpartum endometritis) and the preservation of clinical and laboratory criteria for inflammation, the issue of removal of the uterus – hysterectomy is resolved.
The prognosis of postpartum endometritis depends on the severity of the disease: treatment of mild and moderate forms ends with recovery and preservation of reproductive function; severe decompensated form can be complicated by septic condition, loss of the uterus, death. Prevention of postpartum endometritis consists in monitoring the vaginal microflora of pregnant women, proper management of childbirth and the postpartum period, preventive antibiotic therapy after cesarean section.