Postpartum infections are a group of diseases of infectious etiology that develop within 6 weeks after childbirth and are directly related to them. They include local wound infections, pelvic infections, generalized septic infections. In the diagnosis of postpartum infections, the time of their development and the connection with childbirth, the picture of peripheral blood, the data of gynecological examination, ultrasound, bacteriological examination are of paramount importance. Treatment of postpartum infections includes antibiotic therapy, immunostimulating and infusion therapy, extracorporeal detoxification, sanitation of the primary focus, etc.
Postpartum (puerperal) infections are purulent-inflammatory diseases pathogenetically caused by pregnancy and childbirth. They include wound infections (postpartum ulcers, endometritis), infections limited to the pelvic cavity (metritis, parametritis, salpingoophoritis, pelvioperitonitis, metrothrombophlebitis, etc.), diffuse infections (peritonitis, progressive thrombophlebitis) and generalized infections (septic shock, sepsis). The time frame during which these complications may develop is from the moment of the release of the afterbirth to the end of the sixth week of the postpartum period. Puerperal diseases of infectious etiology occur in 2-10% of maternity patients. Septic complications play a leading role in the structure of maternal mortality, which puts them in a number of priority problems of obstetrics and gynecology.
Causes of postpartum infections
The occurrence of postpartum infections is caused by the penetration of microbial agents through wound surfaces formed as a result of childbirth. The entrance gates may be ruptures of the perineum, vagina and cervix; the inner surface of the uterus (placental site), a postoperative scar during cesarean section. At the same time, pathogens can get to the wound surface both from the outside (from the instruments, hands and clothes of personnel, operating underwear, care items, etc.), and from endogenous foci as a result of activation of their own conditionally pathogenic flora.
The etiological structure of postpartum infections is very dynamic and variable. Of conditionally pathogenic microorganisms, aerobic bacteria (enterococci, E. coli, staphylococci, group B streptococci, Klebsiella, proteus) predominate, but anaerobes (fusobacteria, bacteroids, peptostreptococci, peptococci) are also quite common. The importance of specific pathogens is great – chlamydia, mycoplasmas, fungi, gonococci, trichomonas. The peculiarity of postpartum infections is their polyetiology: more than 80% of observations sow microbial associations that have greater pathogenicity and resistance to antibiotic therapy.
The risk of developing postpartum infections is significantly increased in women with pathology of pregnancy (anemia, toxicosis) and childbirth (early discharge of water, weak labor, prolonged labor, bleeding, retention of parts of the placenta, lochiometra, etc.), extragenital pathology (tuberculosis, obesity, diabetes mellitus). Endogenous factors predisposing to microbial contamination of the birth canal can be vulvovaginitis, colpitis, cervicitis, pyelonephritis, tonsillitis, sinusitis in the maternity hospital. With infection with highly virulent flora or a significant decrease in the immune mechanisms of the maternity hospital, the infection can spread beyond the primary focus by hematogenic, lymphogenic, intracanalicular, perineural route.
Based on the anatomical, topographic and clinical approach, 4 stages of the progression of postpartum infection are distinguished:
- Stage 1 – local infection that does not spread beyond the area of the wound surface (postpartum ulcer of the perineum, vagina and uterine wall, suppuration of sutures, suppuration of hematomas, postpartum endometritis)
- Stage 2 – postpartum infection that goes beyond the boundaries of the wound surface, but is limited by the pelvic cavity (metroendometritis, adnexitis, parametritis, metrothrombophlebitis, limited pelvic thrombophlebitis, pelvioperitonitis)
- Stage 3 – diffuse postpartum infection (peritonitis, progressive thrombophlebitis)
- Stage 4 – generalized septic infection (sepsis, infectious and toxic shock).
Lactation mastitis is isolated as a separate form of postpartum infection. The severity of infectious complications after childbirth depends on the virulence of the microflora and the reactivity of the macroorganism, so the course of diseases varies from mild and erased forms to severe and fatal cases.
Postpartum ulcer is formed as a result of infection of abrasions, cracks and tears of the skin of the perineum, vaginal mucosa and cervix. The clinical picture of this postpartum complication is dominated by local symptoms, the general condition is usually not disturbed, the temperature does not exceed subfebrile figures. The maternity patient complains of pain in the suture area, sometimes itching and dysuric phenomena. Examination of the birth canal reveals an ulcer with clear boundaries, local edema and inflammatory hyperemia. At the bottom of the ulcer, a grayish-yellow plaque, areas of necrosis, mucopurulent discharge is determined. The ulcerative defect bleeds easily upon contact.
Postpartum endometritis (metroendometritis), among other postpartum infections, is most common – in 36-59% of cases. There are classical, erased, abortive forms and metroendometritis after cesarean section. In a typical (classical) variant, postpartum endometritis manifests on 3-5 days after delivery with an increase in temperature to 38-39 ° C and chills. Locally, there is a subinvolution of the uterus, its soreness during palpation, cloudy pus-like discharge from the cervical canal with a fetid odor. The abortive form of postpartum infection develops on 2-4 days, but undergoes rapid reverse development due to the start of therapy. For the erased course of postpartum endometritis, a typically late onset (5-8 days), prolonged or undulating course, less pronounced symptoms. Clinical manifestation of endometritis after delivery by caesarean section occurs on 1-5 days; pathology proceeds with general and local manifestations.
Postpartum parametritis develops on the 10th – 12th day when the infection passes to the parametrium – parotid tissue. A typical clinic includes chills, febrile fever, which lasts 7-10 days, intoxication. The maternity hospital is concerned about pain in the iliac region on the side of inflammation, which gradually increase, radiate into the lower back and sacrum. A few days after the onset of postpartum infection, a painful infiltrate is palpated in the area of the lateral surface of the uterus, first of a soft, and then of a dense consistency, soldered to the uterus. The outcomes of postpartum parametritis may be resorption of the infiltrate or its suppuration with the formation of an abscess. Spontaneous opening of the abscess can occur in the vagina, bladder, uterus, rectum, abdominal cavity.
Postpartum thrombophlebitis can affect superficial and deep veins. In the latter case, it is possible to develop metrothrombophlebitis, thrombophlebitis of the veins of the lower extremities and pelvic veins. They usually appear within 2-3 weeks after delivery. Clinical harbingers of postpartum complications of this type are prolonged fever; persistent step-like pulse rate; pain in the legs when moving and pressing on soft tissues; swelling in the ankles, lower leg or thigh; cyanosis of the lower extremities. The development of metrothrombophlebitis is indicated by tachycardia up to 100 beats / min., uterine subinvolution, prolonged blood discharge, palpation of painful cords along the lateral surfaces of the uterus. Thrombophlebitis of the pelvic veins is dangerous for the development of ileofemoral venous thrombosis and pulmonary embolism.
Postpartum pelvioperitonitis, or inflammation of the peritoneum of the pelvis, develops 3-4 days after delivery. The manifestation is acute: the body temperature rapidly increases to 39-40 ° C, there are sharp pains in the lower abdomen. Vomiting, flatulence, painful defecation may occur. The anterior abdominal wall is tense, the uterus is enlarged. Postpartum infection is resolved by resorption of the infiltrate in the pelvis or the formation of an abscess of the Douglas space.
Clinic of diffuse and generalized postpartum infection (peritonitis, sepsis) it does not differ from that in infectious diseases of a different etiology. Lactation mastitis is discussed in detail in the section “Diseases of the mammary glands”.
Diagnosis of postpartum infections
Factors indicating the development of postpartum infections are signs of infectious-purulent inflammation in the area of the birth wound or pelvic organs, as well as general septic reactions that occurred in the early period after childbirth (up to 6-8 weeks). Complications such as postpartum ulcer, suppuration of sutures or hematomas are diagnosed on the basis of a visual examination of the birth canal. A vaginal examination allows a gynecologist to suspect postpartum infections of the pelvic organs. In these cases, there is usually a delayed contraction of the uterus, its soreness, pasty parotid space, infiltrates in the pelvis, cloudy fetid discharge from the genital tract.
Additional data is obtained during gynecological ultrasound. In case of suspected thrombophlebitis, dopplerography of the pelvic organs, ultrasound of the veins of the lower extremities is indicated. With postpartum endometritis, hysteroscopy is informative; with purulent parametritis, puncture of the posterior vaginal arch. According to the indications, radiation diagnostic methods are used: phlebography, hysterography, radioisotope examination.
All clinical forms of postpartum infection are characterized by a change in the picture of peripheral blood: significant leukocytosis with a neutrophil shift to the left, a sharp increase in ESR. In order to identify infectious agents, the seeding of the separated genital tract and the contents of the uterus is performed. Histological examination of the afterbirth may indicate signs of inflammation and, consequently, a high probability of developing postpartum infections. An important role in planning therapy and assessing the severity of complications is the study of blood biochemistry, CSF, blood electrolytes, coagulogram.
The whole complex of therapeutic measures for postpartum infections is divided into local and general. Bed rest and applying ice to the abdomen helps to stop the further spread of infection from the pelvic cavity.
Local procedures include the treatment of wounds with antiseptics, dressings, ointment applications, removal of sutures and opening of the wound during its suppuration, removal of necrotic tissues, local application of proteolytic enzymes. With postpartum endometritis, curettage or vacuum aspiration of the uterine cavity may be required (if placental tissue and other pathological inclusions are delayed in it), expansion of the cervical canal, aspiration-washing drainage. When a parametric abscess is formed, it is opened through the vagina or by laparotomy and drainage of the parotid tissue.
Local measures for postpartum infections are carried out against the background of intensive general therapy. First of all, antibacterial agents are selected that are active against all isolated pathogens (broad-spectrum penicillins, cephalosporins, aminoglycosides, and others), which are administered intramuscularly or intravenously in combination with metronidazole. It is advisable to interrupt breastfeeding for the duration of treatment. For the purpose of detoxification and elimination of water-salt imbalance, infusions of colloidal, protein, salt solutions are used. Extracorporeal detoxification is possible: hemosorption, lymphosorption, plasmapheresis.
In postpartum infections of staphylococcal etiology, antistaphylococcal gamma globulin, staphylococcal toxoid, and antistaphylococcal plasma are used to increase specific immunological reactivity. In order to prevent thrombosis, anticoagulants, thrombolytics, antiplatelet agents are prescribed under the control of a coagulogram. Antihistamines, vitamins, glucocorticoids are widely used in the complex of drug therapy. At the stage of rehabilitation, laser therapy, local UFO, UHF therapy, ultrasound, electrical stimulation of the uterus, balneotherapy and other methods of physiotherapy are prescribed.
In some cases, surgical assistance may be required – removal of the uterus (hysterectomy) with its purulent melting; thrombectomy, embolectomy or phlebectomy – with thrombophlebitis.
Prognosis and prevention
With wound infections and infections limited to the pelvic region, the prognosis is satisfactory. Timely and adequate therapy can stop the further progression of postpartum infections. However, in the long-term period, the prognosis for reproductive function may be variable. The most severe consequences for the health and life of the maternity hospital entail spilled peritonitis, sepsis and septic shock.
Prevention of postpartum infections is ensured by strict and strict observance of the sanitary and hygienic regime in maternity institutions, the rules of asepsis and antiseptics, personal hygiene of personnel. The rehabilitation of endogenous infection at the stage of pregnancy planning is important.