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Postpartum diseases

Postpartum diseases (synonymous with puerperal diseases) are diseases developing in the postpartum period associated with pregnancy and childbirth. There are infectious (septic) and non-infectious postpartum diseases.

Classification of infectious postpartum diseases (proposed by Bublichenko): 1) diseases localized in the vagina and in the uterus - postpartum ulcers, metroendometritis (see), lohiometer; 2) diseases localized outside the uterus - adnexitis (see), pelvioperitonitis (see), parametritis (see), thrombophlebitis (see), mastitis (see); 3) general septic diseases - various forms of sepsis (see).

The causative agents of infectious postpartum diseases are staphylococcus and streptococcus , rarely E. coli, gas gangrene bacilli, gonococci and other microbes. Postpartum diseases occur when microbes enter the body through the wound surface (entrance gate): the inner surface of the uterus after separation of the afterbirth , tears, cracks, abrasions formed on the cervix, in the vagina and in the perineum . Pathogens are introduced onto the wound surface from the outside (exogenous infection) or microbes that existed in the woman’s body (endogenous infection) enter the wound. Activation of endogenous infection can be promoted by premature and early discharge of water, prolonged labor , blood loss with subsequent anemia, trauma of the birth canal, delay in the uterus of fetal membranes and blood clots (see the postpartum period ). In exogenous infections, germs are brought in by non-sterile hands, instruments that come into contact with the birth canal, in the process of care and treatment of the puerperal, as well as by airborne droplets.

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The onset of postpartum diseases is characterized by the formation of an inflammatory process in the area of ​​the wound surface.

With good body resistance and proper treatment, the infected wound surface heals and the disease stops. With the weakening of the body's defenses and high microbial virulence, the latter spread beyond the primary focus. The spread of microbes can occur through the lymphatic vessels (lymphogenous pathway), blood vessels (hematogenous pathway), or fallopian tubes (canalicular pathway). It is possible for microbes to spread simultaneously in lymphatic and blood vessels.

In puerperas with infectious postpartum disease, the temperature rises. With a mild course of the disease, it can be low and rapidly decreases, and with severe ( sepsis , septicemia), the temperature is kept at high numbers. There is an increase in pulse rate, which in a light current corresponds to temperature, and in severe cases it is very frequent and exceeds the figures characteristic of this temperature. Chills are often observed. A midwife should remember that these symptoms are typical of postpartum septic diseases. Therefore, with increasing temperature, increased heart rate and chills in the puerperal, in the first place, it should be assumed that there is a septic infection. In the presence of lochyometers (delayed discharge from the uterus), metroendometritis, subinvolution of the uterus can be noted (its contraction is not good enough). With a favorable course of the disease, subinvolution ends by the end of the 3rd week.

Prevention of postpartum diseases consists primarily in the preparation of a pregnant woman for childbirth, her personal hygiene; daily washing of the external genital organs is necessary; sexual intercourse in the last two months of pregnancy is contraindicated. Pregnant women should avoid contact with infectious patients.

During childbirth, the midwife should carefully handle her hands before each manipulation. The fetal bladder cannot be opened until the cervix is ​​fully opened without special indications. After the birth of the placenta, it must be carefully examined, since a part of the placenta that lingers in the uterus may provide fertile ground for the development of infection. The midwife should protect her hands from abrasions and injuries and not have contact with infectious patients. Chambers of the maternity ward should be systematically aired, irradiated with mercury-quartz lamps .

In postpartum diseases, the puerperal needs medical help. The doctor prescribes antibacterial drugs (antibiotics, sulfonamides), uterus-reducing agents, fortifying treatment. The patient needs bed rest.

Non-infectious postpartum diseases include: postpartum eclampsia (see), birth shock, postpartum psychosis (see Postpartum period). Birth shock is observed after severe painful childbirth and occurs after the birth of the fetus or afterbirth. The woman suddenly appears blanching of the skin and visible mucous membranes, dizziness, nausea , vomiting , cold sweat ; pulse is thready, blood pressure drops. Often comes fainting.

Treatment of birth shock: subcutaneously 1 ml of 2% omnopon solution, warming the patient, intravenous drip of 5% glucose solution (up to 1 l), cardiac agents (camphor 2 ml of 20% oily solution subcutaneously, caffeine 1 ml of 10% solution subcutaneously); blood transfusion under the guidance of a doctor.

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Postpartum diseases . To postpartum diseases include diseases (mainly of infectious origin) directly related to pregnancy and childbirth. Less common are non-infectious diseases (postpartum eclampsia, postpartum hemorrhage). However, not every complication that occurs in the postpartum period is a “postpartum disease”, for example, flu, sore throat , malaria, etc.

Postpartum infection is a wound infection that occurs as a result of infection in the process of childbirth of the wound surfaces of the soft birth canal, the placental site. The postpartum infection also includes a lohiometer, insufficient inverse involution of the uterus, accompanied by fever, postpartum mastitis, single and multiple temperature rise without precise localization of the process.

Selected cases and outbreaks of postpartum infection have been observed at all times and are described by Hippocrates. Currently, postpartum diseases (including all types of diseases, both related to infection and unrelated to it) make up from about 2 to 3 to 5%. Outbreaks of postpartum infections are currently not observed. Cases of generalized sepsis are extremely rare, and mortality from it occupies the last place in general maternal mortality in obstetric institutions of the USSR.

Classification. Infectious postpartum diseases are divided into localized, i.e., limited to a specific organ, and generalized (postpartum sepsis). Localized diseases include postpartum ulcers (infected tears of the perineum, vagina and cervix), postpartum endometritis (deciduitis), metroendometritis (see) and metrotromboflebit (see :), adnexitis (see), pelvic peritonitis, parametritis (see). For generalized - sepsis (see) without metastases (septicemia) and with metastases (septicopyemia and thrombophlebitic form of sepsis). Postpartum diffuse peritonitis is considered as the peritoneal form of septicemia.

Infectious postpartum diseases are also divided by severity into mild, moderate and severe. In mild cases, the infectious process is usually cured quickly (puerperal endometritis and metroendometritis, puerperal ulcers). In cases of moderate severity, the infection spreads beyond the genitals, but does not go into generalized. These include: parametric infiltrates and suppurations, inflammation of the uterus with the involvement of the pelvic peritoneum - pelvioperitonitis (see). The disease often lasts a long time, but the vast majority of women recover. Severe general infection in the form of puerpera sepsis is the most dangerous postpartum disease in which the primary focus of infection (its entrance gate) is of temporary importance.

Etiology and pathogenesis. Postpartum infection occurs as a result of either the introduction of pathogenic microbes from the outside, or the activation of the microbial flora that inhabit the genital tract of the puerperal (self-infection). The causative agents of puerpera infection are predominantly strepto-staphylococcus, less commonly E. coli, gonococci, rarely tetanus infections, diphtheria bacilli, scarlet fever pathogens, etc. As a rule, a mixed infection (microbial associations) prevails.

The introduction of infection from the outside is possible if the medical staff does not comply with the aseptic and antiseptic rules when preparing a woman for childbirth and childbirth. Activation of one's own infection is promoted by birth trauma, a violation of the protective mechanisms inherent in the female sexual ways, as well as various obstetric manipulations.

The following ways of spreading infection can be distinguished: 1) direct infection of wound surfaces (cracks, tears, placental site), 2) ascending infection through the birth canal (intracanalicular pathway), 3) spreading through lymphatic and blood vessels, and 4) metastasis from non-genital foci of infection ( with sore throat, flu, purulent otitis, etc.).

The development of postpartum infection depends not only on the type of pathogen, its virulence, localization, nature and state of the gate of infection, how it spreads, but to a large extent on the reactivity and resistance of the woman to the puerperal. The occurrence of postpartum infection predispose diseases suffered during pregnancy and childbirth, especially bleeding. Hemolytic streptococci are particularly dangerous. Primary infection of the placental site is prognostically more serious than infection of wounds of the perineum and vagina.

Symptoms and course . Symptoms of postpartum infection are numerous: febrile temperature, single or repeated chills, symptoms of general intoxication, delayed lochia or, conversely, abundant dirty, odorous discharge, pain of varying intensity and nature, decrease or lack of appetite, sleep disturbance, unsharp dysuric and dyspeptic phenomena (with sepsis is often abundant, liquid, fetid stool), a decrease in the percentage of hemoglobin and the number of red blood cells in peripheral blood, increased leukocytosis (in some cases up to 25 000–35 00 0 and more), accelerated ROE, neutrophilia, aneosinophilia, lymphopenia. In the urine with severe and prolonged postpartum infection, albuminuria is noted. With septicopyemia with metastatic kidney damage in the urine, significant changes are observed: albuminuria, microhematuria, pyuria, cylindruria, bacteriuria, etc.

The course of the disease depends on the type and virulence of the pathogens, on the state of the entrance gate of the infection, the intensity of the inflammatory response, the initial state of the puerperal, its reactivity and resistance. Against the background of prior anemization in patients weakened by postponed or existing extragenital diseases, postpartum infection occurs more often and is more severe. In severe cases, instead of hyperleukocytosis and accelerated ESR, leukopenia and a slower ESR can be observed. There are various kinds of local inflammation.

Of the postpartum diseases, postpartum endometritis is most often observed, which occurs in a mild or severe form. The latter is accompanied by high and prolonged temperature, more pronounced phenomena of general intoxication. From the endometrium (residues of the decidual membrane), the process can transfer to the uterus muscle (endomyometritis), uterus veins (metrotromboflebit) and serve as a further source of infection spreading beyond the uterus (pelvic phlebitis, parametritis, pelvioperitonitis, adnexitis).

The time of onset of clinical symptoms and their severity depend largely on the localization of the postpartum infection. For example, signs of endometritis can appear on the 3-4th day after birth, parametritis in the middle or at the end of the second week, sepsis - already in the first hours or the first days after birth. Rising gonorrhea proceeds at first sluggish against the background of subfebrile temperature, and when it goes to the uterus and pelvic peritoneum - acute (usually in the second week). With localized postpartum infection, the duration and severity of the disease depends on the nature of the inflammation. With purulent inflammation, the disease is more prolonged and difficult. Especially difficult postpartum sepsis.

Diagnostics is carried out on the basis of the evaluation of the patient's complaints, the onset of the disease, general condition, temperature curve, data from an external examination, examination of the external genital organs, perineum, vagina and cervix, if necessary, a two-handed examination (vaginal and rectal), the nature and amount of discharge - lochia, bacterioscopy and bacteriological their research, blood culture, blood and urine analysis and some special functional tests. In postpartum sepsis, bacteremia may be absent. It is necessary to differentiate between true postnatal diseases and diseases of a different origin, and also between infectious and non-infectious postnatal diseases.

The prognosis depends on the nature and localization of postpartum diseases, the type of infection, its clinical manifestations, relatively favorable for all types of localized infection and dubious for postpartum sepsis, in which the maternal mortality remains high.

Treatment . Etiotropic therapy with the use of large doses of broad-spectrum antibiotics and sulfonamides (after a preliminary determination of the sensitivity of the pathogenic flora to them). General tonic and antitoxic agents (glucose, calcium chloride intravenously, vitamins). If necessary, repeated transfusions of small doses of donor blood or erythromass, plasma, polyglucin, cardiac drugs. Strict bed rest. Careful care of the patient. High-calorie, easily digestible, fortified food in small portions at 2-3-hour intervals. Regulation of bowel activity. Impact on infected wounds (puerpera ulcers) with antiseptics and antibiotics (powders, emulsions), ultraviolet irradiation of infected perineal tears (dissolve stitches). Septic patients require special supervision, for which organization of individual care is desirable. Purulent accumulations are surgically emptied. Postpartum peritonitis is subject to surgical treatment with possibly wide drainage of the abdominal cavity. In postpartum thrombophlebitis, the use of anticoagulants and hirudotherapy (intravenous administration of drugs is contraindicated), long-term very strict bed rest, elevated limb position, dry heat, small doses of iodide preparations are indicated.

Prevention . Rehabilitation of pregnant women. Prevention of common infections during pregnancy. Hardening, physical therapy. Strongest antiseptic and aseptic in labor. Vaginal examination only by indications. Rational management of childbirth. Prevention of generic injury. Timely fight with bleeding. Proper management of the postpartum period. Isolation of sick puerperas from healthy.