RU2453274C1 - Method of selecting tactics of treating puerperas with post-natal purulent-septic diseases - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to medicine, obstetrics, gynecology and includes estimation of puerperas' state, depending on which treatment tactics is selected. Severity of state is estimated by two groups of criteria of table No 3, presented in the description, by 1 point: absence of factors of risk of purulent-septic complications (PSC), subfebrile condition with single rise to 38C, arrested by antibacterial therapy (ABT), absence of easily arrested intestine paresis after Cesarean section, the cervix of uterus is formed, presence of uterus involution in hysteroscopy at the background of treatment with endometrectomy or vacuum-aspiration, USE-data - increase and extension of uterus cavity by 0.5-1.0 cm, absence of deformation in the area of scar or deformation up to 0.5 cm, on uterus walls - linear echo-positive structures up to 0.2-0.3 cm thick, local sections of reduced myometrium echogenicity in the region of scars not larger than 1.5x1.5 cm, absence of infiltration, hematoma in the region of scars, improvement of laboratory indices in dynamics. Criteria of group 2 are estimated in 2 points: presence of PSC risk factors, long-lasting fever with resumption after finishing ABT, intestine paresis with absence of effect from intensive or repeated treatment courses, absence of tendency to formation of uterus cervix, stable uterus subinvolution, by USE data: extension of uterus cavity ëÑ1 cm, deformation in scar ëÑ0.5 cm, echopositive structures ëÑ0.4 cm, reduces echogenicity in scar zone ëÑ2.5ù1.5 cm, hematoma or infiltrate in retrovesical space, in area of scars, absence of positive dynamics or change of laboratory indices to the worse. If state of puerpera is characterised by criteria of the first group to 7 points, it is estimated as uncomplicated form of disease, if - more than 7 points or at least by one criterion from group 2, as complicated form. ^ EFFECT: method ensures reliable justification of adequate tactics of patient management, strict control of their state in dynamics, reduction of frequency of complicated generalised forms of PSC, terms of staying in hospital. ^ 2 ex, 3 tbl

Description

The invention relates to medicine, namely to obstetrics and gynecology, and can be used for postpartum management of puerperas.

Postpartum purulent-septic diseases represent a serious problem and are one of the main causes of maternal morbidity and mortality (Krasnopolsky V.I., Buyanova S.N., Schukina N.A., 2006). Postpartum purulent-septic diseases often lead to the development of severe local and generalized complications (panmetritis, salpinoferritis, parametritis, peritonitis, sepsis), when radical surgical interventions have to be performed, leading to disability of women, depriving them of their menstrual and reproductive functions. Inpatient treatment of patients with postpartum purulent-septic diseases is very long, which affects the rhythm of the work of many enterprises, the inability of women to actively participate in production activities, generates family problems and requires high economic costs in hospitals (Abramchenko V.V., Kostyuchek D.F. , Hadzhieva E.D., 2005). The basic principle of the organization of obstetric and gynecological care for women in rural areas is the stage-by-stage provision of qualified and highly qualified care, consisting in a different volume and level of medical examination and treatment, depending on the power of equipping obstetric and gynecological institutions, the qualifications of doctors, and the availability of anesthesiology and resuscitation services (Frolova O. G., Gavrilova L.V., 2000).

In modern literature, many sources of information have been identified that highlight this problem. Currently, the most popular classification of postpartum infectious diseases according to Sazonov-Bartels. According to this classification, various forms of postpartum infection of the birth canal are considered as separate stages of a single dynamically occurring infectious (septic) process. The disadvantages of this classification include the lack of clear clinical manifestations in each nosological unit, with a specification of the scope of the examination and the choice of treatment tactics.

The management of obstetric and gynecological care is known, edited by academician of the Russian Academy of Medical Sciences, professor V.I. Kulakov, 2000, which provides for the stages of obstetric and gynecological care, which vary in the volume and level of medical examination and treatment, depending on the capacity of obstetric and gynecological hospitals . Disadvantages: there are no clear indications for choosing the tactics of treating puerperas, and there are no standards for the necessary volumes of examination at each stage and indications for transporting patients to a higher level of the medical institution.

For the closest analogue, the Model-scheme for the prevention and treatment of purulent-septic complications in puerperas in an agricultural region with a large territory and low population density, developed in the Altai Territory in 1990, is adopted (Monograph "Infected abortion, sepsis and peritonitis in obstetrics and gynecology," edited by V.V. Abramchenko, D.F. Kostyuchek, E.D. Khadzhieva, I.A. Shamkhalova, 2002). According to this method, 4 levels of obstetric and gynecological care are provided: level 1 - feldsher-midwife station (FAP); Level 2 - district hospital (UB); Level 3 - Central District Hospital (CDH); Level 4 - Regional Center. Levels 1 and 2 of help were considered only as a prehospital stage. Inpatient care for puerperas with PHSZ began to be provided from level 3 - the central hospital, and only within 24-48 hours, in the absence of positive dynamics, the puerperium was transferred even to the regional level hospital during the localized process, due to the rather low level of technical equipment of the hospital. A method was developed for the early diagnosis of postpartum metroendometritis by measuring the intrauterine pressure, temperature and pH of the uterine contents with a special domestic device. Depending on these indicators and their dynamics, further tactics of conducting puerperas was formed. The published analysis of the effectiveness of this Model and the presented results indicate the effectiveness of the developed Model.

Disadvantages: a high percentage of complications and the duration of treatment due to the lack of clear criteria for the selection of puerperal management tactics, untimely intensification of treatment, inaccuracy in assessing the patient's condition.

Tasks:

1. To provide tactics of conducting puerperas with PPH.

2. To increase the reliability of the diagnosis of puerperas.

3. To improve the effect of treatment by reducing mortality, duration of hospital stay, improving the quality of life in a shorter time.

The essence of the invention is the choice of tactics for treating puerperas with postpartum purulent-septic diseases (PHSZ), including the identification of clinical indicators, while the novelty is that at the first stage of medical care, the severity of the condition is evaluated in accordance with the scale of criteria for two forms of severity of PHSZ according to the table No. 3, where

- the first group includes criteria for an uncomplicated form of the disease: the absence of risk factors for the development of purulent-septic complications - 1 point, subfebrile condition with one-time temperature rises up to 38 ° C, stopping against the background of antibiotic therapy, - 1 point, the absence of intestinal paresis or the presence of easily stopping paresis after cesarean section surgery, against the background of stimulating intestinal motility therapy - 1 point, the cervix during vaginal examination formed - 1 point, the presence of uterine involution with hysteroscopy on treatment with curettage or vacuum aspiration - 1 point, according to ultrasound, the presence of an increase and expansion of the uterine cavity from 0.5 to 1.0 cm, the absence of deformation in the scar or deformity up to 0.5 cm, the presence of linear echopositive structures on the walls of the uterus a thickness of 0.2-0.3 cm, a local change in the structure of the myometrium in the form of sections of reduced echogenicity in the suture area of no more than 1.5 × 1.5 cm, the absence of infiltration or hematoma in the suture area on the uterus or in the suture of the anterior abdominal wall with clinical examination and according to ultrasound - 1 point, improvement aboratornyh indicators over time - relief of anemia, reduced leukocytosis, mild hypoproteinemia, no electrolyte imbalance - 1 point;

- the second group of criteria characterizes the complicated form of the disease: the presence of risk factors for the development of purulent-septic complications - 2 points, a long febrile period, with the resumption of hyperthermia after the end of antibiotic therapy - 2 points, the presence of transient intestinal paresis, lack of effect from the use of intensive or repeated courses of treatment paresis - 2 points, no tendency to form the cervix - 2 points, persistent subinvolution of the uterus - 2 points, according to ultrasound, expansion of the uterine cavity ≥1 cm, deformation in the suture ≥0.5 cm, the presence in the cavity of echopositive structures ≥0.4 cm, reduced echogenicity in the suture area ≥2.5 × 1.5 cm, the presence of hematoma or infiltrate in the posteriorbubble space, in the suture on the uterus or in the suture on the front the abdominal wall - 2 points, the absence of positive dynamics or the deterioration of laboratory parameters - 2 points;

- and if the condition of the puerpera is characterized by the criteria of group 1 and corresponds to a level of up to 7 points, then it is assessed as an uncomplicated form of the disease and conservative therapy is carried out, including antibacterial, detoxification, syndromic, metabolic therapy, stimulation of intestinal motility, curettage of the uterus under the control of hysteroscopy or vacuum aspiration followed by suction-washing drainage;

- if the condition of the postpartum woman at admission or in dynamics is estimated to be over 7 points or there is at least one of the criteria of group 2 according to table 3, the complicated form of the disease is determined and surgical intervention is performed against the background of intensive therapy.

EFFECT: reliably justified management tactics of patients, tight control over the state of the puerperas in dynamics, timely provision of adequate treatment tactics, due to which the frequency of complicated and generalized forms of PHHS is reduced, the length of hospital stay is reduced, which is economically beneficial for the budget of medical institutions, allows maintain the reproductive health of women, reduce the period of disability and improve the quality of their future life.

The method has been tested in a clinical setting.

All puerperas with PHHS (333 puerperas) who were treated from 2002 to 2008 were divided into two groups: 1 retrospective group - puerperas with PHHS from 2002 to 2005. (174 puerperas); Prospective group 2 - puerperas who were treated from 2006 to 2008. (159 puerperas). The puerperas of the 1st group (2002-2005) were examined at the stages of the Central district hospitals, city hospitals of the region in insufficient volume, taking into account the lack of examination standards and the necessary equipment. This did not allow timely identification of complicated forms of PHSZ and the provision of necessary assistance, which in turn led to untimely transportation to a hospital with a higher level of equipment. In this regard, the frequency of adverse outcomes was high, for example, among puerperas of the 1st group who were in serious condition, disability was 33.33%, among puerperas in extremely serious condition, disability was 46.67%, and mortality was 26.67%.

For examination and treatment of the 2nd group of puerperas, since 2006, an optimized examination scheme has been developed and introduced, identifying all possible risk factors for the occurrence of PHH, treatment of puerperas with postpartum purulent-septic diseases at each stage. If it was impossible to provide qualified medical care and there was no effect, an immediate evacuation to a higher level hospital or a call of specialists to themselves was ensured.

The choice of treatment tactics for puerperas with postpartum purulent-septic diseases depends on the severity of the patient's condition and is evaluated in accordance with the severity scale (table 3), including anamnestic, clinical and ultrasound criteria.

An in-depth comparative analysis of the retrospective and prospective groups was carried out.

The following results were obtained.

From 2002 to 2008 The treatment outcomes are as follows: 298 puerperas (89.49%) recovered; 23 puerperas received disability, which amounted to 6.9%; mortality was 3.6% (12 puerperas), this is due to the fact that a large number of patients were admitted in serious condition, with mechanical ventilation (mechanical ventilation), in coma 3, with multiple organ failure. In the pathological anatomical study, morphological changes were irreversible. The outcome of the disease was directly dependent on the severity of the condition of each patient.

Table 1 Treatment outcomes for severe patients with PHSS who were treated in a hospital from 2002 to 2008. Treatment outcomes Survey groups R I group, n = 21 II group, n = 41 abs % abs % Recovery fourteen 66.67 38 92.68 P <0.05 Disability 7 33.33 3 7.32 P <0.05 Fatal outcome 0 0.00 0 0.00 0

When comparing two groups of patients with PHHS who were in serious condition, it was reliable that recovery in a higher percentage occurred among women in the 2nd group (92.68%) than among women in the 1st group (66.67%), p <0.05 . Disability was 33.33% among puerperas of group 1, only 7.32% among puerperas of group 2 (p <0.05).

table 2 Treatment outcomes for extremely severe patients with PHSS who were treated in a hospital from 2002 to 2008. Treatment outcomes Survey groups R I group, n = 15 II group, n = 43 abs % abs % Recovery four 26.67 29th 67.44 P <0.05 Disability 7 46.67 6 13.95 P <0.05 Fatal outcome four 26.67 8 18.60 P> 0.05

When comparing two groups of patients with PHHS who were in an extremely serious condition, it was significant that recovery in a higher percentage occurred among postpartum women of group 2 (67.44%) than among postpartum women of group 1 (26.67%), - p <0 , 05. Disability amounted to 13.95% among postpartum women of group 2, 46.67% among postpartum women of group 1 (p <0.05). Fatal outcome occurred in puerperas of the 2nd group at 18.60%, while among puerperas of the 1st group at 26.67%.

Given the severity of patients with postpartum purulent-septic diseases, the length of hospital stay is long.

But despite this, patients of group 2 (27.67%) were more likely than patients of group 1 (15.52%) to remain in the hospital for up to 10 days - p <0.05. Two times less puerperas of the 2nd group (16.98%), unlike the 1st group (31.61%), were in the hospital for more than 20 days (p <0.05). When optimizing the stages of medical care for women with postpartum purulent-septic diseases, the length of hospital stay was reduced by 2 times, which is economically viable.

Thus, the use of an optimized scheme for the examination and treatment of patients with postpartum purulent-septic diseases at each level of medical care, as well as the rapid evacuation of patients with complicated forms of PHC in higher medical institutions with higher levels of qualified care, reduced the frequency of complicated forms of PHC and maintained women's reproductive health, increase the percentage of recovery in extremely severe patients, reduce the period of disability, improve quality your their later life.

A method of choosing a treatment strategy for puerperas with postpartum purulent-septic diseases (PHSZ) is as follows.

Upon receipt of puerperas with PHSZ, the task of specialists is to assess the severity of the inflammatory process and the degree of infection, i.e. distribution of patients into two forms of the disease: uncomplicated and complicated forms (see table 3).

When examining puerperas with PHSZ carry out:

1. Collection of complaints and medical history.

2. Assessment of the general condition (color of the skin, consciousness, blood pressure, Ps, temperature, urination, the amount of urine, NPV).

3. Laboratory examination: general blood count with leukoformula count, erythrocyte sedimentation rate, urinalysis, smear on the flora, blood coagulation time, prothrombin index, MPA, biochemical coagulogram, blood biochemical analysis (glucose, total bilirubin, indirect bilirubin, total protein, protein fractions, creatinine, urea, alanine aminotransferase, aspartate aminotransferase, electrolytes), blood type, Rh factor, urine according to Nechipurenko, Zemnitsky, antibodies to HIV, HBsAg, antibodies to HCV, research on sexually transmitted infection, sowing on the flora and sensitivity to antibiotics from the cervical canal, blood, urine, examination for a viral infection).

4. Instrumental examination: electrocardiography, fluorography, X-ray examination, ultrasound of the abdominal cavity, pleural sinuses, retroperitoneal space and pelvic organs, if necessary, electroencephalography, endoscopic examination, echoencephalography, computed tomography, triplex scanning of the veins of the small pelvis and lower extremities.

5. Genital status is assessed: examination, palpation, percussion of the abdomen, signs of peritoneal irritation, bimanual examination.

6. If necessary, specialist advice: therapist, traumatologist, neurologist, optometrist, etc.

Table 3 Criteria for the distribution of patients with PHSZ groups 1 group
Uncomplicated form 2 group
Complicated form The absence of risk factors for the development of purulent-septic complications - 1 point The presence of risk factors for the development of purulent-septic complications, high risk group - 2 points Subfebrile condition, with a single temperature rises to 38 ° C, stopping against the background of antibiotic therapy - 1 point Long febrile period, with the resumption of hyperthermia after the end of antibiotic therapy - 2 points There is no intestinal paresis or intestinal paresis that can be easily stopped after cesarean section surgery, against the background of the use of stimulating motility therapy - 1 point The presence of transient intestinal paresis, lack of effect from the use of intensive or repeated courses of treatment for intestinal paresis - 2 points The cervix with a vaginal examination is formed - 1 point Lack of tendency to form the cervix - 2 points On the background of treatment (hysteroscopy, curettage of the uterine cavity or vacuum aspiration) uterine involution - 1 point Persistent uterine subinvolution - 2 points Ultrasound - an increase and expansion of the uterine cavity from 0.5 to 1.0 cm, no deformation in the scar area or up to 0.5 cm, the presence on the walls of the uterus of linear echopositive structures 0.2-0.3 cm thick, local change in structure myometrium in the form of sections of reduced echogenicity in the suture area of no more than 1.5 × 1.5 cm, the absence of infiltration or hematoma in the suture area on the uterus or in the suture of the anterior abdominal wall during clinical examination and according to ultrasound, 1 point Ultrasound - expansion of the uterine cavity ≥1 cm, deformation in the suture ≥0.5 cm, presence in the cavity of echopositive structures ≥0.4 cm, reduced echogenicity in the suture area ≥2.5 × 1.5 cm. The presence of hematoma or infiltrate in the posterior space (in the area of the suture on the uterus) or in the suture on the anterior abdominal wall - 2 points Improvement of laboratory parameters (anemia stops, leukocytosis decreases, slight hypoproteinemia, no electrolyte disturbances) - 1 point Lack of positive dynamics or deterioration of laboratory parameters - 2 points

If the condition of the postpartum woman upon admission to the hospital is characterized by the criteria of group 1 and corresponds to a level of up to 7 points, according to table 3, then it is assessed as an uncomplicated form and conservative treatment methods are performed: antibiotic therapy, detoxification therapy, stimulation of intestinal motility, syndromic therapy, metabolic therapy, FTL, HBO. Against the background of conservative therapy, the uterine cavity is scraped under the control of hysteroscopy or vacuum aspiration of decidual tissue, followed by suction-washing drainage.

If the condition of the postpartum woman at admission or in dynamics (24-48 hours after the start of therapy) is estimated to be over 7 points or there is at least one criterion from group 2 in Table 3, the complicated form of the disease is determined and surgical intervention is performed against the background of intensive therapy. Such patients are prescribed antibacterial, infusion therapy, uterotonics with antispasmodics, non-steroidal anti-inflammatory drugs, stimulation of intestinal motility, prevention of thromboembolic complications, antihistamines, immunomodulators, FTL, HBO. In the presence of a symptom complex against the background of the therapy: repeated temperature increase above 38 ° C; lack of a tendency to form the cervix; persistent subinvolution; the presence of a hematoma or infiltrate in the prevesical space; the presence of transient intestinal paresis; Ultrasound signs - expansion of the uterine cavity ≥1.0 cm, deformation in the suture ≥0.5 cm, presence of echopositive structures in the cavity ≥0.4 cm, decreased echogenicity in the suture area ≥2.5 × 1.5 cm, prebubble hematomas; deterioration of laboratory parameters - surgery is performed (the volume of the operation depends on the degree of spread of the inflammatory process, ranging from laparoscopy, emptying of hematomas, debridement, drainage of the abdominal cavity to laparotomy, extirpation of the uterus, debridement and drainage of the abdominal cavity).

When the generalization of the process is detected, in the intensive care unit, urgent forced preoperative preparation is performed for 2-3 hours (central vein catheterization, urinary catheter, fully transfusion therapy under the control of central venous pressure and urine output, correction of disturbances in protein and water-electrolyte metabolism, broad-spectrum antibacterial therapy, hemodynamic correction - vasopressors, corticosteroids, respiratory support from inhalation with moistened oxygen to mechanical ventilation, the phenomenon of coagulopathy). After this, mandatory emergency surgery aimed at the complete removal of the purulent focus (hysterectomy without peritonizing sutures) and adequate drainage of the purulent cavities, sanitation of the abdominal cavity. If necessary, repeated rehabilitation relaparotomy.

Postoperative management in the intensive care unit: prolonged mechanical ventilation, vasotropic correction, infusion-transfusion therapy, correction of disturbances in protein and water-electrolyte metabolism, antibacterial therapy, extracorporeal detoxification methods, elimination of coagulopathy, adequate analgesia, stimulation of intestinal motility, intestinal tract immunocorrective therapy, symptomatic therapy, FTL, IRT, HBO.

Examples

1. Patient M., medical history No. 1683, 19 years old. From the anamnesis: pregnancy 1st, desired, registered from 10 weeks of pregnancy, regularly visited an obstetrician-gynecologist in a antenatal clinic; examined for urogenital infection - not detected; 1 half of pregnancy - in the period of 10-11 weeks, the threat of abortion is diagnosed, outpatient treatment; 2 half of pregnancy was uneventful. Delivery 1 urgent - 08/01/2008, without features, anhydrous period of 3 hours. She gave birth to a boy weighing 3100, 49 cm long, on an Apgar scale of 7-8 points. Discharged with a child in satisfactory condition for 5 days home. On the 7th day, the temperature rises in the evening to 37.8 ° C, aching pains in the lower abdomen. She independently applied to the emergency room of the Central District Hospital on August 9, 2008, where she was examined by a general practitioner, gynecologist, and was hospitalized in the gynecological department of the Central District Hospital. A complete general clinical and laboratory instrumental examination was carried out. Objectively: satisfactory condition, complaints of aching pains in the lower abdomen, weakness, body temperature 37.4 ° C, normal skin color, clean, tongue moist, Ps - 84 beats. in min, blood pressure 120/85 mm Hg, the abdomen is soft, moderately painful with deep palpation in the lower sections, the symptoms of peritoneal irritation are negative, physiological functions are unremarkable, genital status: the cervix is formed, the discharge is mucous and sucrose in moderation, the cervical canal passes the tip of the finger to the internal pharynx, in the region of the internal pharynx, the ring of compaction, the uterus is enlarged up to 11-12 weeks of pregnancy, sensitive during the study, condenses during the study, the appendages are not determined, the arches are free. Ultrasound data - uterus 115 × 105 × 96 mm, expansion of the uterine cavity up to 1.0 cm, presence of linear echopositive structures on the uterus walls with a thickness of 0.3 cm. In the general blood test - red blood cells - 3.2, hemoglobin - 105 g / l , white blood cells - 12.5, platelets - 310, in biochemical analysis - total protein - 63 g / l, no electrolyte disturbances. The severity of the patient's condition in table 3 was rated at 7 points. Thus, the criteria found in Table 3 are identified (the absence of risk factors for the development of PHD; subfebrile condition with a one-time increase in temperature to 38 ° C, stopping during therapy; the absence of intestinal paresis; cervix is formed; ultrasound signs; after hysteroscopy, uterine involution; improvement laboratory indicators).

Diagnosis: Postpartum metroendometritis, uncomplicated form (8 days after the first urgent birth). Subinvolution of the uterus. Anemia 1 tbsp. Antibacterial therapy was prescribed (cefobide at 2.0 g 2 r./day IM, metrogil 0.05% 100.0 ml iv, 3 r./day), infusion therapy, anti-inflammatory therapy (calcium chloride 10% 10 , 0 ml iv, ketonal 100 mg 2.0 ml 2 r./day IM), iron preparations, FTL, HBO. 08/10/08 - hysteroscopy was performed with curettage of the uterine cavity (decidual tissue), followed by suction-washing drainage No. 3. 08/12/08, the evaluation of the effectiveness of treatment was made: the patient’s condition was improved - there were no complaints, the temperature returned to normal, uterine involution was objective, in blood tests leukocytosis decreased, the anemia stopped. Conservative therapy continued. The outcome is recovery. The patient was discharged on 08/17/08 in satisfactory condition. Long-term results - healthy.

2. Patient N., medical history No. 2673, 28 years old, honey. the employee is a nurse. From the anamnesis: 6th pregnancy; abortions - 4, childbirth 1st by cesarean section in 1996, due to weak labor, hypoxia of the fetus, renal failure; from gynecological diseases - hr. adnexitis, UGI - chlamydia, tank. vaginosis; during a real pregnancy, three times inpatient treatment - at 11-12 weeks, the threat of termination of pregnancy, PID - chlamydia, at 20 weeks - exacerbation of chronic pyelonephritis, at 32-33 weeks of pregnancy, the threat of premature birth, asymptomatic bacteriuria. 05/13/2009 - cesarean section in the period of 38-39 weeks of pregnancy, on an emergency basis, indication: prenatal discharge of amniotic fluid, improper position of the fetus - transverse, fetal hypoxia, PSF. During the operation, technical difficulties arose - adhesions of the p / o process, the duration of the operation is more than 2 hours, the total blood loss of about 1000 ml. In the postoperative period, from 3 days, the temperature rises to 38 ° C, a state of moderate severity, weakness, pain in the area of surgery interfere. Objectively, May 17, 2009: moderate severity, complaints of aching pains in the lower abdomen, weakness, body temperature 38.0 ° C, normal skin color, clean, tongue dried, coated at the root, Ps - 92 beats. in min, blood pressure 120/85 mm Hg, the abdomen succumbed, painful with deep palpation in the area of surgical intervention, intestinal motility is sluggish, against the background of stimulation of intestinal motility, the symptoms of peritoneal irritation are negative, genital status: the cervix is in the center, purulent discharge in moderate amounts, the cervical canal passes freely over the internal pharynx of the finger, the uterus is enlarged to 16-17 weeks of pregnancy, a soft consistency, limited mobility, moderately painful in the study , infiltration is determined in the area of the suture on the uterus, appendages are not determined, the arch on the right is shortened. Ultrasound data - uterus 165 × 145 × 100 mm, expansion of the uterine cavity 1.5 cm, deformation in the suture 1 cm, the presence of echopositive structures in the cavity 0.6 cm, reduced echogenicity in the suture area 2.5 × 1.5 cm. hematomas in the postbubble space (in the area of the suture on the uterus) 45 × 53 mm, in the small pelvis free fluid in a volume of 25 ml. In the general blood test, erythrocytes - 2.9, hemoglobin - 99 g / l, leukocytes - 14.5, with a shift in the leukocyte formula, platelets - 210, ESR 45, in the biochemical analysis - total protein - 57 g / l, electrolyte disturbances no. The severity of the patient’s condition according to table 3 was evaluated at 8 points, the following criteria from the 2 group were identified: the presence of risk factors for the development of PPH; the presence of transient intestinal paresis, lack of effect from stimulation of intestinal motility; lack of a tendency to form the cervix; ultrasound data. Diagnosis: Postpartum suppurative metroendometritis, complicated form (4 days after cesarean section). Partial failure of sutures on the uterus. Hematoma of the prevesical tissue. Intestinal paresis. OASA. UGI (chlamydia treated). Chr. pyelonephritis. Anemia 1-2 tbsp. The patient is prescribed antibiotic therapy, infusion therapy, uterotonics with antispasmodics, non-steroidal anti-inflammatory drugs, stimulation of intestinal motility, prevention of thromboembolic complications, antihistamines, immunomodulators, iron preparations, FTL, HBO. After the preoperative preparation, 05/18/10, the surgical intervention was performed in the amount of: laparoscopy, emptying of the prebubble hematoma, debridement and drainage of the abdominal cavity, instrumental emptying of the uterine cavity under the control of hysteroscopy, followed by suction-washing drainage No. 3. In the postoperative period, conservative therapy was continued, with an assessment of effectiveness after 4 days. 05/22/10 satisfactory condition, complaints of minor pain in the lower abdomen, body temperature 36.7 ° C, normal skin, clean, tongue moist, clean, Ps - 72 beats. in minutes, blood pressure 120/75 mm Hg, the abdomen is soft, slightly painful in the area of the suture, intestinal motility is heard, physiological functions are normal, genital status: the cervix is formed, mucous-sucrose secretions are insignificant, cervical the canal is closed, the uterus is enlarged up to 7-8 weeks of pregnancy, dense, somewhat limited in mobility, sensitive during examination, the arches are free. Ultrasound data - the uterus is 65 × 55 × 49 mm, the contours are clear, even, the structure is heterogeneous, M-ECHO is 6 mm thick, liquid, in the area of the suture, deformation is up to 0.5 cm, reduced echogenicity in the area of the suture is 1.2 × 1.0 cm; data for limited fluid formations in the pelvis were not found, traces of fluid in the pelvis. In the general blood test, erythrocytes - 3.2, hemoglobin - 108 g / l, white blood cells - 8.5, platelets - 290, ESR 25, no biochemical and electrolyte disturbances. The outcome is recovery. The patient was discharged 05/26/09, in satisfactory condition. Long-term results - healthy.

Claims (1)

A method for choosing treatment tactics for puerperas with postpartum purulent-septic diseases (PHSZ), including the identification of clinical indicators, characterized in that at the first stage of medical care, the severity of the condition is assessed in accordance with the criteria scale of two forms of severity of PHSZ, where
the first group includes criteria for an uncomplicated form of the disease: the absence of risk factors for the development of purulent-septic complications - 1 point, subfebrile condition with one-time temperature rises up to 38 ° C, stopping against the background of antibiotic therapy - 1 point, the absence of intestinal paresis or the presence of easily stopping paresis after surgery caesarean section, against the background of stimulating intestinal motility, 1 point, cervix with vaginal examination formed - 1 point, the presence of uterine involution with hysteroscopy not treated by curettage or vacuum aspiration - 1 point, according to ultrasound, the presence of an increase and expansion of the uterine cavity from 0.5 to 1.0 cm, the absence of deformation in the scar area or deformation up to 0.5 cm, the presence of linear echopositive structures on the walls of the uterus a thickness of 0.2-0.3 cm, a local change in the structure of the myometrium in the form of sections of reduced echogenicity in the suture area of no more than 1.5 × 1.5 cm, the absence of infiltration or hematoma in the suture area on the uterus or in the suture of the anterior abdominal wall with clinical examination and according to ultrasound - 1 point, improvement la boratorial indicators in dynamics - relief of anemia, decreased leukocytosis, slight hypoproteinemia, lack of electrolyte disturbances - 1 point;
the second group of criteria characterizes the complicated form of the disease: the presence of risk factors for the development of purulent-septic complications - 2 points, a long febrile period, with the resumption of hyperthermia after antibiotic therapy - 2 points, the presence of transient intestinal paresis, lack of effect from the use of intensive or repeated courses of treatment for paresis - 2 points, no tendency to form the cervix - 2 points, persistent subinvolution of the uterus - 2 points, according to ultrasound, expansion of the uterine cavity ≥1 cm, deformation in the suture ≥0.5 cm, the presence in the cavity of echopositive structures ≥0.4 cm, reduced echogenicity in the suture area ≥2.5 × 1.5 cm, the presence of hematoma or infiltrate in the posteriorbubble space, in the area of the suture on the uterus or in the suture on the front the abdominal wall - 2 points, the absence of positive dynamics or the deterioration of laboratory parameters - 2 points; and if the condition of the puerperas is characterized by the criteria of group 1 and corresponds to a level of up to 7 points, then it is assessed as an uncomplicated form of the disease and conservative therapy is carried out, including antibacterial, detoxification, syndromic, metabolic therapy, stimulation of intestinal motility, curettage of the uterus under the control of hysteroscopy or vacuum -aspiration followed by suction-washing drainage; if the condition of the postpartum woman at admission or in dynamics is estimated to exceed 7 points, or if there is at least one criterion from group 2, the complicated form of the disease is determined and surgery is performed against the background of intensive therapy.