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application of broad spectrum antibiotics and disinfectants strains of

bacteria have Summary


multidrug resistant
to antibiotics and disinfectants.
Annotation
Selection occurred with the disappearance of the weaker and lessx1
1 annotation by humainsuperbe
resistant to adverse conditions and accumulation of microorganisms in
hospitals antibiotic species and strains. It also led to an increase erased
and abortive forms of diseases, which are now found in 40% of the total
NHS.
Negative role played as the creation of large maternity hospitals.
At a concentration of large contingents pregnant, postpartum women and
newborns "under one roof", because of their physiological characteristics
very susceptible to infection, the risk of infectious diseases increases
dramatically. One of the factors contributing to an increase in infectious
complications in obstetric practice is widespread use of invasive
diagnostic methods (Fetoscopy, amniocentesis, cordocentesis, etc.), the
#1implementation of the operational benefits in pregnant women (surgicalp.1
correction Cervical incompetence in miscarriage), increasing the
frequency Caesarean section.

Postpartum infectious diseases - diseases observed in


postpartum women directly related to pregnancy and childbirth and
due to bacterial infection occurring within 42 days after delivery.
Infectious diseases identified in the postpartum period, but the
pathogenesis is not related to pregnancy and childbirth (influenza,
dysentery etc.), the group does not include postnatal diseases.
Postpartum
purulent-inflammatory
diseases
and
their
complications are a major health and social problem, as both currently
occupy one of the first places in the structure of maternal morbidity and
mortality. Application of new diagnostic and therapeutic technologies
could substantially reduce the number of severe chronic inflammatory
diseases and mortality from them. However, despite this, their frequency
is high, amounting, according to different authors, from 5 to 26%.
Over the past 10-15 years, sepsis and septic complications of
childbirth remain among the three most common causes of maternal
mortality in Russia, accounting for 26% of its structure. Obstetric
complications of septic worldwide die every year about 150 thousand
women.
High incidence of postpartum infections due to a number of
factors: severe ekstarenitalnaya pathology, preeclampsia, anemia and
pyelonephritis caused during pregnancy, placenta previa, fetoplacental
insufficiency, intrauterine infection of the fetus, polyhydramnios induced
by pregnancy, hormonal and surgical correction of prematurely born,
genital infection.
One of the factors affecting the frequency of postpartum purulentseptic infection, obstructed labor are: long dry period, the weakness of
labor, multiple vaginal studies chorioamnionitis in labor, uterine rupture,
bleeding, surgical interventions in childbirth.
In addition, due to the wide and not always well-founded
application of broad spectrum antibiotics and disinfectants strains of
bacteria have multidrug resistant
to antibiotics and disinfectants.
Selection occurred with the disappearance of the weaker and less
resistant to adverse conditions and accumulation of microorganisms in
hospitals antibiotic species and strains. It also led to an increase erased
and abortive forms of diseases, which are now found in 40% of the total
NHS.
Negative role played as the creation of large maternity hospitals.
At a concentration of large contingents pregnant, postpartum women and
newborns "under one roof", because of their physiological characteristics
very susceptible to infection, the risk of infectious diseases increases
dramatically. One of the factors contributing to an increase in infectious
complications in obstetric practice is widespread use of invasive
diagnostic methods (Fetoscopy, amniocentesis, cordocentesis, etc.), the
implementation of the operational benefits in pregnant women (surgical
correction Cervical incompetence in miscarriage), increasing the
frequency Caesarean section.
Wide practical caesarean section contributed to the reduction of
perinatal losses, however, contributed to an increase in the frequency
and severity of postpartum purulent-inflammatory diseases. Despite
progress in surgical technique, the use of the cross-section in the lower
segment of the uterus, improving sewing techniques, preventive
purpose of broad spectrum antibiotics, the number of inflammatory
complications after cesarean section remains high.

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Infectious process is classically considered as a result of a
complex interaction of three factors: the presence of the
pathogen (its quantity and virulence), the state of the
primary focus and the body's resistance.
Consider these factors.
Pathogens NHS.
A characteristic feature of septic puerperal diseases is their
polymicrobial etiology.Pathogens can be both pathogenic and
opportunistic microorganisms.
Potentially disease pathogens include Gram-positive (enterococci,
Staphylococcus epidermidis and Staphylococcus, Streptococcus group A
and B), Gram-negative (Escherichia coli, Klebsiella, Proteus,
Enterobacteriaceae, Pseudomonas aeruginosa) aerobic bacteria.Among
the anaerobic bacteria are Bacteroides, peptokokki, peptostreptokokki.
Microbial associations have a more pronounced pathogenic properties
than monoculture, due to the synergism between them. This
phenomenon is called " Quorum sensing ", or" quorum sensing. "
Bacteria are able to communicate with each other via signals of protein
molecules, and the accumulation of a certain amount of bacterial
biomass allocation of pathogenicity factors increases.
Over the last decade has changed the species spectrum of
pathogens postpartum purulent-septic diseases. Along with leading
etiological your negative bacteria increases the importance of Grampositive flora. If before the main etiological factor is rightly considered
E. coli, at least - Pseudomonas aeruginosa and Proteus, now the leading
role belongs enterococci (up to 65% of all cases of postpartum purulentseptic diseases). This is especially important to know, because
enterococci sensitive to cephalosporins I and II generation and
aminoglycosides, which are often used in maternity hospitals.
Diagnostic criterion is the number of microbial bodies of more
than 10 4 CFU / ml.Bacteriological examination, indicating the
development of the infectious process.
It should be noted that increasing the number of diseases caused
by microorganisms, sexually transmitted infections (chlamydia,
mycoplasma, and viruses) It should be noted that mycoplasma (10%)
and chlamydia (2%) cause indolent forms of endometritis, often
connected to the primary causative agents of infection.

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Resistance of the host.
It is caused by the presence of the normal microflora (lactobacilli)
that competes with pathogens for adhesion to epithelial cells, and local
factors and systemic immunity female genital tract.
Causes changes in the composition of the vaginal flora in pregnant
women may be: unjustified and / or inconsistent antibacterial treatment,
as well as the use of surface disinfectants in otherwise healthy pregnant
women. Against this background, lactobacilli and die in their place
begins to develop opportunistic anaerobic flora, resulting in the
development of bacterial vaginosis in pregnant women. Bacterial
vaginosis - vaginal ecosystem pathology is caused mainly by increased
growth of obligate anaerobic bacteria.Bacterial vaginosis in pregnant
women is on average 14-20%. In 60% of postpartum women with
postoperative endometritis allocated the same microorganisms from the
vagina and of the uterus. In bacterial vaginosis in pregnant several times
increased risk of wound infection.
By the end of pregnancy in women noted significant change of
serum specific immunoglobulin classes (G, A, M), the absolute decrease
in the number of T-and B-lymphocytes (normal secondary
immunodeficiencies).
At birth there are additional factors contributing to the
development of postpartum infectious diseases. First of all, with a
discharge of mucus plug, which is a mechanical and immunological
barrier (secretory lgA) for microorganisms, lost one of the physiological
barriers antiinfective female genital tract. Amniorrhea causes an increase
in pH (decrease acidity) vaginal contents, and the study of vaginal
contents after the outpouring of water revealed important fact - the
complete absence of secretory immunoglobulin A. The reason for this
phenomenon is purely mechanical removal belkovosoderzhaschih
substrates with mucosal surfaces of the birth canal, drastically reducing
local secretory protection . Found that 6 hours after rupture of
membranes is not a single anti-infective barrier female genital tract, and
the degree of contamination and the nature of the microflora depend on
the duration of dry period. Against this background, dramatically
increase the risk of postpartum infectious complications of premature
rupture of water, prolonged labor, early amniotomy unreasonable,
multiple vaginal research, invasive methods of research status of the
fetus during labor, violation of sanitary-epidemiological regime. Clinical
manifestation of ascending infection in childbirth is chorioamnionitis. In
mothers, amid prolonged dry period or childbirth, general condition
worsens, the temperature rises, there is a fever, pulse quickens, amniotic
fluid become cloudy with odor, pus-like discharge sometimes appear, the
blood picture changes.Already a 12-hour dry interval 50% maternal
chorioamnionitis develops, and 24 hours later, this percentage is close to
100%.
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State of the primary lesion.
In the postpartum period in the genital tract in childbed, not a
single anti-infective barrier. The inner surface of the postpartum uterus is
a wound surface, and the contents of the uterus (blood clots, epithelial
cells, land decidua) is a favorable environment for microbial growth.
The uterine cavity is easily infected by the ascent of pathogenic and
conditionally pathogenic flora of the vagina. As mentioned above, some
women in childbirth, postnatal infection is a continuation of
chorioamnionitis.
Postpartum infection - mostly wound. Development of infection in
the postpartum period contribute: subinvoljutcija uterus, placenta parts
delay, inflammatory diseases of the genital organs in history, the
presence of bacterial infection of extragenital lesions, anemia, endocrine
diseases, violation of sanitary-epidemiological regime.
Speaking of septic complications of caesarean section, the matter
is also the method by which it was made. Thus, the risk of postpartum
purulent-septic diseases is higher after cesarean corporal, because with
this method is difficult to compare the wound edges, formed more
hematomas, which are easily infected. If a cesarean section is performed
in the lower uterine segment, it is preferable to cut Derfleru when
incision is made acute by (with scissors), than Gusakov (when the
wound edges stupidly bred in hand with your fingers). This is due to the
fact that the incised wound healing better than jagged.
Persistence of wound infection also contributes to the phenomenon
of "bacterial film."This accumulation of microorganisms on the foreign
bodies that may be in obstetrics seam on the cervix or sutures in the
uterus after cesarean section. Microorganisms form clusters, covered
with a thick layer of mucopolysaccharides, preventing the penetration
of antibiotics, which reduces the effectiveness of antibiotic therapy.
Transmission path . In 9 out of 10 cases of postpartum infection
as such transmission route does not exist, since the activation of selfpathogenic flora (autozarazhenie). In other cases, infection occurs
outside hospital strains resistant in violation of the rules of asepsis and
antisepsis. Should be identified as a relatively new way of infection - the
intra-amniotic associated with the introduction of invasive obstetric
practice methods (amniocentesis Fetoscopy, cordocentesis).
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Concept of systemic inflammatory response syndrome.
The main mechanism of pathogenesis of postpartum purulentinflammatory diseases is a systemic inflammatory response syndrome,
which is the first stage of postpartum endometritis, and the last - septic
shock.
The basic starting point is the selection of phospholipase
microorganisms - enzyme that destroys cell membranes Phospholipids.
This starts a cascade of arachidonic acid, which is formed from
phospholipids. From the arachidonic acid produced prostacyclin and
thromboxane A 2. imbalance in favor of thromboxane
leading to
vasospasm and increased platelet aggregation, which leads to
generalized disturbance of microcirculation in tissue hypoxia and
metabolic acidosis.
Infection triggers cytokine release. Neutrophils, which fall into
the site of infection, also secrete biologically active substances: Nitric
oxide and superoxide contribute to the formation of oxygen radicals and
peroxides, which contributes to damage of the vascular endothelium. In
the process involves histamine, proteolytic enzymes. All this leads to
generalized endothelial defeat, hemostatic disorders and vascular tone,
impaired microcirculation, oozing liquid part of blood into the tissues,
which leads to a decrease in the bcc - comes hypovolemia. Increases the
risk of edema, especially the lungs, brain. Because of the deposit of
blood in the microvasculature open arteroivenoznye shunts. Because
hyperactivation of vascular-platelet
and plasma components of
hemostasis begins to develop DIC. Ultimately, it all leads to the
development of septic shock.
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CLASSIFICATION.

In practical obstetrics widely used classification of postpartum


infectious diseases Sazonov-Bartels , according to which different
forms of postpartum infectious diseases are treated as separate stages of
a single infection.
The first stage - infection limited to the area of labor injuries:
postpartum endometritis, postpartum ulcer (on the perineum, the wall of
the vagina, cervix), infintsirovanie postoperative wound on the anterior
abdominal wall after cesarean section.
The second stage - the infection has spread beyond the generic
wounds, but remained localized within the pelvic: metroendometritis,
Options, salpingo limited thrombophlebitis, pelvic abscess.
The third stage - the infection has moved beyond the pelvis and
has a tendency to generalization: progressive thrombophlebitis,
peritonitis, septic shock, anaerobic gas infection.
Fourth stage - generalized infection: sepsis (septicemia,
pyosepticemia).

CLINICAL PICTURE.

Postpartum ulcer. infection arises due to abrasions, cracks,


breaks the vaginal mucosa and vulva. Puerperas remains satisfactory
condition. This group of diseases also include festering wounds after
perineotomy or perineal.
Diagnosis of the disease does not cause trouble. There is
congestion, edema, and purulent necrotic plaque on the wound.
Held a topical treatment, treatment with an antiseptic solution,
with festering wounds after perinetomii - impose secondary
seams.
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Postpartum endometritis.
In the structure of inflammatory diseases postpartum endometritis
retains its leading position. After normal delivery rate of postpartum
endometritis is 3-8%, after pathological births, this figure rises to 1020%. Chance of postpartum endometritis after cesarean increases 5-10
times compared with vaginal birth path. After repeated cesarean
delivery, it increases still 2.5 times. Caesarean section, making only 20%
of births, causes 80 - 90% of postpartum endometritis.
There are several reasons:
incision on the uterus during a cesarean section is accompanied by a
violation of the integrity of the blood and lymph vessels, which
contributes to direct bacterial invasion of the bloodstream and the
lymphatic system of the uterus;
operation performed on the background horionamnionita causes direct
spread of infection to the peritoneum with the emergence of early
peritonitis;
infectious agents in the zone of the uterine scar, acquire the ability to
proliferate, increased virulence, which leads to the spread of outside
wounds (myometrium, parameters);
Availability seam to slow uterine involution of the uterus in the
postpartum period, violating the normal flow of lochia, creating
favorable conditions for microbial growth.

Endometritis occurs in two forms: acute and worn.


The acute form occurs at 2-5 days post-partum period with the
temperature rise to 38.5 - 39 C, lower abdominal pain and pus in the
lochia impurities. Involution of the uterus is delayed. There is a severe
intoxication.
Assays blood - anemia, leukocytosis, with a shift
neytrofillez leykoformuly left, lymphopenia.
In the diagnosis method used ultrasound study that reveals delay
uterine involution, expansion chamber, with availability of placental and
decidual tissue.
In the event of an acute form of endometritis plays an important
role Gram-positive and Gram-negative flora, so the drugs of choice for
antibiotic therapy are penicillins and cephalosporins.
Worn form endometritis occurs without clinical symptoms. The
disease begins late, 7-9 day, often after discharge from the hospital
women.
The main features of this form of endometritis are low-grade fever,
subinvoljutcija uterus and spotting from the genital tract. Often this
results in the form of endometritis mycoplasma and chlamydial
infection, so to be effective in the treatment of macrolide drugs.
Parameters.
Process develops in the presence of injury or infection in the
cervix. Most affected side sections parametrial tissue, rarely-back.
Recognized parameters when vaginal examination: infiltrate comes to
pelvic walls, vaginal mucosa on the affected side becomes stationary.
Treatment - conservative, on the general principles of therapy of
inflammatory diseases. In the case of suppuration parametrial tissue
shown Abscess through vaginal vault.
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Metrotromboflebit.
Often observed after surgical delivery. Clinical symptoms usually
appear not earlier than 6 days post-partum period.
Runs hard, with high fever and intoxication. When vaginal study
determined enlarged, painful on palpation of the lateral surfaces of the
uterus, on the side surfaces Ingoda palpable tight, painful "cords." In
the clinical analysis of blood marked leukocytosis with a shift to the left
leykoformuly.
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Puerperal mastitis.
Puerperal mastitis is one of the most frequent complications of the
postpartum period.In recent years, according to domestic and foreign
authors, the incidence of mastitis varies widely - from 1% to 16%, with
an average of 3-5%. Among lactating women rate it has no tendency to
decrease.
In domestic obstetrics most widely found mastitis classification
proposed in 1975. BL Gurtovoy:
1. Purulent mastitis:
a.) serous (starting) mastitis;
b.) infiltrative mastitis.
purulent mastitis:
a). Infiltrative-purulent
b). Abscessed
abrasions areola
Abscess areola
abscess deep in the gland
abscess behind cancer (retromammary)
c). Phlegmonic
d). Gangrenous

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Etiology, pathogenesis, clinical manifestations, diagnosis.
Under modern conditions the major cause of lactation mastitis is
Staphylococcus aureus, which is characterized by a highly virulent
and resistant to many antibiotics.
Penetration of the pathogen in the breast tissue occurs
lymphogenous way through cracked nipples and galaktogennym way through dairy moves. Extremely rare inflammatory foci in the gland is
formed secondarily in generalizing postpartum infection localized in the
reproductive system.
Development of inflammation in the mammary gland promotes
lactostasis associated with occlusion of the ducts that bring milk, so
mastitis in 80-85% of cases occur in nulliparous.
For a typical clinical form of serous mastitis characterized by
acute onset usually 2-4 week postpartum period. Body temperature rises
rapidly to 38-39 C, often accompanied by chills. Develop general
weakness, fatigue, and headache. Pain arises in the mammary
gland.However there may be variants of the clinical course of mastitis in
which the general phenomena precede local. When inadequate therapy
beginning mastitis within 2-3 days goes into infiltrative form. In the
breast begin to palpate pretty tight painful infiltration. The skin over the
infiltration - always hyperemic.
Daylight purulent mastitis in form occurs within 2-4 days. The
temperature rises to 39 C, there is a fever, growing signs of
intoxication: lethargy, weakness, loss of appetite, headache. Growing
local signs of inflammation: swelling and soreness in the lesion, areas of
softening in the infiltrative-purulent form of mastitis occurring in about
half of patients with purulent mastitis.
In 20% of patients with purulent mastitis manifests as abscess
forms. When this dominant variants are abrasions and abscess halos rarer
and intramammary paramastitis representing purulent cavities defined
connective tissue capsule.
In 10-15% of patients with purulent mastitis occurs as a form of
abscess. Process captures most of the gland tissue and its melting
transition to the surrounding tissue and skin.General condition puerperal
in such cases - heavy. Temperature reaches 40 C, shaking chills
watching expressed intoxication. Mammary gland dramatically increases
in volume, her skin was swollen, flushed with a bluish tint, palpation of
the prostate - sharply painful. Gathered breast may be accompanied by
septic shock.
Sharp form gangrenous mastitis is extremely difficult for a
pronounced intoxication and necrosis of the breast. Gangrenous
mastitis outcome is unfavourable.
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Basic principles of starting therapy (serous) mastitis. most
important component of a comprehensive treatment of lactation mastitis
is a complex application of antibiotics. Before starting antibiotic therapy
seeded milk from diseased and healthy breast flora. Currently
Staphylococcus aureus reveals the greatest sensitivity to semisynthetic
penicillins (methicillin, oxacillin, dicloxacillin), cephalosporins III - IV
generation, lincomycin and aminoglycosides (gentamicin, kanamycin).
While maintaining breastfeeding choice of antibiotics is associated with
the possibility of adverse effects on the newborn. Used penicillins and
cephalosporins.
In the initial stages of lactation mastitis antibiotic usually
administered intramuscularly.
In modern obstetrics indication for suppression of lactation
mastitis are:
rapidly progressing process, despite ongoing intensive therapy;
multifocal infiltrative-purulent and mammary abscess;
abscess and gangrenous forms of mastitis;
any form of mastitis in relapsing course;
5. Sluggish current mastitis is not amenable to complex therapy
including surgical opening of the hearth.

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Obstetric peritonitis.
This severe complication of the postpartum period, which occurs
on the background of endometritis, myoma node necrosis, torsion legs
ovarian tumor. However, the most common cause of obstetric peritonitis
is endometritis after cesarean section.
Peritonitis caused by diverse microflora and characterized early
occurring endogenous intoxication associated with systemic
inflammatory response syndrome. Disturbed microcirculation, there is
tissue hypoxia and metabolic acidosis. A special place in the
pathogenesis of peritonitis takes enteroplegia. Broken motor, secretory,
suction bowel function. In the lumen of the small intestine accumulate
significant amounts of fluid containing a large amount of protein and
electrolytes. Hyperextension and ischemia of the bowel wall is likely to
disrupt the intestinal barrier function and the further strengthening of
intoxication.
Obstetric peritonitis as surgical differs phasic flow.
The first phase - the initial or reactive (first 24 hours).
Compensatory mechanisms are preserved. No hypoxia. Patients few
euphoric, excited. Moderate enteroplegia, sluggish peristalsis.
Tachycardia is slightly ahead temperature reaction of the body. In the
blood, died leukocytosis with a shift to the left leykoformuly.
The second phase - toxic (24-72 h). In this period begin to dominate
the "general" response: developing hemodynamic disturbances,
microcirculatory changes liver and kidney function, gradually increasing
hypoxia and worsens tissue respiration. Patient sluggish, the color of the
skin, nausea, vomiting. Increases leukocytosis with toxic granulation
neutrophils. Distended belly.
The third phase - terminal (over 72 hours), is characterized by
decompensation syndromic disorders occurring in the toxic phase of
peritonitis. There is a complete absence of peristalsis, expressed
flatulence, diffuse tenderness throughout the abdomen. Formed
hypovolemic and septic shock with multiple organ failure. Patient
inhibited, arrhythmic heartbeat, shortness of breath, decreased blood
pressure.
Peritonitis caused after cesarean section, can be manifested in
three versions, depending on the route of infection.
Option 1 - against the background of horionamnionita . clinical picture
of peritonitis in this situation is characterized by an early start on the 1st
2 days after surgery, high body temperature to 38-39, tachycardia 120140 beats.
min., intestinal paresis.
allows Early Start eliminate
gapping in the uterus. May be a high leukocytosis (15,0-16,0 - 109 / l),
increasing the number of stab leukocytes. When monitoring for 12-24 h
the deterioration of the general condition. Rising enteroplegia takes
consistent, peristalsis is not defined, bowel stimulation measures are not
effective. Enhanced thirst, the tongue becomes dry, increases
tachycardia. Developed septic shock.
Option 2 - occurs when infection of the peritoneum associated with the
development of postoperative endometritis. The condition of patients
after surgery may remain relatively satisfactory. Body temperature
within 37,4-37,6 C, moderate tachycardia (90-100 beats. / Min.),
Appears early enteroplegia. Abdominal pain is not. Periodically is
nausea and vomiting. Abdomen is soft, no peritoneal signs. The most
characteristic symptom is recurrent. With the progression of the process,
despite ongoing medical therapy, with 3-4 days the patient's condition
worsens, growing signs of intoxication. It should be emphasized that the
differential diagnosis between normal postoperative intestinal paresis
and developing peritonitis is not simple.
The third option - the development of peritonitis in insolvency seams
on the uterus. This usually occurs due to an infection, at least - a
technical error sutures. At the wrong angle suturing wounds, where there
may be a bundle of muscles, separation of the uterus begins to flow into
the retroperitoneal space and the abdominal cavity. Clinical symptoms
usually appear early. From the earliest days growing signs of peritonitis.
The patient's condition worsens, concerned about pain in the lower
abdomen on the right or left. Noteworthy is the paucity of discharge
from the uterus. Steadfastly held tachycardia, vomiting, bloating. When
percussion define exudate in the abdominal cavity, the number of which
is increasing.Intoxication comes quickly.
day.

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In the diagnosis of peritonitis guided by abdominal pain,


symptoms of peritoneal irritation, persistent intestinal paresis
(bloating, constipation). Of the common symptoms are
characterized by high fever, vomiting, tachycardia, cold sweat.
According to laboratory data - marked leukocytosis with a shift to
the left leykoformuly, toxic granularity neutrophils.
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Basic principles of treatment of septic puerperal diseases.

Treatment should be etiotropic, comprehensive, systematic and


active. It should be started as early as possible in identifying the initial
manifestations of postpartum infection, which greatly contributes to the
prevention of severe generalized forms.
Treatment begins first of all with the reorganization of the
primary focus .Depending on the stage of infection may be as vacuum
aspiration or curettage (with endometritis) and hysterectomy with uterine
tubes (with peritonitis). In the case of surgical treatment of mastitis only
shown in purulent mastitis (radial or retromammary incision depending
on the localization of the evacuation of pus, drainage glove drainage).
Serous and infiltrative forms treated conservatively (antibiotic, infusion
therapy).
In case of fever and signs of intoxication in women with
endometritis treatment begins with a detoxifying and antibiotic therapy
(to avoid the development of bacterial toxic shock), and after relieving
the symptoms of intoxication held vacuum aspiration. The purpose of
aspiration or curettage of the uterine cavity - remove substrate (necrotic
decidua tissue, membrane, remnants of the placental tissue, blood clots),
which causes perstistentsii infection.An important role is given to
hysteroscopy, which allows to evaluate the presence of the substrate, and
after cesarean - to assess the condition of the seam on the uterus, its
consistency, sagging ligatures produce control after vacuum aspiration.
In the presence of peritonitis sanitation primary focus is carried
out in three stages:
preoperative preparation for 2-3 hours (nasogastric tube, infusion,
antibiotic therapy, subclavian vein catheterization, symptomatic
therapy);
surgery (laparotomy nizhnesredinnoy, hysterectomy with uterine tubes,
sanitation and drainage of the abdominal cavity). The operation is
performed on the background of ETN that contributes to a better
relaxation and oxygenation of the patient.
posleoperatsionnny period in the ICU (detoxification, antibacterial,
symptomatic therapy).
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Infusion and detoxification therapy. To eliminate hypovolemia,
and detoxification of the correction of underlying colloid osmotic state
spend multicomponent fluid therapy.Infusion using crystalloid, colloid
solutions, according to testimony - protein solutions.
Infusion volume varies depending upon the forms of the disease
from 1,500 ml. (At endometritis) 3 000 - 3500 ml. (With peritonitis).
Maintenance
Mode
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microcirculation and rheological characteristics of blood coagulation.
The most commonly used plasma expanders (reopoliklyukin,
polyglukin), synthetic colloids (gemodez, hydroxyethylated starches
(Infukoll, Refortan, stabizol)), protein drugs (Albumin, polyamine),
gelatin (zhelatinol) saline.
Fresh frozen plasma is introduced in peritonitis, when to use its
main value: the presence of procoagulants, anticoagulants, and
plasminogen. Indication for transfusion er.massy serves only decreased
hemoglobin below 70 g / l and hematocrit less than 0.2%.
Ratio of colloidal and crystalloid solution should be an average 1:2
ratio of protein and non-protein drugs -1:3.
For the purpose of infusion should be used infusion antihypoxants
mafusol and reamberin that cropped symptoms of systemic
inflammatory response.
In marked metabolic acidosis use
bicarbonate.

100-200 ml. 4.2% sodium

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Anti-infective treatment is a major component in the complex
treatment of inflammatory diseases postpartum.
Antibiotic therapy is started on a background infusion therapy as
antibiotics with bacteriolytic action (penicillins, cephalosporins) may
cause the release of large doses of endotoxin that will lead to greater
systemic inflammatory response syndrome and septic shock.
If at the time the therapy we have no evidence of bacteriological
tests with the definition of sensitivity to antibiotics, we prescribe
antibiotics empirically based is polymicrobial disease.
Currently, using a combination of cephalosporins I and II
generation aminoglycosides impractical because most microorganisms
insensitive to these drugs.
By means of first-line combination refers
(lincomycin, clindamycin) with aminoglycosides.

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As an alternative means you can use the protected penicillins


(augmentin, amoksiklav) as monotherapy or in combination with
aminoglycosides.
You can also use a combination of cephalosporins III and IV
generations with metronidazole.
Metronidazole can also be combined
intravenous administration.

with fluoroquinolones for

Broad spectrum of activity also possess drugs of carbapenems


(Meron imipinem), which are introduced in / drip 2-3 times a day.
The use of antibiotics requires prevention of candidiasis, which
resorted to the appointment of nystatin, in the absence of breastfeeding fluconazole tablets, severe infections - intravenously.
In these schemes, clindamycin, and metronidazole are used for the
treatment of anaerobic infections.
In case of failure of antibiotic therapy within 48 hours produce
replace antibiotics.Duration of antibiotic treatment is not more than 3648 hours after the disappearance of clinical symptoms in 5-7 days on
average.
To increase the effectiveness of antibiotics in tissue penetration
can assign interstitial electrophoresis. At the same time introduced
antibiotki / drip and held galvanizing uterine region. Blood supply and
delivery of the antibiotic in the tissue increases.

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Immunotherapy.
In order to use the immune preparations for passive
immunotherapy
- interferons (genferon, viferon), human
immunoglobulin and antistaphylococcal, pentaglobin, Intraglobin; and
immunomodulators (taktivin, timalin, timogen, roncoleukin). It should
be emphasized that the immunomodulators used only under the
supervision immunograms agreeing appointment with the immunologist.
In the course of treatment necessarily include sedatives,
desensitizing, painkillers.
To enhance the effectiveness of therapy in treatment sessions using
quantum therapy, ultraviolet blood irradiation in combination with
hyperbaric oxygenation. Hyperbaric oxygen promotes the relief of
bacterial infections, particularly anaerobic,
improves tissue
oxygenation, reduces or eliminates metabolic acidosis.
Very effective methods of efferent therapy , which include
plasmapheresis, hemofiltration, enterosorption. They contribute to the
elimination of biologically active substances (histamine, reactive oxygen
species, arachidonic acid metabolites) and eliminate systemic
inflammatory response syndrome. It is proved that for background use
efferent therapies mortality from septic shock is reduced by 4 times.
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Anticoagulant and antiaggregantnaya therapy conducted in
order to improve the microcirculation as well as prevention of
thromboembolic complications. Antiaggregantov use of Trental
and chimes of anticoagulants is preferable to use low molecular
weight heparins (fraksiparin, Clexane). Especially shows how to
use the presence of low molecular weight heparins
metrotromboflebita (high risk of pulmonary embolism) and
peritonitis (due to massive tissue destruction develops DIC).
Prevention enteroparesis women with postoperative peritonitis
held neostigmine methylsulfate, tserukalom assigned enema.
Symptomatic therapy - uterotonics with endometritis, with
peritonitis - means supporting the function of the heart (strofantin,
koglikon), liver (essentiale, Syrepar).

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Prevention of postpartum purulent-septic diseases.

Prevention of inflammatory diseases postpartum should start with


the first weeks of pregnancy. At the clinic, you must reorganize foci of
chronic infection (carious teeth, ENT diseases, vaginitis, diseases
transmitted by poloavym).
During labor to prevent prolonged dry period, to prevent blood
loss, reduce maternal injuries.
During caesarean section operation on Derfleru produce, use
modern suture preferred single-row suture on the uterus. In
posleroperatsionnom period prophylactic antibiotics
.
In patients need antibiotics after manual revision of the uterus,
with horionamnionitom in childbirth.
In the postpartum period : newborn earlier attachment to the
breast, rooming mother with a child with subsequent early
discharge from the hospital. In order to prevent the formation of
multi-drug resistant strains of nosocomial infection in a single
maternity hospital should be a limited number of antibiotics of the
first stage, and combinations thereof, and the second line
antibiotics used strictly on the evidence.

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