Sepsis and septic shock in gynecology. Sepsis in obstetrics

GYNECOLOGICAL SEPSIS (ETIOPATHOGENESIS, CLINIC, DIAGNOSIS, TREATMENT).

A severe complication of abortion is severe sepsis (septicemia, septicopyemia).

Septicemia- an acute disease that occurs with symptoms of severe intoxication. Characteristic: onset immediately after surgery, 40-41 C body temperature, repeated chills, oliguria, pain in the calf muscles and joints, cardiac dysfunction (drop in blood pressure, cyanosis of the mucous membranes, arrhythmia, increasing congestion of the right side of the heart), pale skin with earthy tint, petechial rash, toxic diarrhea, neurological symptoms. Blood test: neutrophilic leukocytosis with a shift to the left, increased ESR, proteinemia, decreased platelet count, increasing anemia. The tongue is dry, the stomach may be swollen and painful. Later the spleen and liver enlarge.

Septicopyemia as the next stage of septicemia, it is characterized by the formation of metastatic purulent foci in various organs.

Clinical picture characterized high temperature body, repeated repetition of chills, increasing cardiovascular failure, tachypnea (25-40 breaths per minute), microcirculation disorders (acrocyanosis, cold extremities, bluish spots on the face, hemorrhagic petechial rash). Septic pneumonia and endocarditis may occur. If the causative agent is anaerobes, then jaundice and anuria quickly occur. A blood test determines a decrease in the content of hemoglobin, red blood cells, a neutrophil shift in the blood formula, leukocytosis, toxic granularity of neutrophils, poikilocytosis, anisocytosis, increased ESR, hypoproteinemia, hypoalbuminemia, disorders of the hemostasis system.

Treatment combined: ABT, infusion, desensitizing therapy, administration of cardiac drugs, glucocorticoids.

Indications for surgery (hysterectomy):

septic shock against the background of sepsis, pyosactosalpinx, ovarian abscess, tubo-ovarian abscess, peritonitis, anaerobic sepsis, necrosis of the uterine walls (after insertion into its cavity chemical substances in case of criminal abortion).

Anaerobic sepsis. The causative agent is a gram(-) bacillus, which forms spores and produces an exotoxin. The clinical picture is dominated by symptoms associated with the formation of gases and tissue melting. A classic triad of symptoms appears: severe jaundice with a bronze tint to the skin, oligo- and anuria (urine the color of meat slop), indicating acute renal failure. In case of anaerobic sepsis, immediate curettage of the uterine cavity is necessary; if peritonitis or uterine gangrene is suspected, hysterectomy is indicated. The patient is administered a polyvalent anti-gangrenous serum, a broad-spectrum antibiotic, and infusion-transfusion therapy are prescribed. Patients diagnosed with anaerobic sepsis require strict isolation and care.

INFECTIOUS-TOXIC SHOCK (ITS) IN GYNECOLOGY(ETIOPATHOGENESIS, CLINIC, DIAGNOSIS, TREATMENT).

Among the various types of shock, infectious-toxic shock ranks third, but in terms of mortality it ranks first (the mortality rate for this type of shock is 60%).

Microcirculation disturbance- the main pathogenetic link of ITS. These disorders are associated: 1) with the release into the bloodstream large quantity mediators influencing the tone of pre- and post-capillaries, promoting the opening of shunts and impaired permeability (cytokines: tumor necrosis factor, interleukin-1, itreferon); 2) with a significant violation of the aggregate state of the blood and its rheological properties, the development of thrombohemorrhagic syndrome.

Criteria for diagnosing ITS are:

1. Surgery performed within the next 48 hours or the presence of a septic condition.

2. Hyperthermia above 38 C, chills after surgery, abortion.

3. Erythroderma (diffuse or plantar), turning into desquamation of the epithelium on the extremities.

4. Damage to the mucous membranes - conjunctivitis, hyperemia of the mucous membrane of the oropharynx, vagina, vaginal discharge.

5. Arterial hypotension (not associated with blood loss) - systolic blood pressure below 90 mmHg, orthostatic collapse and impaired consciousness.

6. Multiple organ failure syndrome (GTT - nausea, vomiting, diarrhea; CNS - disturbances of consciousness without focal neurological symptoms; kidneys - oliguria, liver - increased bilirubin, enzyme activity; lungs - ARDS, tachypnea; CVS - myocardial ischemia, microcirculation disorders).

Clinical picture of ITS. The clinical course of shock includes 3 phases: 1). Warm normotension (not clinically detected). 2) . Warm hypotension (“warm” or hyperdynamic phase). Rising temperature, hyperventilation, increased pulse blood pressure and increased cardiac output, shortness of breath. This shock phase lasts from 30 minutes to 16 hours. 3) . Cold hypotension ("cold" or hypodynamic phase). Develops under the influence of hypoxemia, cardiodepressive bacterial factors, cytokines, endorphins. Pale skin, covered with sticky cold sweat, marbled skin pattern.

Intensive therapy of ITS is carried out jointly by a resuscitator and an obstetrician-gynecologist with constant monitoring of body temperature, skin condition, respiratory rate, pulse, blood pressure, central venous pressure, hourly diuresis, hematocrit, protein, electrolyte, acid-base composition of plasma, state of the coagulation system, bilirubin content blood. The sequence of resuscitation measures determined by the formula: VIP - PhS: V - ventilation, I - infusion therapy, P - maintenance of cardiac output and blood pressure, Ph - pharmacotherapy (ABT), S - specific therapy (removal of a purulent focus).

Urgent hysterectomy is indicated: 1. Suspicion of uterine perforation, presence of blood or pus obtained during puncture of the posterior fornix. 2. If there is a purulent process in the uterine appendages, increasing signs of peritoneal irritation. 3. When anaerobic infection. 4. Progressive decrease in fibrinogen, platelets, acute renal failure, lack of clinical effect intensive care, carried out over 4-6 hours.

is a systemic complication of infections of the female genitourinary system and mammary gland that develops during pregnancy, expulsion of the fetus and in the postpartum (post-abortion) period. It manifests itself as a severe general condition, increasing weakness, fever, palpitations, shortness of breath, and decreased blood pressure. As it progresses, clouding of consciousness, severe difficulty breathing, sharp decrease volume of urine excreted. The diagnosis is established based on physical examination, ultrasound, and laboratory blood tests. Treatment is complex: surgical sanitation of abscesses, antibiotic therapy, intensive care.

ICD-10

O75.3 Other infections during childbirth

General information

Obstetric sepsis (puerperal fever) is a life-threatening condition characterized by disorders of hemodynamics, metabolism, blood coagulation, multiple organ failure and occurs in response to infectious inflammation in the genital and urinary organs, as well as in the mammary gland during the gestational, birth and postpartum periods. The outdated synonym for sepsis “blood poisoning” is now irrelevant: the penetration of an infectious agent into the blood is not prerequisite development of a septic process - bacteremia is recorded only in 50% of patients. Sepsis develops in one out of 5,000 pregnant and childbirth women and is accompanied by septic shock in 10% of cases, the share of the disease in the structure of maternal mortality is 12%. In 44% of cases, sepsis is registered during pregnancy (with an even distribution across gestational periods), in 10% - during childbirth, in 46% - in the postpartum period.

Causes

Obstetric sepsis is always secondary, its source is a local infection. The main causative agents of purulent-inflammatory diseases are representatives of opportunistic flora (pyogenic streptococcus, group B streptococcus, Staphylococcus aureus, coli, Klebsiella, Proteus, Peptococcus, Peptostreptococcus, Bacteroides, Candida fungus), most often inhabit the lower parts of the genitourinary tract and intestines and lead to pathology only under the influence of certain factors. The main causes and sources of infection include:

• Surgery and tissue trauma. The wound surface serves as a gateway to infection and contributes to a significant decrease in local immunity. A purulent process can result in a cesarean section, early discharge of amniotic fluid (with incorrect position fetus, multiple pregnancy), ruptures and surgical interventions in the perineum obtained during childbirth.
• Therapeutic and diagnostic procedures. The pathogen is transmitted by contact with a contaminated instrument; in addition, microtraumas obtained during the study create favorable conditions for lympho- and hematogenous infection. Risk factors include cervical cerclage, amniocentesis, cordocentesis, urethral catheterization, in vitro fertilization, multiple vaginal examinations during childbirth.
• Physiological changes caused by pregnancy. The growing uterus compresses and displaces surrounding anatomical structures, and progesterone reduces smooth muscle tone. These factors lead to disruption of urodynamics and create preconditions for the development of gestational pyelonephritis and urosepsis.
• Stagnation breast milk . As a result of lactostasis, active growth of staphylococci occurs, causing mastitis. Impaired milk flow is the main cause of postpartum abscesses and cellulitis.

On the other side, purulent processes can be complicated by sepsis only if the immune response is hypo- or hyper-responsive. Functional disorders immune system lead to increased activity of opportunistic microorganisms and the formation of a pathological reaction to purulent inflammation. Risk factors include obesity, diabetes mellitus, anemia, acute and chronic inflammation (genital and extragenital), lack of nutrition, and age over 35 years.

Pathogenesis

Massive tissue damage by infection is accompanied by a permanent or periodic release of inflammatory response mediators into the bloodstream, which depletes the regulatory function of the immune system and triggers a number of uncontrolled reactions in distant organs and tissues. As a result, the endothelium is damaged, microcirculation (perfusion) deteriorates, and oxygen transport decreases. These changes lead to disturbances in homeostatic regulation, the development of acute multiple organ failure syndrome (MODS) and disseminated intravascular coagulation syndrome.

The myocardial ventricles dilate, cardiac output decreases, and vascular tone. Atelectasis forms in the lungs, and respiratory distress syndrome develops. As a result of a decrease in circulating blood volume (CBV) and hemostatic disorders, microcirculation deteriorates renal tissue and blood supply to the cortex with subsequent acute functional failure. Metabolic processes in the liver are disrupted, and lack of blood supply leads to the formation of necrotic areas. Hypoperfusion leads to pathological permeability of the intestinal mucosa with the release of toxins and microorganisms into the intestinal mucosa. lymphatic system, as a result of ischemia, stress ulcers form on the walls of the gastrointestinal tract. Violation metabolic processes and microcirculation of the brain determines neurological disorders.

Classification

Obstetric sepsis is classified according to different criteria: by pathogen, by metastatic spread (septicemia, characterized by the presence of only a primary focus, and septicopyemia - the presence of purulent screenings in other tissues and organs) or by clinical course. In modern obstetrics, a classification has been adopted that reflects the successive stages of the formation of a systemic inflammatory response:

• Systemic inflammatory response syndrome(SSVO). A harbinger of a septic condition is a systemic reaction to an inflammatory process of any etiology. Is established in the presence of an inflammatory disease and on the basis of at least two clinical manifestations SIRS: tachycardia, tachypnea or hyperventilation, hypo- or hyperthermia, leukocytosis (leukopenia) or increased proportion of immature neutrophils. In 12% of patients with sepsis, there are no signs of SIRS.
• Sepsis. Pathological systemic response to a primary or secondary infection. The diagnosis is made in the presence of an infectious focus or on the basis of verified bacteremia and acutely developed signs of functional failure of two or more organs (MOF).
• Septic shock. An extreme form of pathological reaction. Accompanied by pronounced, persistent, difficult to respond medicinal correction hypotension and impaired perfusion.

Symptoms of obstetric sepsis

Postpartum sepsis manifests itself on the second or third day after expulsion of the fetus with sanguineous-purulent discharge, symptoms of general intoxication (tachycardia, shortness of breath, weakness, loss of appetite, sometimes vomiting and diarrhea) and an increase in temperature to 39-40°C with chills. Hyperthermia is usually stable, but forms with a gradual increase or wide variation in daily temperature and rare bouts of chills can be observed. Pain in the abdomen or mammary glands is noted, and generalized rashes may be recorded. The severity of symptoms and duration of the disease vary depending on the form of the clinical course.

For fulminant obstetric sepsis, an increase in symptoms is typical during the day, with acute form The clinical picture unfolds over several days. In the subacute form, the symptoms are less pronounced, and the process takes weeks to develop. Chroniosepsis is poorly characterized pronounced changes(low-grade fever, increased sweating, headache and dizziness, drowsiness, diarrhea) and a sluggish course for many months. The recurrent form represents a series of attenuations (periods of remission without noticeable manifestations) and exacerbations (periods with severe symptoms) and is characteristic of septicopyemia, when the deterioration of the condition is caused by repeated episodes of the formation of secondary abscesses.

In the absence of treatment, intoxication of the body increases and a severe form with shock syndrome develops. In the early (“warm”) phase, weakness progresses and dizziness is noted. At the same time, the temperature drops to normal or subfebrile levels, and tachycardia increases. The mucous membranes and nail beds acquire a bluish tint, and the skin is hyperemic. Excitement is observed, consciousness can be clear or confused, psychosis and hallucinations are not uncommon. The average duration of the early stage is 5-8 hours, less often – up to two days. In the case of a gram-negative infection, this phase may last several minutes.

The late (“cold”) stage is marked by an increase or decrease in heartbeat with a transition to bradycardia, a drop in temperature below normal, and significant difficulty breathing. Anxiety and excitement intensify, then give way to adynamia, consciousness darkens. The skin takes on an earthy tint, becomes covered in sticky cold sweat, and a cyanotic marble pattern appears on the legs, especially pronounced in the knee area. Oliguria develops, and sometimes jaundice appears.

Especially severe course and nearby specific signs Anaerobic sepsis associated with uterine gangrene is different. The disease occurs lightning fast or acutely, accompanied by intense, intractable pain in the lower abdomen, crepitus and increased pain on palpation of the uterus, discharge of gas and foul-smelling liquid from the vagina with air bubbles, bronze coloration of the skin, and brown urine. The symptoms of septic shock appear at the very beginning of the disease.

Complications

Patients who survive the acute period may develop a severe, often fatal complication - superinfection. A significant deterioration in the quality of life or death of the patient often entails other consequences of sepsis: irreversible organ changes in the kidneys, liver, lungs, heart, brain associated with ischemia or purulent metastasis, perforation and bleeding from gastrointestinal stress ulcers, arterial thromboembolism and phlebothrombosis. Sepsis in pregnant women can cause premature birth, fetal death, encephalopathy and cerebral palsy of the born child.

Diagnostics

The diagnosis of obstetric sepsis involves an obstetrician-gynecologist, therapist, resuscitator, and microbiologist; complicated forms require the involvement of a nephrologist, cardiologist, neurologist, and hepatologist. During a gynecological examination and general examination, a septic condition can be suspected based on the presence of a focus of purulent inflammation in the pelvic organs or mammary gland, as well as signs of SIRS. The following studies are being carried out:

• Determination of pathogen. A culture test of blood and a vaginal smear allows you to identify the infectious agent and select effective drug to treat infection. Bacteremia confirms the presence of a septic process. In the absence of bacteremia, a procalcitonin test is performed to differentiate between local and generalized infection.
• Instrumental studies. Ultrasound of the pelvis and kidneys confirms (detects) the presence of a primary purulent focus in the genitourinary organs. Ultrasound of the abdominal organs, chest x-ray, echocardiography can detect secondary abscesses in the liver, lungs, and heart.
• Clinical and biochemical blood tests. General analysis blood detects leukocytosis, leukopenia, shift leukocyte formula to the left – values ​​that indirectly confirm the septic condition. Data from biochemical studies indicate disturbances in water-electrolyte balance and renal and liver function. Blood gas analysis reveals acid-base balance disorders and respiratory failure. Based on the results of a coagulogram, blood clotting disorders are determined. Testing plasma lactate levels can detect tissue hypoperfusion and assess the severity of shock. An immunogram indicates disorders of immune activity.

Obstetric sepsis should be differentiated from gestosis, amniotic embolism and pulmonary embolism, acute infections(severe influenza, brucellosis, typhus, malaria, miliary tuberculosis), acute pancreatitis, leukemia, lymphogranulomatosis. For differential diagnosis You may need to consult a cardiac surgeon, infectious disease specialist, phthisiatrician, or oncohematologist.

Treatment of obstetric sepsis

Treatment activities are carried out in a gynecological or observational obstetric department; patients with severe forms of sepsis are transferred to the intensive care unit. Treatment is complex, includes surgical and conservative methods and is aimed at fighting infection and correcting vital functions:

• Infusion therapy. Treatment involves correction of homeostatic disorders (hypotension, coagulopathy, acid-base and water-salt metabolism disorders, BCC deficiency), restoration of tissue perfusion, and detoxification. For these purposes, saline and colloidal solutions, albumin, cryoplasma, inotropes and vasopressors are administered.
• Antibacterial therapy. Aimed at destroying the infectious agent in order to block the inflammatory cascade. Initial treatment includes intravenous administration of a combination of broad-spectrum drugs. After the pathogen is isolated, etiotropic antibiotic therapy is started.
• Surgery. Elimination of purulent foci increases the effectiveness of intensive care and improves the prognosis. Treatment involves sanitation of the primary and secondary lesions - opening and emptying of abscesses, curettage, vacuum aspiration or removal of the uterus (hysterectomy).

If necessary, artificial ventilation of the lungs and enteral nutrition of the patient are performed. Additional Methods intensive care includes the use of corticosteroids, surgical detoxification (hemosorption, hemofiltration) after surgical treatment of suppuration, immunotherapy.

Prognosis and prevention

On early stages, when pronounced signs of MODS, persistent hypotension and disseminated intravascular coagulation have not developed, the prognosis is favorable. With the development of septic shock, mortality can reach 65% (average 45%). Preventive actions consist of timely treatment of inflammatory diseases (both at the planning stage and during pregnancy), the fight against out-of-hospital interventions (intrauterine and vaginal manipulations, criminal abortions, home births), rational preventive antibiotic therapy during surgical interventions, good nutrition, stabilization of blood glucose levels in diabetes mellitus.

Its causative agents can be staphylococcus, streptococcus, E. coli, pneumococcus, etc. The source of sepsis is sometimes a wound or an inflammatory process various localizations. Sometimes the cause of the infection is not found (cryptogenic sepsis). A significant role in the development of sepsis is played by the microbial factor, its toxins and toxic substances formed during tissue breakdown. Sepsis is distinguished by pathogen - staphylococcal, streptococcal, gonococcal, etc.; By etiological factor- wound, inflammatory, postoperative, cryptogenic; according to the localization of the primary focus - surgical, gynecological, urological.

There are pyaemia, septicemia and septicopyemia. Pyemia is a type of sepsis when there are foci of infection (often metastatic) in the blood and tissues of the body. In septicemia, the main role is played by toxins that cause degenerative changes in body tissues. Septicopismia is a mixed form when there is both pyaemia and septicemia.

There are two main types of sepsis: with and without metastases.

Symptoms of gynecological sepsis, like sepsis of other etiologies, are changes in nervous system(central, peripheral, autonomic): agitation, irritability, sometimes lethargy, muscle pain, insomnia or drowsiness; increase in body temperature up to 40° C with chills, small and rapid pulse, discrepancy between temperature and pulse, low blood pressure; changes in parenchymal organs (liver, kidneys, heart); enlargement of the liver, spleen, change in the specific gravity of urine (hypoisosthenuria), the appearance of toxic jaundice, protein in the urine, granular and hyaline casts; changes in the blood: ESR increases, hemoglobin decreases; leukocytosis, shift of the leukocyte formula to the left; dysfunction gastrointestinal tract- loss of appetite, gastritis, decreased secretion of the stomach, pancreas, constipation, sometimes diarrhea; general serious condition, painting infectious disease with severe dehydration, with euphoria. The clinical picture of the local lesion is somewhat blurred, although vaginal examination shows characteristic features gynecological disease. The course of sepsis can be fulminant, acute, subacute, chronic and recurrent. With a fulminant course, death can occur on the 1st day; with a chronic course, the disease lasts for months. In the metastatic form, the course of sepsis is usually more severe.

Treatment of gynecological sepsis must be pathogenetic and etiological. To normalize water, mineral and protein metabolism, 500 ml of a 5% glucose solution, 500 ml of an isotonic sodium chloride solution, vitamins B and K, cardiac medications, and ascorbic acid are administered. Sleeping pills and painkillers are prescribed. High-calorie food, in the first period (sensitization or intoxication) - parenteral, in the second period (period of desensitization or convalescence) - high-calorie food, well digestible. Local treatment is usual for this gynecological disease.

General principles of treatment of gynecological sepsis are as follows: anti-inflammatory treatment; decongestant therapy, which helps restore intestinal motility; detoxification measures; maintaining and stimulating the cardiovascular system and the body's defense mechanisms. Anti-inflammatory treatment comes down to removing, even at the height of sepsis, the source of inflammation and establishing peritoneal dialysis. For dialysis, the following solution is used: to 20 liters of isotonic sodium chloride solution add 30 g of glucose, 160 g of sodium chloride, 10 g of sodium bicarbonate, 4 g of potassium chloride, 2 g of calcium chloride, 1 g of monosubstituted sodium phosphate, 2 g of magnesium chloride. For every 2 liters of prepared solution, add 1000 units. heparin, 200 thousand units of penicillin and streptomycin.

Broad-spectrum antibiotics are used. For gynecological sepsis, monomycin, neomycin, kanamycin, tetraolean, streptomycin, tetracycline, gentamicin sulfate, etc. have proven their effectiveness. In addition, patients are prescribed large doses (up to 600 mg) of ascorbic acid (delays the removal of antibiotics from the body), nystatin or levorin, from sulfa drugs- etazol, during the first 3 days - corticosteroids in large doses (hydrocortisone 600-900 mg once a day).

Decongestant therapy includes the administration of 10 ml of 2.4% aminophylline solution every 4 hours (6 times), 30-40 ml of mannitol 2 times a day. Among the agents that stimulate intestinal motility, we should recommend 2 ml of a 0.2% solution of aceclidine 2-3 times a day, 0.5-1 ml of a 0.5% solution of prozerin 2 times a day, 2 ml of thiamine 3 times a day, pentamin (at maximum pressure not lower than 110 mm Hg. Art.), dill water 1 tablespoon 4 times a day.

From antihistamines Prescribe 2 ml of a 2.5% solution of diprazine 4 times a day, 2 ml of a 2% solution of suprastin 4 times or 2 ml of a 2% solution of diphenhydramine 3 times a day.

For stimulation cardiovascular activity prescribe 0.5 ml of a 0.05% solution of strophanthin, 10 ml of panangin per 100 ml of isotonic sodium chloride solution, 1 ml of pyridoxine 2 times a day; for the ventilation ability of the lungs - 2 ml of 20% camphor with ether (1 ml) 2 times a day, as well as rubbing the chest and back camphor alcohol, massage along the lymphatic drainage, breathing exercises (inflating the bag), oxygen therapy.

Detoxification therapy includes intravenous drip administration of 400 ml of 10% glucose solution, 10 ml of 7% potassium chloride solution, 10 ml of 25% magnesium sulfate solution, 4 ml of ATP. During the treatment process, all of the above drugs must be administered 6-8 times, depending on the general condition of the patient. Such patients need to be administered plasma, 10-20% albumin solution, compensan, hemodez, antistaphylococcal plasma, gamma globulin, freshly prepared whole blood. It is best to place such patients in intensive care wards and resuscitation departments.

Sepsis is a generalized (systemic) reaction of the body to an infection of any etiology (bacterial, viral, fungal).

The presence of bacteria in the bloodstream (bacteremia) does not always accompany sepsis and therefore cannot be its mandatory criterion. However, detection pathogenic microorganisms in the blood in combination with other signs of sepsis confirms the diagnosis and helps in the choice of antibacterial therapy.

Sepsis in obstetrics occurs due to the following diseases:

Endometritis after an infected abortion;

Chorioamnionitis;

Endometritis after childbirth;

Phlegmanous and gangrenous mastitis;

Suppuration, especially phlegmon, wounds abdominal wall after a caesarean section or perineal wound.

The infection can spread by hematogenous and lymphogenous routes. The severity of clinical manifestations depends on the virulence of the pathogen and the immune defense of the macroorganism. As a result of the progression and spread of the local infectious process, a systemic inflammatory reaction and organ failure develop.

Currently, Russia has adopted the classification of sepsis proposed by the Society of Critical Care Medicine Specialists. Sepsis is distinguished; severe sepsis; septic shock.

Etiology and pathogenesis. The most common causative agent of infection in obstetrics is gram-positive microflora: Streptococcus spp, Staphylococcus and Enterococcus spp etc. Sepsis may develop with the participation of gram-negative flora: Pseudomonas aeruginosa, Acinetobacter spp, Klebsiella pneumonia, E. coli and etc.

The development of sepsis and organ-system damage is associated with the launch and uncontrolled spread of cascade humoral reactions, the key of which is the release of cytokines both at the site of inflammation and far from it. The developing reaction is controlled by both pro-inflammatory (IL-1, IL-6, IL-8, TNF) and anti-inflammatory mediators (IL-4, IL-10, IL-13, etc.). Exo- and endotoxins of microorganisms activate lymphocytes and endothelial cells. A key proinflammatory mediator playing a role in the pathogenesis of sepsis is TNF. TNF increases the procaogulant properties of the endothelium, activates neutrophil adhesion, induces the synthesis of other proinflammatory cytokines, stimulates catabolism (synthesis of “acute-phase” proteins), and fever.

The total effects of mediators form the systemic inflammatory response syndrome. There are three stages to this reaction.

Stage 1 - local; focal release of cytokines that regulate immune and inflammatory reactivity at the site of inflammation. As a result of the activation of these systems and, accordingly, the synthesis of T cells, leukocytes, macrophages, endothelial cells, platelets, stromal cells, the processes of wound regeneration and localization of infection are stimulated.

Stage 2 is systemic, when a small amount of cytokines are released into the systemic circulation. The course of the infectious process is determined by the balance between pro-inflammatory and anti-inflammatory mediators. IN normal conditions prerequisites are created for maintaining homeostasis and destroying microorganisms. At the same time, adaptive changes develop: increased leukocytosis in bone marrow, hyperproduction of proteins acute phase in the liver, generalization of the immune response, fever.

Stage 3 is the stage of generalization of the inflammatory reaction. When anti-inflammatory mechanisms are insufficient, a significant amount of pro-inflammatory cytokines penetrate into the systemic circulation, exerting a destructive effect on the endothelium with the release of a significant amount of a powerful vasodilator - nitric oxide. This leads to disruption of the permeability and function of the vascular epithelium, triggering of DIC syndrome, vasodilation, and disruption of microcirculation.

The continued damaging effect of bacterial toxins leads to worsening circulatory disorders. Selective spasm of venules in combination with the progression of disseminated intravascular coagulation promotes sequestration of blood in the microcirculation system. An increase in the permeability of the walls of blood vessels leads to sweating of the liquid part of the blood, and then shaped elements into the interstitial space. These pathophysiological changes contribute to a decrease in blood volume - hypovolemia develops. Blood flow to the heart is significantly reduced. The minute volume of the heart, despite the sharp tachycardia, cannot compensate for the increasing disturbance of peripheral hemodynamics, and a persistent decrease in blood pressure occurs. Progressive impairment of tissue perfusion leads to further deepening tissue acidosis against the background of severe hypoxia, which in combination with toxic effect pathogen quickly leads to dysfunction of organs, and then to their necrosis. Vital important organs are subject to significant morphological and functional changes: “shock lung”, “shock kidney”, “shock uterus”, etc.

Clinical picture and diagnosis determined by the stage of the septic process.

At sepsis there is a focus of infection (endometritis, peritonitis, mastitis, etc.) and two or more signs of systemic inflammatory response syndrome:

Body temperature 38°C or higher or 36°C or lower, chills;

Heart rate 90 per minute or more;

RR greater than 20 minutes or hyperventilation (PaCO2 32 mm Hg or less);

Blood leukocytes more than 12,109/ml or less than 4,109/ml, the presence of immature forms is more than 10%.

Severe sepsis manifested by multiple organ failure: cardiopulmonary, renal, hepatic acute lesion CNS. Clinically manifested by hypotension and oliguria. To assess the severity of multiple organ failure, the international SOFA scale (see Table 31.1) (Sepsis organ failure assessment) is used, in which each symptom is scored. The more points, the more serious condition patients.

Septic shock- multiple organ failure and arterial hypotension that cannot be eliminated with infusion therapy and require the administration of catecholamines.

Diagnostics. To clarify the diagnosis and select targeted therapy for sepsis, it is necessary to determine the source of infection. In addition, they carry out:

Blood pressure monitoring, determination of mean blood pressure, heart rate, respiratory rate;

Measure body temperature at least every 3 hours, especially after chills;

Complete blood count (leukocyte count, hemoglobin, hematocrit);

Study of blood coagulation parameters - the number of platelets, fibrinogen, soluble complexes of fibrin monomers, fibrin and fibrinogen degradation products, antithrombin III, platelet aggregation;

Bacteriological examination of blood, especially during chills, determination of the sensitivity of microflora to antibiotics;

Hourly monitoring of diuresis, bacteriological examination of urine, determination of the sensitivity of microflora to antibiotics;

Determination of serum electrolyte concentrations (Na+, Ka+), creatinine, gases arterial blood, pH;

X-ray examination chest;

Determination of procalcitonin and C-reactive protein in the blood.

Intensive care septic conditions are carried out jointly with resuscitators in intensive care units. It includes:

Elimination of the primary source of infection;

Use of antibacterial drugs;

Infusion therapy to normalize metabolism and function internal organs;

Hemodynamic and respiratory support;

Immunoreplacement therapy;

Correction of hemostasis and prevention of deep vein thrombosis;

Enteral nutrition;

Extracorporeal methods treatment.

Elimination of the source of infection for endometritis, it involves removing purulent detritus from the uterine cavity, which is formed either as a result of a criminal abortion, or after a cesarean section, less often after childbirth. For this purpose, under ultrasound control, tissue is first carefully removed with a blunt curette, and then the uterine cavity is washed with a 1% solution of chlorhexidine or a 0.01% solution of Miramistin. If therapy is ineffective, the uterus and tubes are removed.

If the source of sepsis is purulent mastitis, suppuration postoperative wound, then a wide opening, emptying and drainage of the abscess is indicated.

Adequate antibacterial therapy is one of the important conditions for the treatment of sepsis. Antibiotics are prescribed taking into account the sensitivity of the pathogen. Modern methods Blood culture studies make it possible to record the growth of microorganisms up to 24 hours, and after 24-48 hours to identify the pathogen. Empiric therapy using first-line antibiotics is indicated until the results of a microbiological study are obtained. These include third generation cephalosporins (ceftriaxone, cefotaxime, cefoperazone); fluoroquinolones (levofloxacin, moxifloxacin, ciprofloxacin, ofloxacin); carbapenems (imipen, meronem).

After the pathogen is isolated, etiotropic antibiotics are used, taking into account sensitivity to them.

It is advisable to combine antibiotics with nitronidazole derivatives (metronidazole), which are highly active against anaerobic infections.

Antibacterial drugs in case of sepsis, it is administered only parenterally (intravenously) for 5-10 days until a lasting result is achieved, normalization of the leukocyte formula (no shift to the left).

In order to prevent fungal infections during antibiotic therapy, Levorin, Diflucan, Nizoral, and Orungal are prescribed.

An important component in the treatment of sepsis is infusion therapy. Its purpose is to detoxify, improve rheological and coagulation properties of blood and tissue perfusion, eliminate electrolyte disturbances, dysproteinemia, recovery acid-base balance. Infusion therapy, by reducing blood viscosity, improves the delivery of antibiotics to the site of inflammation and increases the effectiveness of antibacterial therapy. Both colloids and crystalloids are used for infusion therapy.

Plasma substitutes (dextrans, gelatinol, hydroxyethyl starches) are indicated for severe BCC deficiency. Hydroxyethyl starches with molecular weights of 200/0.5 and 130/0.4 have a potential advantage over dextrans due to a lower risk of membrane leakage and lack of clinically significant effects on hemostasis.

In the process of treating sepsis, they strive to restoration of lung function(breathing support). In case of septic shock, there are often indications for mechanical ventilation. More mild course sepsis is an indication for oxygen therapy using a face mask and nasal catheters.

In severe sepsis and septic shock, rapid restoration of adequate hemodynamics is necessary: ​​CVP 8-12 mm Hg. Art., ADsr. more

65 mmHg Art., diuresis 0.5 mm/(kg h), hematocrit more than 30%, blood saturation -

at least 70%.

In order to quickly restore hemodynamics against the background of respiratory support and central vein catheterization, infusion therapy is performed. When the cardiac index decreases to 3.5-4 l/(min m2) and Sv O2 (saturation) to more than 70%, catecholamines are used: dopamine (10 mcg/(kg min) or norepinephrine at a dose of up to 10 mcg/(kg min).

When the cardiac index is less than 3.5 l/(min m2) and Sv O2 is less than 70%, dobutamine is used at a dose of 20/mcg/(kg min), with SBP less than 70 mm Hg. Art. in combination with norepinephrine or dopamine.

To normalize hemodynamics, corticosteroids are prescribed: prednisolone, dexamethasone, betamethasone. Hydrocortisone in doses of 240-300 mg/day for 5-7 days is used for concomitant adrenal insufficiency or refractory shock to increase the effectiveness of catecholamines.

To correct the disturbed immunity in sepsis, the effectiveness of pentaglobin (IgG, IgM, IgA) has been proven. It reduces mortality at doses of 5 ml/kg when administered at a rate of 28 ml/hour for three days.

The effectiveness of other immunocorrective drugs for sepsis has not been proven.

For correction hemostasis use:

Replacement therapy fresh frozen plasma when consuming clotting factors;

Low molecular weight heparin for hypercoagulation in the plasma and cellular parts of hemostasis for the prevention of deep vein thrombosis;

Activated protein C, which has anticoagulant, profibrinolytic and anti-inflammatory properties. It is used for severe sepsis and multiple organ failure with tissue hypoperfusion.

An important part of the treatment of sepsis against the background of hypermetabolism and destruction of one’s own cells is enteral nutrition. Depending on the biochemical parameters, fat imulsions, glucose, proteins, vitamins, microelements, and electrolytes are used for this.

The composition of nutrient media and the route of their administration in sepsis depend on the state of the gastrointestinal tract. If its functions are preserved and only swallowing is impaired, then the mixture is administered through a probe.

Glucose levels are maintained at 4.5-6.1 mmol/l. When administering glucose intravenously, insulin is used according to indications.

Significant value in the complex therapy of sepsis belongs extracorporeal methods to neutralize sepsis mediators. For this use:

Plasma exchange with the removal of up to 5 volumes of plasma in 30-36 hours. Using fresh frozen plasma, colloids and crystalloids;

Plasmapheresis using membranes characterized by wide limits of adsorption of toxic substances;

Combined plasma excretion and adsorption (this procedure consists of the exchange of plasma, which is returned to the bloodstream after passing through a cartridge consisting of a solid resin with increased adsorbent abilities)

BIBLIOGRAPHY

1. Obstetrics: National leadership/ Ed. E.K. Ailamazyan, V.I. Kulakov, V.E. Radzinsky, G.M. Savelyeva. - “GOETAR-Media”, 2009.
2. Gynecology. Textbook for universities / Ed. acad. RAMS, prof. G. M. Savelyeva, prof. V. G. Breusenko. - “GOETAR-Media”, 2007.
3. Practical gynecology: A guide for doctors / V.K. Likhachev. - Medical Information Agency LLC, 2007.
4. Gynecology. Textbook for students medical universities/ V. I. Kulakov, V. N. Serov, A. S. Gasparov. - "Medical Information Agency LLC", 2005.
5. Inflammatory diseases of the female genital organs. Brochure of a practical gynecologist / A. L. Tikhomirov, S. I. Sarsania. - Moscow, 2007.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols Ministry of Health of the Republic of Kazakhstan - 2017

Obstetric pyemic and septic embolism (O88.3), Other infections during childbirth (O75.3), Other puerperal infections (O86), Puerperal sepsis (O85), Septicemia unspecified (A41.9), Toxic shock syndrome (A48.3 )

obstetrics and gynecology

general information

Short description

Approved
Joint Commission on Healthcare Quality
Ministry of Health of the Republic of Kazakhstan
dated December 27, 2017
Protocol No. 36

Sepsis - life-threatening organ dysfunction, the cause of which is the body’s dysregulatory response to infection.
Organ dysfunction - acute changes in total number points on the Sepsis-related Organ Failure Assessment scale by -2 points as a consequence of infection.
NB! Systemic inflammatory response syndrome is no longer a criterion for sepsis, because one in eight patients (12.5%) with severe sepsis is “SIRS negative.”

INTRODUCTORY PART

ICD-10 code(s):

ICD-10
Code	Name
A41.9	Septicemia, unspecified
A48.3	Toxic shock syndrome
O75.1	Maternal shock during labor or after labor and delivery
O85	Postpartum sepsis If it is necessary to identify the infectious agent, an additional code (B95-B97) is used. Excluded: Obstetric pyemic and septic embolism (O88.3); Septicemia during childbirth (O75.3).
086	Other postpartum infections. Excludes: infection during childbirth (O75.3). O86.0 Infection of an obstetric surgical wound. O86.1 Other genital tract infections after childbirth. O86.4 Unexplained hyperthermia occurring after childbirth Excluded: Hyperthermia during labor (O75.2); Puerperal fever(O85).
O88.3	Obstetric pyemic and septic embolism.

Date of protocol development/revision: 2017

Protocol users: obstetricians-gynecologists, resuscitators, doctors general practice, emergency medical doctors.

Level of evidence scale:

Recommendation Strength Classification
Level of evidence	Description
I	Evidence from at least one high-quality randomized controlled trial.
II-1	Evidence obtained from a well-designed controlled trial without randomization.
II-2	Evidence obtained from a well-designed cohort or case-control study, single or multicentre.
II-3	Evidence from multiple case series with and without intervention.
Level of recommendation
Class A	requires at least one meta-analysis, systematic review or RCT, or the evidence is judged to be good and directly applicable to the target population.
Class B	requires evidence derived from well-conducted clinical trials directly applicable to the target population and demonstrates complete consistency of results; or evidence extrapolated from meta-analysis, systematic review and RCT.
Class C	requires evidence obtained from expert panel reports, or the opinions and/or clinical experience of authorities, indicates a lack of good quality clinical studies.
Class D	expert opinion without critical judgment, or based on clinical experience or laboratory studies.

Classification

Classification:

· Sepsis.
· Ceptic shock- this is sepsis, combined with the need for therapy with vozopressors to raise blood pressure to an average of 65 mmHg and with a lactate level of more than 2 mmol/l against the background of adequate infusion therapy.

Diagnostics

DIAGNOSTIC METHODS, APPROACHES AND PROCEDURES

Diagnostic criteria(The Third International Consensus Definitions for Sepsis and Septic Shock - Sepsis-3). Mandatory criteria for the diagnosis of sepsis are: the focus of infection and signs of multiple organ failure.
Complaints and anamnesis:

Complaints:
increased body temperature;
shortness of breath;
· flu-like symptoms;
· diarrhea, vomiting;
· abdominal pain;
· rash;
· pain in the mammary glands.

Anamnesis :
Risk factors:
· C-section;
· remnants of membranes or fertilized egg after abortion;
amniocentesis or other invasive procedures;
· cervical cerclage;
· prolonged spontaneous rupture of the membranes;
· vaginal trauma, episiotomy, perineal ruptures, wound hematoma;
· multiple (more than 5) vaginal examinations;
· anemia;
· obesity;
Impaired glucose tolerance/ diabetes;
· decreased immunity/taking immunosuppressants;
· vaginal discharge;
· GAS infections (group A streptococcal infection).

Physical examination :
hyperthermia or hypothermia (temperature<36C/более 38С), пик и температуры указывают на абсцесс;
NB! normal temperature may be associated with antipyretics or NSAIDs.
· tachycardia (pulse>100 beats/min);
Tachypnea (>20 breaths/min);
· convulsions;
· diarrhea or vomiting (may indicate the presence of an exotoxin - early toxic shock);
· lactostasis/breast redness;
· rash (generalized maculopapular rash);
pain on palpation of the abdomen;
· wound infection (caesarean section, wound on the perineum, on the walls of the vagina, cervix) - spread of cellulite or discharge;
· copious vaginal discharge (smelly, suggestive of anaerobes; serous-hemorrhagic, suggestive of streptococcal infection);
· productive cough;
· delayed uterine involution, abundant lochia;
· are common nonspecific signs, such as lethargy, decreased appetite;
· signs of organ decompensation (hypoxemia; hypotension; cold extremities (decreased capillary refill)); oliguria, etc.;
· some cases of sepsis in the postpartum period manifest only with severe abdominal pain, in the absence of fever and tachycardia.

SIRS - presence of 2 or more symptoms :
body temperature above 38C or below 36C;
· tachycardia more than 90 beats/min;
· tachypnea more than 20 minutes or a decrease in partial pressure of CO2, 32 mmHg;
NB! According to the Sepsis-3 criteria, “Sepsis is a life-threatening organ dysfunction caused by dysregulation of the body's response to infection,” the “Severe sepsis” criterion is redundant (1).

Sepsis criteria:
· suspected or documented infection;
· organ dysfunction (score of two or more points on the SOFA scale).
The qSOFA scale is a simplified SOFA scale for quick assessment of prehospital stage and outside the intensive care unit (Table 1)

Table 1. qSOFA scale.
NB! A qSOFA score of 2 or more is a strong predictor unfavorable outcome and the patient requires transfer to the intensive care unit.
NB! The SOFA scale should be used in the intensive care unit

Table 2. SOFA scale

ScaleSOFA	0	1	2	3	4
Breath PaO2/FiO2, mmHg	More than 400	Less than 400	Less than 300		Less than 200 with respiratory support
Coagulation Platelets, x 10 3/mm 3	More than 150	Less than 150	Less than 100	Less than 50	Less than 20
Liver Bilirubin, µmol/l	20	20-30	33-101	102-204	>204
Cardiovascular Hypotension	BP avg. more than 70 mmHg.	BP avg. less than 70 mmHg	Dopamine less than 5, or dobutamine (any dose)	Dopamine 5-15, or adrenaline<0,1, или норадреналин <0,1	Dopamine >15, or adrenaline >0.1, or norepinephrine >0.1
CNS Glasco Coma Scale	15	13-14	10-12	6-9	<6
Kidneys Creatinine, mg/dl, mmol/l	Less than 1.2 (110)	1,2-1,9 (110-170)	2,0-3,4 (171-299)	3,5-4,9 (300-440)	More than 4.9 (440)
Diuresis	-	-	-	<500 мл/сут	<200 мл/сут

Criteria for septic shock:
· persistent arterial hypotension requiring the use of vasopressors to maintain mean arterial pressure of 65 mmHg;
lactate level more than 2 mmol/l, despite adequate infusion therapy;
NB! If these criteria are met, the probability of in-hospital death exceeds 40%.

Laboratory tests for suspected sepsis:
· blood culture before antibiotics are prescribed (UD-D);
· determination of lactate in blood serum (UD-D);
· clinical blood test (increased number of leukocytes or low number of leukocytes - more than 12-10 9, less than 4*10 9), platelets;
· coagulogram;
Plasma electrolytes;
· general urine analysis;
· bacteriological examination depending on the clinic (lochia, urine, discharge from a wound, nasopharynx);
· biomarkers (C-reactive protein - more than 7 mg/l, procalcitonin, presepsin). NB! These biomarkers have relative diagnostic value regarding the generalization of bacterial infection and indicate the presence of a critical condition. Normalization of procalcitonin levels can serve as one of the criteria for discontinuation of antibacterial therapy (UD-2C).

Instrumental research methods:
Investigations aimed at finding the source of infection (UD-D):
X-ray of the lungs;
· Ultrasound of organs abdominal cavity;
· Ultrasound of the pelvic organs;
· Echo-KS.

Indications for specialist consultation:
· consultation with a resuscitator - if symptoms requiring resuscitation appear
· clinical microbiologist (if a specialist is available) - if necessary, verify the results of bacteriological tests
· clinical pharmacologist - to adjust the dosage and combination of medications.
· consultation with a surgeon - if necrotizing fasciitis is suspected.

Diagnostic algorithm (Figure 1)

Algorithm for diagnosing sepsis (SSC) .
1. Diagnosis and treatment of infection. Doctors should be aware of the signs and symptoms of infection to ensure early diagnosis of the infectious complication. In patients with infection, treatment should begin as early as possible, and blood and other cultures should be tested to identify the pathogen. Antibacterial drugs are used and at the same time laboratory evaluation is carried out for infection-related organ dysfunction.
2. Screening for organ dysfunction and treatment of sepsis (formerly severe sepsis). It is necessary to use the qSOFA and SOFA scales to assess organ dysfunction. Patients with organ dysfunction require blood culture testing and broad-spectrum antibiotics.
3. Identification and treatment of arterial hypotension. In patients who have infection and hypotension or a lactate level greater than or equal to 2 mmol/L, a 30 mL/kg crystalloid infusion should be started with a reassessment of volume response and tissue perfusion. The six-hour activities and treatment goals must be met. Sepsis 3 introduces qSOFA as a tool to identify patients at risk of sepsis with a higher risk of inpatient death or prolonged ICU stay.
NB! Patients with an infectious focus should be assessed for signs of multiple organ failure, and patients with signs of multiple organ failure should be assessed for overt or suspected infection. This serves as the basis for early diagnosis and maximum early treatment of sepsis by doctors of all specialties.

Diagnosis and assessment of the severity of multiple organ failure for sepsis and septic shock should be carried out according to the SOFA scale (UD-1B).

Differential diagnosis

Differential diagnosis and rationale for additional studies

Diagnosis	Septic shock	EOW	Anaphylactic shock
Inclusion criteria	Drop in blood pressure, tachycardia, apnea	Apnea, tachycardia, drop in pressure	-
Diagnosis exclusion criteria	-	The appearance of symptoms during childbirth, cesarean section or within 30 minutes after birth, hemostasis - changes characteristic of the second phase of disseminated intravascular coagulation; against the background of intravenous infusion of the solution, an increase in blood pressure can be achieved	Connection with the administration of the drug, there are no signs of hemostasis impairment, consciousness is preserved

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